Go Back   Professional Soldiers ® > TMC 14 > Medical Pearls Of Wisdom

Reply
 
Thread Tools Display Modes
Old 05-07-2013, 00:52   #1
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Medical scenario

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.
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!

Last edited by Sdiver; 05-07-2013 at 00:58.
Sdiver is offline   Reply With Quote
Old 05-07-2013, 13:46   #2
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
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.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 05-07-2013, 14:44   #3
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by DocIllinois View Post
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.
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 05-07-2013, 15:35   #4
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Quote:
Originally Posted by DocIllinois View Post
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.
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 05-07-2013, 16:12   #5
doctom54
Quiet Professional
 
doctom54's Avatar
 
Join Date: Feb 2009
Location: Northwest AR
Posts: 489
PE

Pulmonary embolism is in the DDX
__________________
"For exercise I recommend vigorous walking... and carrying a gun. The gun’s weight will increase the level of exercise and the possession of a gun on a walk produces real confidence."
Thomas Jefferson
doctom54 is offline   Reply With Quote
Old 05-07-2013, 17:21   #6
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by Sdiver View Post
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?
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 05-07-2013, 17:25   #7
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by doctom54 View Post
Pulmonary embolism is in the DDX
Didn't report any thoracic petechiae on physical exam
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 05-07-2013, 17:39   #8
Sacamuelas
JAWBREAKER
 
Sacamuelas's Avatar
 
Join Date: Jan 2004
Location: Gulf coast
Posts: 1,905
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.


Last edited by Sacamuelas; 05-07-2013 at 17:42.
Sacamuelas is offline   Reply With Quote
Old 05-07-2013, 17:48   #9
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Quote:
Originally Posted by Trapper John View Post
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 ????
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 05-07-2013, 17:58   #10
Trapper John
Quiet Professional
 
Trapper John's Avatar
 
Join Date: Nov 2012
Location: Harrisburg, PA
Posts: 3,834
Quote:
Originally Posted by Sdiver View Post
Yes, I'll post up the outcome later on.

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

Holy crap .... I am no fun, aren't I ????
__________________
Honor Above All Else
Trapper John is offline   Reply With Quote
Old 05-08-2013, 00:08   #11
Patriot007
Guerrilla
 
Join Date: Nov 2006
Location: Free Pennsylvania
Posts: 138
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.
Patriot007 is offline   Reply With Quote
Old 05-08-2013, 10:50   #12
UWOA (RIP)
Quiet Professional
 
UWOA (RIP)'s Avatar
 
Join Date: Jan 2013
Location: You can't get here from there; you have to go someplace else first.
Posts: 967
Me ... I was thinking viral infection ....
__________________
No one knows whether you're a genius or an idiot until you open your mouth and remove all doubt.

Don't know where I'm goin', but there's no use in bein' late.
I've never been lost. I've been a mite confused at times, but never lost.
I'm not lost! I know where I am; I just don't know where everybody else is.
UWOA (RIP) is offline   Reply With Quote
Old 05-08-2013, 11:12   #13
Sdiver
Area Commander
 
Sdiver's Avatar
 
Join Date: Feb 2004
Location: The Black Hills of SD
Posts: 5,917
Here's some answers to your questions ..... In BOLD below.

Quote:
Originally Posted by Brush Okie View Post
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
__________________
Non Sibi Sed Suis
_____________________________________________
It's Good To Be Da King !!!! Just ask NDD !!!!
Sdiver is offline   Reply With Quote
Old 05-08-2013, 14:31   #14
PedOncoDoc
Area Commander
 
PedOncoDoc's Avatar
 
Join Date: Oct 2009
Location: Northeast Utah
Posts: 1,712
Quote:
Originally Posted by Brush Okie View Post
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.
__________________
‎"The dignity of man is not shattered in a single blow, but slowly softened, bent, and eventually neutered. Men are seldom forced to act, but are constantly restrained from acting. Such power does not destroy outright, but prevents genuine existence. It does not tyrannize immediately, but it dampens, weakens, and ultimately suffocates, until the entire population is reduced to nothing better than a flock of timid, uninspired animals, of which the government is shepherd." - Alexis de Tocqueville
PedOncoDoc is offline   Reply With Quote
Old 05-08-2013, 19:04   #15
PedOncoDoc
Area Commander
 
PedOncoDoc's Avatar
 
Join Date: Oct 2009
Location: Northeast Utah
Posts: 1,712
Quote:
Originally Posted by Brush Okie View Post
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.
__________________
‎"The dignity of man is not shattered in a single blow, but slowly softened, bent, and eventually neutered. Men are seldom forced to act, but are constantly restrained from acting. Such power does not destroy outright, but prevents genuine existence. It does not tyrannize immediately, but it dampens, weakens, and ultimately suffocates, until the entire population is reduced to nothing better than a flock of timid, uninspired animals, of which the government is shepherd." - Alexis de Tocqueville
PedOncoDoc is offline   Reply With Quote
Reply


Currently Active Users Viewing This Thread: 1 (0 members and 1 guests)
 
Thread Tools
Display Modes

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is Off
HTML code is Off

Forum Jump



All times are GMT -6. The time now is 16:37.



Copyright 2004-2022 by Professional Soldiers ®
Site Designed, Maintained, & Hosted by Hilliker Technologies