skyblu Posted October 14, 2011 Share Posted October 14, 2011 I had a case in the ED yesterday that still has me baffled. A 67 year old male presents with left posterior ribcage pain, over the area of the inferior scapular margin. He is a very poor historian, but he states he had a mechanical fall "a few days ago" and he sustained a distal fibular fracture. He thinks he may have also struck his back during that fall, but his pain began yesterday. It is constant, worse with inspiration, and worsening today. He denies new fall or other trauma. He has no fever, no chest pain or tightness, some nausea but no vomiting, no dizziness. He denies alcohol use and has been sober for 8 years. Denies any other substance. States he has been very sweaty and drinking about 1/2 gallon of water today. No other PMH. Meds include ibuprofen (in fact, he took 6 Advil PM last night) and Lisinopril. On exam, he looks way sicker than a fractured rib, which was his original thought. He is pale, diaphoretic, tachycardic and tachypneic, breathing shallow, and has very significant tenderness diffusely on the left thoracic back. No point tenderness. No CVA tenderness. Abdomen is soft and non tender, neuro exam non focal. With his recent ankle fracture and his poor historic details, I sent him straight to the scanner for a CTA of the chest, as I was worried about PE. I didn't get a D-Dimer, he just looked sick. And yes, I realize that the back tenderness doesn't fit with PE. CT shows no sign of PE. No rib fractures or PTX. Labs, however, are freaking me out. This guy has a normal CBC, but in his CMP, he has a bicarb of 11! Somewhat hypochloremic as well, and an anion gap of 32. Alcohol level is 0. Propylene glycol and methanol also negative. His kidney function is perfect. His glucose is actually slightly low, 57. ASA and lactic acid also normal. WHY does this guy have an AG metabolic acidosis? My attending, the hospitalist and I are scratching our heads. We went over MUD PILES differential, and nothing fits. It isn't an ingestion (methanol, ethanol, prop glycol, or ASA), it isn't uremia, it isn't DKA. He's got no white count, so I don't think it's an infection. No iron or Isoniazid. It's not lactic acidosis. What am I missing here? Link to comment Share on other sites More sharing options...
flyingsquirrel Posted October 14, 2011 Share Posted October 14, 2011 Can you post his labs? How about a blood gas? Link to comment Share on other sites More sharing options...
pawag Posted October 14, 2011 Share Posted October 14, 2011 Great case. I just have a few thoughts. The CT was a great idea considering the Sx and Hx. Remember the CP of a PE doesn't have to be anterior. This sounds like a sick guy. I have seen a lot of these elderly pt's that have normal CBC's and no fever but a positive blood/urine cutures. Some other things I think about in this situation are the odd presentation of MI/PE, toxins, and of course the big CA. I would guess a guy who looks this sick is not eating well and this can cause an AG like his ("starvation"). I am sure you kept him and they are giving him a good going over. I don't think you are really missing anything, def on the right track. I agree with post above about seeing all labs. Keep us posted. Thanks. Link to comment Share on other sites More sharing options...
TraumawannabPAs Posted October 14, 2011 Share Posted October 14, 2011 In the name of Zebras' did you consider aldosterone and cortisol? What was the Na, K? Link to comment Share on other sites More sharing options...
NewtonsApple Posted October 14, 2011 Share Posted October 14, 2011 Another zebra/student question, but could significant rhabdomyolysis related to the injury cause this? Link to comment Share on other sites More sharing options...
rcdavis Posted October 15, 2011 Share Posted October 15, 2011 Need all labs, gases, and Osm gap and delta gap, tox screen, and cct and / pelvis if renal fxn can tolerate it preload fluids as just had large dye load w/ CCTa. Then results of pan cultures (early sepsis is good idea). More data is needed. Need urine electrolytes and spec grav Ddx ? Toxidrome, Renal abscess, spenic abscess/ infarction, pleurisy, early pneumonia, myelitis, SBE...valvular heart dz, tb, Is he taking any retrovirals HIV.??, My suspicion however is that he has a occult form of ketosis, ketoacidosis, either alcoholic or not.b-hydroxyketones. The hypoglycemia supports a desire by TGE body to feed the brain in the form of ketones.. What are his ketone levels? Waiting for the gases and labs... Link to comment Share on other sites More sharing options...
Acebecker Posted October 16, 2011 Share Posted October 16, 2011 Definitely need more labs, but is there a possibility this is early Shingles? Andrew Link to comment Share on other sites More sharing options...
Acebecker Posted October 16, 2011 Share Posted October 16, 2011 Definitely need more labs, but is there a possibility this is early Shingles? Andrew Link to comment Share on other sites More sharing options...
deborah212 Posted October 16, 2011 Share Posted October 16, 2011 Did the UA have ketones in it? Though the AG is impressive, I've never seen such a significant acidosis just from starvation ketoacidosis. Figuring out the delta-delta would be helpful. I'm also wondering if some of this presentation is from an anti-cholinergic syndrome. If he took 5 advil PMs, that's equivalent to 190mg of diphenhydramine citrate. Suspecting that this was more than a one time occurrence, could explain why he was so thirsty, tachycardic, tachypneic, and could possibly explain part of his acidosis... though this is only one thing in the differential. Link to comment Share on other sites More sharing options...
deborah212 Posted October 16, 2011 Share Posted October 16, 2011 Did the UA have ketones in it? Though the AG is impressive, I've never seen such a significant acidosis just from starvation ketoacidosis. Figuring out the delta-delta would be helpful. I'm also wondering if some of this presentation is from an anti-cholinergic syndrome. If he took 5 advil PMs, that's equivalent to 190mg of diphenhydramine citrate. Suspecting that this was more than a one time occurrence, could explain why he was so thirsty, tachycardic, tachypneic, and could possibly explain part of his acidosis... though this is only one thing in the differential. Link to comment Share on other sites More sharing options...
RetNavyPAC Posted October 27, 2011 Share Posted October 27, 2011 Also - have the lab run the CMP again. Link to comment Share on other sites More sharing options...
Febrifuge Posted November 20, 2011 Share Posted November 20, 2011 Yo Skyblu, what happened with this one? Any news or updates? Link to comment Share on other sites More sharing options...
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