After a two-month hiatus, Case of the Month returns!
Get your thinking caps on for July’s Edition…
The patient is a 50-year-old woman with a previous history of type II diabetes, and recently completed a 6-month course of treatment for tuberculosis, presenting with 5-6 days of worsening lower abdominal pain, back pain, nausea, non-bloody non-bilious emesis, and anorexia. She is adamant about compliance with her insulin regimen. She notes 40-lb. weight loss over the past year but denies any cough or night sweats. She has no fevers/chills, change in bowel habits, recent travel, or CP/SOB. She was placed on observation one month ago for hyperglycemia and vomiting and was discharged after 1 day.
No known drug allergies
Insulin glargine 14U every night
Insulin aspart 5U three times daily with meals
PMH/PSH: No history of abdominal surgeries
SH: Denies toxic habits; works for the police department
VS: T 98.6 HR 111 RR 18 BP 99/54 SaO2 100% (room air)
General: Uncomfortable woman lying in stretcher
HEENT: No conjunctival pallor or scleral icterus, slightly dry mucous membranes
CV: Tachycardia; normal S1S2; no murmurs, rubs, or gallops
Pulm: Clear to auscultation bilaterally; no wheezes, rales, rhonchi or crackles
Abd: Soft, diffusely tender to palpation, most pronounced in RLQ without rebound or guarding; bilateral CVA tenderness.
Ext: No C/C/E
Skin: No changes noted on limbs, trunk, palms, or soles
ECG: Sinus Tachycardia, no other abnormalities
46.22>12.1|37.2<125 (11% bands)
Na 116 K 5.2 Cl 79 CO2 20 BUN 88 Cr 3.23 Calcium 8.4 Glucose 526
Protein 5.8 Albumin 2.77 AST 10 ALT 14 Alk Phos 145 Bili 0.8
VBG pH:7.37 Lactate 1.9 Na 108
Urinalysis: Large leukocyte esterase, >500 Glucose
Urine culture: pending
CT Abdomen/Pelvis: Massively enlarged kidneys, hepatomegaly, large bulky uterus, ascites
CXR: No airspace opacity
You give 2L NS, 4 mg morphine, regular insulin 10U, antibiotics
After a couple of hours, your patient’s vitals are:
HR 106 BP 150/99 RR 20 SaO2 100%
A repeat VBG after the 2L bolus shows sodium of 107, glucose 435, Cr 2.89.
- What is your differential diagnosis for the patient’s presenting chief complaint?
- What antibiotics would you choose?
- Does this patient need to be on isolation?
- How would you characterize the sodium disturbances, both on initial presentation, and after the initial interventions? How would you address it?
- What is the ultimate disposition for this patient?