Case conference -- Conscious disturbances

1
Case conference-- Conscious disturbances
2

• ?? ?
• Age 47 y/o
• Date of Admission94?7?31?
• Date of Discharge94?8?1?
• Cons AVPU
• Vital signs TPR37.6/119/16 BP100/63mmHg
• Triage I

3
Chief complaints

• Consciousness change at home

4
Present Ilness

• A case of hepatic adenocarcinoma s/p TAE
  diagnosed at 2005.3
• Just discharged from GI ward on 2005.7.20 with
  initial presentation of abdominal pain and
  consciousness change
• Gradual onset of drowsy consciousness in recent 2
  days
• Fever was noted.

5
Past history

• Allergy penicillin
• Hepatic adenocarcinoma s/p TAE

6
Physical Examination

• Cons slow response E4V6M5
• HEENT grossly normal
• Lung clear BS
• Heart RHB
• Abd soft and flat, tenderness(), mild
  distention
• Ext freely movable, jaundice(-)
• Neurological EOMfull pupil3/3

7

• What you else?
• What is your differential diagnosis?

8
D/D of Altered Level of Conscious

• A ( Alcohol , abuse)
• E ( Electrolyte, encephalopathy)
• I ( Infection)
• O ( Overdose ingestion)
• U (Uremia)
• T ( Trauma)

9
D/D of ALOC

• I ( Insuline, intussuception, inborn error of
  metabolism)
• P (Psychogenic)
• S (Shock, stroke, seizure)

10

• What will you do next?

11

• O2
• IV
• Monitor
• A
• B (Kussmaul , Cheyne-Stokes)
• C
• D
• E

12
Order(7/31)

• CBC/DC PT/aPTT
• Panel I, iCa
• GPT T/D bilirubin
• Ammonia
• N/S run 60cc/hr
• B/C xII
• ABG
• F/S (104mg/dl)
• U/A
• EKG NSR

13
Lab data(7/31)

• WBC12600 S/L84/8
• BUN/Cr15/0.7
• Na/K129/4.8
• T/D bilirubin 1.4/0.7
• AST/ALT 87/16
• NH3 111
• CRP 6.7
• iCa 7.48

14
ABG(R.A)

• pH 7.428
• pCO2 36mmHg
• pO2 72.3mmHg
• HCO3- 23.9mmol/L
• Sat 94.8

15
(No Transcript)
16
Diagnosis

• Hypercalcemia, HCC related
• Hepatic adenocarcinoma s/p PEIT
• Hyponatremia

17

• What will you do next with this impression?

18
Order (8/1)

• Fleet enema
• Lactulose 30cc tid x2D
• Stool OB
• ?GI??
• ?EC
• ? P

19

• What is will you do next with after seeing the
  lab data?

20
Order

• Bonfos 2 po tid and st
• NS 500cc st
• Zometa 1 vial in N/S 100cc run 30 mins
• F/U iCa
• Burinex 1 amp iv st and q12h x 1 D
• Record Urine output

21

• Burinex 1 amp ? iv q6h
• F/U iCa at 10 a.m -gt iCa8.13
• N/S ?run 200cc/hr
• On CVP
• F/U CXR
• Consult??for ICU admission
• Haldol 1 amp im q4h
• Patient AAD

22
Paraneoplastic syndromes

• Definition caused by factors produced by cancer
  cells that act at a distance from both the
  primary cancer site and its metastasis.
• 3 major classes of hormones are steroids,
  monoamines, and peptides/proteins.

23
Hypercalcemia

• Hypercalcemia with cancer-Humoral hypercalcemia
  with malignancy (HHM)
• Caused by local osteolytic hypercalcemia (LOH)
• PTHrP causes nearly all cases of malignancy
• Binds to receptors in bone and kidney and causes
  increased bone resorption.

24

• The cancers associated with HHM are non-small
  cell lung cancers
• Breast cancers
• Renal cell carcinoma
• Head and neck cancer
• Bladder cancer
• Myeloma

25

• S/S Hypercalcemia
• Initial symptoms (calcium level
  ?2.6mmol/L)-anorexia, malaise, fatigue,
  confusion, bone pain, polyuria, polydipsia,
  weakness, constipation
• Neurologic symptoms (calcium level
  ?3.5mmol/L)-confusion, lethargy, coma and death.

26
Diagnosis

• Normal level of PTH level and a low serum
  phosphate level in the absence of bone metastases
  support the diagnosis of HHM
• A normal PTHrP level and normal phosphorus in a
  pt with bone metastases suggest LOH.

27
Treatment

• Moderate hypercalcemia
• Pamidronate 90mg iv with Diuretics
• 2-4 L of normal saline
• Severe hypercalcemia
• Calcitonin 4-8 U/kg IM or SC q12h

28
Thanks for your attention!