Medical scenario

[Sdiver]

Switching gears here.
Here's a good medical call.
The site I got this from has several different diagnosis from its members.
Let's see what the members here come up with.

A 44-year-old woman in moderate respiratory distress for the past two days, she had experienced mild respiratory difficulty, Nausea/vomiting and intermittent vertigo and tinnitus for three days and a headache and back pain for the last week. Her children had complained to her that "she was getting deaf." Low grade temp and has been “In a really bad mood” She appears restless and slightly diaphoretic, Lethargic when not stimulated. Denies Drug or ETOH intake, states she “Can’t remember what meds she has taken today”

PMHX- Bipolar, Sciatica, Fibromyalgia, Migraines, Cardiac w/ 1 stent, HTN

MEDS- Lithium, HCTZ, ASA, Seroquel, Ibuprofen, Gabapentin, OTC Herbals, Indocin

BP- 110/62
HR- 80
RR- 30 labored
SPo2- 90%
Cardiac Monitor- Sinus Rhythm with nonspecific ST-T changes
HEENT- Clear, Headache
Pupils- Clear 3mm
Neck- Clear
Chest- Clr, no pain
Lungs- Diffuse Rales Bilaterally
Abd- Clear
Pel- Clear
Neuro- Clear

What is your Differential DX?
What will your treatment be?
Any Special Concerns or considerations.

[Trapper John]

I am thinking a couple of things are going on here. Most immediate is CHF (diffuse bilateral rales) but also drug interaction/overdose (Seroquel/HTZ/Gabapentin) could give these symptoms. RO hypokalemia. I would admit this patient and get blood chems to RO hypokalemia. Chest films to RO CHF. Control meds to eliminate overdosage and drug-drug interaction.

[Trapper John]

Originally Posted by DocIllinois

At first take, the 'back of my mind voice' said metabolic alkalosis.

Interested in those blood chems...

Ooooh, interesting thought What do you think the proximate cause for this would be? Too many Tums

I forgot to include to RO pneumonia in the DDx too.

[Sdiver]

Originally Posted by DocIllinois

And what the hell are those lab monkeys doing?

Remember Doc, this is "Pre-hospital" where we don't have the luxury of labs to treat our patients. We just have the above scenario to work with.

Just wanted to see what different diagnosis we'd come up with over here.
So far so good.
Keep 'em coming folks.

[doctom54]

Pulmonary embolism is in the DDX

[Trapper John]

Originally Posted by Sdiver

Remember Doc, this is "Pre-hospital" where we don't have the luxury of labs to treat our patients. We just have the above scenario to work with.

Ahhh, Man your no fun Do we at least get to know the outcome?

[Trapper John]

Originally Posted by doctom54

Pulmonary embolism is in the DDX

Didn't report any thoracic petechiae on physical exam

[Sacamuelas]

I am going with a chronic, moderate to severe lithium overdose. Patient is taking numerous medications that cause increased Li concentrations. HCTZ, Ibuprofen, Indocin, gabapentin, and even some OTC herbals all increase serum LI concentrations.

The HCTZ is one of the main culprits seen in interaction overdoses when used by itself. Combining HCTZ with the ingestion of three other KNOWN causes of increased Li levels has to make you consider Li toxicity in your differential diganosis. That is before you even factor in the unknown "herbal" meds that also can increase serum Li levels...


Also, most if not all pertinant findings in history and physical can be onserved in Li toxicity.

[Sdiver]

Originally Posted by Trapper John

Ahhh, Man your no fun Do we at least get to know the outcome?

Yes, I'll post up the outcome later on.

..... and it's YOU'RE ....

Holy crap .... I am no fun, aren't I ????

[Trapper John]

Originally Posted by Sdiver

Yes, I'll post up the outcome later on.

..... and it's YOU'RE ....

Holy crap .... I am no fun, aren't I ????

[Patriot007]

Agree with Lithium toxicity #1. Also have to rule out salicylate toxicity as well.

History and physical sound more tox but need to consider posterior stroke as well as aortic/carotid dissection.

[UWOA (RIP)]

Me ... I was thinking viral infection ....

[Sdiver]

Here's some answers to your questions ..... In BOLD below.

Originally Posted by Brush Okie

Does she have a stiff neck? ... NEGATIVE

What is her blood glucose level? .... BGL 108

Pedal Edema? ... NONE NOTED

I would look at the heart. ST elevation changes, low O2 sat, dizziness (arrhythmia intermittent) Does she also has some CHF ?(rales) .... SHE DOES HAVE DIFFUSE RALES BILATERALLY ..... REMEMBER, SHE DOES HAVE A CARDIAC HX WITH 1 STENT PLACED

[PedOncoDoc]

Originally Posted by Brush Okie

Paraciditas? (infected heart sac for the laymen out there reading this)

I believe the term you are looking for is pericarditis.



When I heard this case the first thing that stuck out to me was the tinnitus which is a classic sign of lithium toxicity.

I would be worried about intentional ingestion/overdose in this patient as a cause for her constellation of signs/symptoms and would need to query about suicidality.

[PedOncoDoc]

Originally Posted by Brush Okie

Yes, my spelling sucks. Thanks.

Come to think of it ASA OD possible?

Would the lithium cause ST changes? If I remember correctly a stint does NOT but I could be wrong. I Google lith OD but did not see tinnitus. I know ASA OD can cause tinnitus as well as SOB. I treated one that had ASA OD but blood levels were high end normal. Turns out that over time ASA can build up at the cellular level but have normal blood levels. The guy was respiratory alkalosis and metabolic acidosis if I remember correctly. This was late 80's early 90's so my memory may be off.

One can OD on almost anything - including water (see polydypsia causing hyponatremia). Aspirin OD is associated with metabolic acidosis and can also cause tinnitus and pulmonary edema (which I believe contributes to the leading cause of death with aspirin poisoning/overdose).

Regarding tinnitus from lithium - this is very well reported - your google-fu must be a bit weak on this one - try searching "lithium toxicity tinnitus" and I'm sure you will get lots of hits from reputable sources that you can select from.