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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: 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

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  1. Case conference-- Conscious disturbances

  2. 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

  3. Chief complaints • Consciousness change at home

  4. 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.

  5. Past history • Allergy : penicillin • Hepatic adenocarcinoma s/p TAE

  6. 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+

  7. What you else? • What is your differential diagnosis?

  8. D/D of Altered Level of Conscious • A ( Alcohol , abuse) • E ( Electrolyte, encephalopathy) • I ( Infection) • O ( Overdose ingestion) • U (Uremia) • T ( Trauma)

  9. D/D of ALOC • I ( Insuline, intussuception, inborn error of metabolism) • P (Psychogenic) • S (Shock, stroke, seizure)

  10. What will you do next?

  11. O2 • IV • Monitor • A • B (Kussmaul , Cheyne-Stokes) • C • D • E

  12. 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

  13. 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

  14. ABG(R.A) • pH : 7.428 • pCO2: 36mmHg • pO2: 72.3mmHg • HCO3- : 23.9mmol/L • Sat : 94.8%

  15. Diagnosis • Hypercalcemia, HCC related • Hepatic adenocarcinoma s/p PEIT • Hyponatremia

  16. What will you do next with this impression?

  17. Order (8/1) • Fleet enema • Lactulose 30cc tid x2D • Stool OB • 排GI住院 • 轉EC • 補 P

  18. What is will you do next with after seeing the lab data?

  19. 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

  20. 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

  21. 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.

  22. 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.

  23. The cancers associated with HHM are non-small cell lung cancers • Breast cancers • Renal cell carcinoma • Head and neck cancer • Bladder cancer • Myeloma

  24. 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.

  25. 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.

  26. 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

  27. Thanks for your attention!

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