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Case conference -- Conscious disturbances. 性別 : 女 Age: 47 y/o Date of Admission:94 年 7 月 31 日 Date of Discharge:94 年 8 月 1 日 Con’s: A VPU Vital signs: TPR:37.6/119/16 BP:100/63mmHg Triage I. Chief complaints. Consciousness change at home . Present Ilness.

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slide2
性別: 女
  • Age: 47 y/o
  • Date of Admission:94年7月31日
  • Date of Discharge:94年8月1日
  • Con’s: AVPU
  • Vital signs: TPR:37.6/119/16 BP:100/63mmHg
  • Triage I
chief complaints
Chief complaints
  • Consciousness change at home
present ilness
Present Ilness
  • A case of hepatic adenocarcinoma s/p TAE diagnosed at 2005.3
  • Just discharged from GI ward on 2005.7.20 with initial presentation of abdominal pain and consciousness change
  • Gradual onset of drowsy consciousness in recent 2 days
  • Fever was noted.
past history
Past history
  • Allergy : penicillin
  • Hepatic adenocarcinoma s/p TAE
physical examination
Physical Examination
  • Con’s: slow response E4V6M5
  • HEENT: grossly normal
  • Lung: clear BS
  • Heart: RHB
  • Abd: soft and flat, tenderness(+), mild distention
  • Ext: freely movable, jaundice(-)
  • Neurological: EOM:full pupil:3+/3+
slide7
What you else?
  • What is your differential diagnosis?
d d of altered level of conscious
D/D of Altered Level of Conscious
  • A ( Alcohol , abuse)
  • E ( Electrolyte, encephalopathy)
  • I ( Infection)
  • O ( Overdose ingestion)
  • U (Uremia)
  • T ( Trauma)
d d of aloc
D/D of ALOC
  • I ( Insuline, intussuception, inborn error of metabolism)
  • P (Psychogenic)
  • S (Shock, stroke, seizure)
slide11
O2
  • IV
  • Monitor
  • A
  • B (Kussmaul , Cheyne-Stokes)
  • C
  • D
  • E
order 7 31
Order(7/31)
  • CBC/DC PT/aPTT
  • Panel I, iCa
  • GPT T/D bilirubin
  • Ammonia
  • N/S run 60cc/hr
  • B/C xII
  • ABG
  • F/S (104mg/dl)
  • U/A
  • EKG: NSR
lab data 7 31
Lab data(7/31)
  • WBC:12600 S/L:84/8
  • BUN/Cr:15/0.7
  • Na/K:129/4.8
  • T/D bilirubin: 1.4/0.7
  • AST/ALT: 87/16
  • NH3: 111
  • CRP: 6.7
  • iCa: 7.48
abg r a
ABG(R.A)
  • pH : 7.428
  • pCO2: 36mmHg
  • pO2: 72.3mmHg
  • HCO3- : 23.9mmol/L
  • Sat : 94.8%
diagnosis
Diagnosis
  • Hypercalcemia, HCC related
  • Hepatic adenocarcinoma s/p PEIT
  • Hyponatremia
order 8 1
Order (8/1)
  • Fleet enema
  • Lactulose 30cc tid x2D
  • Stool OB
  • 排GI住院
  • 轉EC
  • 補 P
order
Order
  • Bonfos 2# po tid and st
  • NS 500cc st
  • Zometa 1 vial in N/S 100cc run 30 mins
  • F/U iCa
  • Burinex 1 amp iv st and q12h x 1 D
  • Record Urine output
slide21
Burinex 1 amp 改 iv q6h
  • F/U iCa at 10 a.m -> iCa:8.13
  • N/S 改run 200cc/hr
  • On CVP
  • F/U CXR
  • Consult總值for ICU admission
  • Haldol 1 amp im q4h
  • Patient AAD
paraneoplastic syndromes
Paraneoplastic syndromes
  • Definition: caused by factors produced by cancer cells that act at a distance from both the primary cancer site and its metastasis.
  • 3 major classes of hormones are steroids, monoamines, and peptides/proteins.
hypercalcemia
Hypercalcemia
  • Hypercalcemia with cancer-Humoral hypercalcemia with malignancy (HHM)
  • Caused by local osteolytic hypercalcemia (LOH)
  • PTHrP causes nearly all cases of malignancy
  • Binds to receptors in bone and kidney and causes increased bone resorption.
slide24
The cancers associated with HHM are non-small cell lung cancers
  • Breast cancers
  • Renal cell carcinoma
  • Head and neck cancer
  • Bladder cancer
  • Myeloma
slide25
S/S Hypercalcemia

Initial symptoms (calcium level ≧2.6mmol/L)-anorexia, malaise, fatigue, confusion, bone pain, polyuria, polydipsia, weakness, constipation

Neurologic symptoms (calcium level ≧3.5mmol/L)-confusion, lethargy, coma and death.

diagnosis1
Diagnosis
  • Normal level of PTH level and a low serum phosphate level in the absence of bone metastases support the diagnosis of HHM
  • A normal PTHrP level and normal phosphorus in a pt with bone metastases suggest LOH.
treatment
Treatment
  • Moderate hypercalcemia

Pamidronate 90mg iv with Diuretics

2-4 L of normal saline

  • Severe hypercalcemia

Calcitonin 4-8 U/kg IM or SC q12h

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