case discussion
Posted: 08 Feb 2013, 23:20
this is a real case
50 female not DM or htn, living renal transplant for 3rd time on prograf, cellcept, hostacortin 10, history three years ago of CMV infection for which she recieved gancyclovir base line creat 2.3
presented to other hospital 3days ago with orthostatic hypotention, hyponateremia 109, hyperkalemia 6.3, abdominal pain epigastric. pt was admitted received iv fluids , supportive management done rotiene laps, ecg, cardiac enzymes. cr was 2.6. calcium corrected :6.7 tlc: 9300 staff: 11% neutr: 80% . hb:10 plt: 90000. t. bil: 5 d bil:3.8 gamma gt: 1300 Alp: 190 Ast: 160 alt: 76 abd us : normal renal graft, mild hepatomegally, minimal perihepatic collection.
two days later pt became confused , shocked, rbs: high (was mildely elevated at admision) and presented to our icu, DKA was suggested but Na hco3 was 20 which make it hyperosmular? pt have had cvp: 8 we started iv fluids, iv albumin, started noreepinephrine , iv antibiotics, infusion insulin (up to 25 units per hour?).
on examination pt gcs: 10/15 no signs of lateralization , moon face, strias allover abdominal wall, and thighs , tenderness over epigastrium. slow intestinal sounds, mod ll oedema. wheezy chest. a diagnosis was suspected we ordered an investigation which support our diagnosis.
1. what could causes of hyponateremia, hyperkalemia, hypocalcemia, hyperglycemia , shock and liver abnormalities in this case?
2. what is the unifying diagnosis and what is the differential diagnosis, what to order next to asses for this D.D?
3.what is the management now?
bp: 100/60 on norepinephrine infusion 0.2 mic/ kg/min pulse: 90 reg temb: 36.8 sat o2: 97% on nasal musk fio2: 40%.rr: 32 cvp: 8 oliguric. Rbs: around 500 on insulin infusion 25 units/hour that was 2nd day of admition.
50 female not DM or htn, living renal transplant for 3rd time on prograf, cellcept, hostacortin 10, history three years ago of CMV infection for which she recieved gancyclovir base line creat 2.3
presented to other hospital 3days ago with orthostatic hypotention, hyponateremia 109, hyperkalemia 6.3, abdominal pain epigastric. pt was admitted received iv fluids , supportive management done rotiene laps, ecg, cardiac enzymes. cr was 2.6. calcium corrected :6.7 tlc: 9300 staff: 11% neutr: 80% . hb:10 plt: 90000. t. bil: 5 d bil:3.8 gamma gt: 1300 Alp: 190 Ast: 160 alt: 76 abd us : normal renal graft, mild hepatomegally, minimal perihepatic collection.
two days later pt became confused , shocked, rbs: high (was mildely elevated at admision) and presented to our icu, DKA was suggested but Na hco3 was 20 which make it hyperosmular? pt have had cvp: 8 we started iv fluids, iv albumin, started noreepinephrine , iv antibiotics, infusion insulin (up to 25 units per hour?).
on examination pt gcs: 10/15 no signs of lateralization , moon face, strias allover abdominal wall, and thighs , tenderness over epigastrium. slow intestinal sounds, mod ll oedema. wheezy chest. a diagnosis was suspected we ordered an investigation which support our diagnosis.
1. what could causes of hyponateremia, hyperkalemia, hypocalcemia, hyperglycemia , shock and liver abnormalities in this case?
2. what is the unifying diagnosis and what is the differential diagnosis, what to order next to asses for this D.D?
3.what is the management now?
bp: 100/60 on norepinephrine infusion 0.2 mic/ kg/min pulse: 90 reg temb: 36.8 sat o2: 97% on nasal musk fio2: 40%.rr: 32 cvp: 8 oliguric. Rbs: around 500 on insulin infusion 25 units/hour that was 2nd day of admition.