student case

[JenGintheED]

58yo female checks in to the ED with complaints of severe fatigue and “feeling off” for three days. She started feeling this way after going to a baseball game with three other adults, none of whom are sick.

She has a history of diabetes type 2 and chronic pain. She reports her blood sugar has been at her baseline the last 3 days, around 160. She has not missed any doses of medications.

Pertinent review of systems - 

• No fever, anorexia. Has been able to maintain normal oral intake which includes a few liters of Diet Coke daily.
• No vision changes, but she is feeling sensitive to light.
• Runny nose when outside. No ear pain, nasal congestion, sore throat.
• No cough, shortness of breath.
• No chest pain, palpitations, peripheral edema.
• Constipation. No nausea, vomiting, diarrhea, bloody/dark stools.
• No dysuria. Urinating a lot but she drinks a lot of fluids. 
• Generalized myalgia but no change in chronic pain.
• No rashes
• No headaches, balance changes, speech difficulties. Patient seemed vaguely confused earlier.

VS: 136/67, HR 105, RR 18, 99% on room air, temp 36.1

Patient appears well on exam. Mucus membranes slightly dry. Slightly tachypneic but lungs are clear with excellent aeration throughout. Tachycardia from triage vitals has resolved. Remainder of exam is benign including normal neurological exam.

What is your differential? What would you order?

 

[Cachi]

DDx: Ischemic Heart Disease/CHD vs UTI vs Hypothyroidism vs Hyperglycemia vs Anemia vs Dehydration/Electrolyte imbalance

Order: CBC, CMP, EKG, Troponin, CRP, TSH, free T3 and T4, Urinalysis, HbA1c

Reasoning: 

• CBC: To check for signs of infection or anemia.
• CMP: Assess kidney + liver function and electrolyte levels (suspicious of daily consumption of multiple liters of Diet Coke and frequent urination). 
• EKG/Troponin: Sometimes ischemia/CHD can present with atypical symptoms like fatigue, especially in females (there's no typical chest pain, but I'm not comfortable missing something big).
• Urinalysis: Checking for signs of infection.
• CRP: Rule out infection or inflammatory conditions, also helpful for ruling out potential cardiovascular event.
• TSH/T3/T4: Hypothyroidism could present with vague symptoms like this.
• HbA1c:  Even though pt reports baseline sugar, 160 is still high and I want a better picture.

Edited September 22, 2023 by Cachi
clarity

[JenGintheED]

Good start - anyone else want to chime in? Any imaging requested? Any additional questions for the patient? 

I’ll give it a day and see if anyone else wants to join in. This is a good case so I don’t want to leave anyone out of the fun

CRP is such a nonspecific test that it isn’t used in the ED to assess for acute coronary syndrome. Is there a specific inflammatory condition you are worried about?

We don’t use T3 often in the ED, at least not in this area. We’re looking for the worst-case scenario so TSH alone is typical. We do have a TSH order that triggers an order for a free T4 if the TSH is abnormal.

It’s definitely a good idea to look closer at diabetic complications, even if the patient reports a relatively decent glucose of 160. However, A1c isn’t a typical initial order in the ED. What complications might she have, and how would you assess for them?

[ohiovolffemtp]

From a "former student":

• Urine: UA & UDS - I practice in areas where some recreational substances are legal and even more are common.  Specific gravity and ketones can suggest dehydration.
• Mag: not part of the CMP, but can be off.  Likely will need repletion if K+ low.
• CPK: eval for rhabdo
• EKG & troponin: eval for cardiac issues.

What meds is she on?  Any recent changes?  Do any need levels checked?  Has she added anything, Rx, herbal, or other to address her chronic pain?

Based on the information so far, sounds potentially most likely metabolic.  No immediate indication for imaging.  Probably worth road testing her on a pulse ox to see if she desats.  Would do this before ordering a d dimer.

[JenGintheED]

“former student”

Her home medications are Jardiance and oxycodone, so no direct levels to check. No recent changes and no supplements.

I’ll post labs tonight… 

[SedRate]

Former student here as well

DDx of medication, allergic rhinitis, sinusitis, cold, migraine, dehydration, hormonal (DI, thyroid, etc), UTI, DM, lupus, cardiac

FH? Surg hx? EtOH, drugs, smoking? Sexual partners? LMP/menopause?

Has this ever happened before?

History of DM but no PMH HTN or dyslipidemia? I find that hard to believe... lol

ROS: dizziness? Sinus pain? Change in bowel habits? Mood changes? MSK swelling or joint pain? 

Weight?

Tests: CBC, CMP, Mg, Phos, TSH, EKG, UA, UDS, trop

I didn't initially think cardiac but given h/o DM, tachy, and fatigue, agree with adding trop. 

[ohiovolffemtp]

DDx: add beer potomania

 

[SedRate]

8 hours ago, ohiovolffemtp said:

DDx: add beer potomania

 

At first I thought you were joking and then looked it up. 

[JenGintheED]

On 9/24/2023 at 9:38 AM, SedRate said:

 

FH? Surg hx? EtOH, drugs, smoking? Sexual partners? LMP/menopause?

Has this ever happened before?

No significant FMH. Only surgical history is laparoscopic cholecystectomy, approximately 5 years ago. Social drinker, denies smoking, drugs including medical marijuana. She presented with her husband. Patient is 58 so I presume she is menopausal.

On 9/24/2023 at 9:38 AM, SedRate said:

ROS: dizziness? Sinus pain? Change in bowel habits? Mood changes? MSK swelling or joint pain? 

Weight?

No dizziness. I did not ask about sinus pain but ENT was essentially negative except that she gets a runny nose when she goes outside. No changes in bowel habits. I did not ask about mood changes. No MSK symptoms. BMI was 31 with no recent weight changes.

 

10 hours ago, ohiovolffemtp said:

DDx: add beer potomania

LOL fits with some of your patient population

[JenGintheED]

Here are her initial labs -

CBC: WBC 11.2, hgb 15.5, platelets 401. Bands 7, differential is otherwise wnl.

CMP: sodium 132 potassium 4.1  chloride 107  CO2 5  anion gap 20  glucose 137  

BUN 8, creatinine 1.5. Calcium 9.1   magnesium 2.1   phosphorus 2.1

Total bilirubin 0.3, ALT 12, AST 15, alkaline phosphatase 143

Troponin I: <0.01

UA: specific gravity >1.030  glucose 2+, bilirubin 1+, ketones 3+, blood trace, protein 1+. WBC 0-4. Negative for nitrites, leukocyte esterase, bacteria.

UDS is negative.

TSH is wnl. I did not check CK.

ECG: Normal sinus rhythm, 94 bpm without ectopy.

 

So… what is your differential now? What steps do you want to take next?

[Cachi]

DDx: Diabetic Ketoacidosis vs Hyperosmolar Hyperglycemic State vs Lactic Acidosis vs Acute Kidney Injury vs Bacteremia

Order: Arterial/Venous Blood Gas, Serum Ketones, Serum Osmolality, Lactate, repeat CMP, repeat UA, Blood Culture

Start: IV Normal saline (bolus of 500 mL to 1L over the first hour) and Insulin drip after receiving ABG/VBG if DKA confirmed (monitor K+ closely)

Consider: Consulting endocrinology for DKA management and nephrology for the AKI. But I would wait for now.

Reasoning:

• ABG/VBG: CO2 of 5 and anion gap of 20, I want a clear picture of pt's acid-base status. I want to know pH, pCO2, bicarbonate, and oxygenation.
• Serum Ketones: Ketonuria present, but I want a more accurate assessment to know the degree of ketosis.
• Serum Osmolality: This will help be differentiate between DKA and hyperosmolar hyperglycemic state.
• Lactate: To assess for lactic acidosis, especially given the elevated anion gap.
• CMP: Keeping track of trends with electrolytes, especially K+, which can fluctuate during treatment for DKA and creatinine for kidney injure.
• UA: Monitoring for changes for AKI
• Blood Culture: Given the elevated WBC with bands, rule out bacteremia or another source of infection. DKA is probably causing it though.

[JenGintheED]

VBG: pH 7.11   pCO2 21   pO2 42   HCO3 6.7  base excess -21   O2 sat 74

lactic acid 1.0

This is a smaller community hospital, so serum ketones and osmolarity are inpatient tests. But you calculate the osmolarity… what is it, and how does it affect your differential?

HHS and DKA are good thoughts, but the glucose is 137

 

 

[EMEDPA]

7.11!!

any tox issues/exposures? 

"well yes, I do take 1000 mg of aspirin every 4 hrs around the clock...."

or this:

https://pubmed.ncbi.nlm.nih.gov/33889468/

[JenGintheED]

On 9/27/2023 at 10:58 PM, EMEDPA said:

7.11!!

any tox issues/exposures? 

No known exposures. She denied drug use, OTC meds and supplements. 
 

On 9/27/2023 at 10:58 PM, EMEDPA said:

or this:

https://pubmed.ncbi.nlm.nih.gov/33889468/

Euglycemic DKA was the diagnosis. Patient was started on an insulin drip with D5NS and admitted to the ICU. Her gap quickly closed and the acidosis resolved.

Jardiance is a game changer since DKA can’t be ruled out with a normal glucose. I’ve started to have a low threshold for ordering a VBG in patients who take Jardiance. I’m not sure of the incidence of this diagnosis, but I’ve seen it three times in the last year. All three responded nicely with usual DKA treatment. 
 

[Apollo1]

Interesting case. An atypical presentation from our usual pts for sure.

For the students out there:

- An A1C is almost never ordered for an ED workup b/c it won’t give you more diagnostic info that a CMP+UA+Bhydroxybutyrate wouldn’t.

- Unless a patient is significantly tachy/brady with other clinically significant symptoms, a TSH usually doesn’t change your dispo.

- Many pts don’t know how to give a succinct HPI, and if given the opportunity will give you some form of a “pan-positive ROS.” You need to be careful what questions you ask, b/c you’ll end up in the weeds with a huge workup.

- Someone above wanted a gas lvl to check bicarb. An FYI that CO2 on the CMP is reflective of the pt’s bicarb; you don’t need a gas specifically for this.

- Bandemia on a CBC/Diff is badness regardless of whether you’ve identified a source. If you don’t have a source, still consider an Obs admit. 

- Endocrinology doesn’t exist in the community setting: re: consulting them (and if your pt is in an endocrine crisis they get admitted to PCU if not ICU). Nephro doesn’t need to be consulted for AKI alone, but does for pts with clinically significant hyperK, renal failure etc.

- With the pt in this case, consider redrawing a BMP after adequate resuscitation. If their AGap reduces to whatever level the inpatient side is comfortable with (at my shop Intensivist likes < 20, Hospitalist groups < 18) you can admit to a stepdown unit and avoid ICU.