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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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Case conference conscious disturbances

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: 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+



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)



  • 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


  • 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.



  • S/S Hypercalcemia cancers

    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 cancers

  • 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 cancers

  • 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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