case discussion

[ismailalamin]

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.

[ismailalamin]

Dd:_
Admission's
Pancrea titis
Cause of hyper glycemia..drug induced
.ca!!!

[ismailalamin]

Dd:_
Admission's
Pancrea titis
Cause of hyper glycemia..drug induced
.ca!!!

very nice i will discuss the case later when return from work , serum lipase was 2896

[ismailalamin]

the scenario is as the following, this pt was cushinoid (drug induced) presented with adrenal insufeciency( explain hyponateremia, hyperkalemia, shock but hyperglycemia was odd thing here) induced by stress which was acute pancreatitis here(explain hyperglycemia, hypocalcemia, abd pain, SIRS), two common causes of pancreatitis can be implicated here (alcoholism, gall stones) and can explain elevated direct bil, gamma GT also drugs could be imblicated, also CMV was suspected here. Also hyperglycemia here can atrributed to prograf (tacrolimus). But not that much hyperglycemia.

[ismailalamin]

to be continued
.

[thuraiaibrahim]

we are waiting...
where are you doctors??..plz come and discuss.
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