MarkH recently gave us a case to play around with. Since this is usually great fun, I thought we could try another one. I’ll start you off with very little information, and I’ll answer any questions you bring up.
I’ll warn you that this one is complex, and shows off the type of intricate problems that internists deal with every day.
A woman in her 60’s came to the ER complaining of weakness and light headedness. This is one of my favorite places to stop. For the non-physicians in the crowd, I’ll give you a head start. Light headedness is often a sign of insufficient blood flow to the brain.
Perhaps this isn’t enough, but let’s start here.
44 thoughts on “Case study—now, with fewer abbreviations!”
Okay, how long has this episode lasted? Has she had this problem before?
I would think a set of vital signs would help. Plus, anything that we would discern visually? (short of breath, sweating, pale, etc.)
A recent victim of vampirism?
OK, reasonable questions (mostly). For a physician, we always start out by taking a history and examining the patient. She’s been feeling lousy for a couple of days, and has never felt this way before.
On visual inspection, she is an obese, elderly female in no acute distress. She does generally appear a bit weak. Her temperature is 37.6 C, respiratory rate is normal, blood pressure is 116/65 (just a bit on the low side), and her heart rate is 30 (normal being 60-90ish).
The only significant finding on exam is a slow heart rate and a slightly dry mouth.
What does the ECG show? Heart block?
ECG, showing the heart’s electrical patterns, shows what is called a narrow-complex bradycardia. What that probably means is that the SA node (the heart’s primary “pacemaker”) is not working properly, and a secondary pacemaker at the AV node has kicked in.
I’d like to savor the history a bit more.
Are the symptoms constant or intermittent?
If intermittent, how frequently are they occurring?
Does anything make the symptoms better or worse?
Does she have any past medical history to report?
Is she on any medications, prescribed or otherwise?
Any herbal, alternative or home remedies?
She only really notices it when she is moving around.
She takes insulin for diabetes, and lisinopril for hypertension.
pulse ox is 98% on room air (normal).
I’ve drawn your electrolytes. Shouldn’t take too long, depending on how the lab is running.
How have her hypertension and diabetes been lately? Has she adjusted her dosing or frequency of either med?
I assume that blood glucose is ok because that is the first thing you would have checked, and that her at home testing is up to snuff.
Recent (few days, same time frame as problem) food intake, urine output, “regularity”, sleep pattern. Disruptive stresses in her life, in her family, friends? At home these past few days? Live alone? Who does meal preparation? (i.e. what level volitional and social activities did she have before this started and what is it now). State of grooming. Is her skin color ok? i.e. is she pale, cyanotic, flushed, jaundiced? Ketones on her breath, alcohol? Who brought her to ER, why. Is there edema.
When you check the electrolytes, check the anion gap (actually lactate is what I want), LDH, SGPT, hematocrit.
Wondering how long on meds since she might not be properly educated on insulin admin or possibly not used to it yet. Also, are those the only 2 meds she’s on since ace inhibitors are often tag teamed with beta-blockers (which would help explain the bradycardia and could mask any hypoglycemia she’s been experiencing)? For her DM, what is her dosing schedule like?
Oops, Anonymous above is from me.
Double oops–the earlier anonymous is from me. Sorry other Anonymous.
Wondering what the cbc,tsh,free t4,bnp and ua results are.
Is she generally weak or does she have focal weakness? Any other neurologic signs? How are her CK and troponin levels? (If she had an MI resulting in a conduction error a few days ago the CK would probably be back to normal but the troponin might still be up. A CK might also show rhabdomyelitis, although this doesn’t sound like the history for it, at least not as a single diagnosis.) I’d press a bit more on the medication issue. Any supplements, herbal meds, or OTC meds that might explain the heart block? The dry mouth sounds like a possible symptom of an unknown medication or possibly part of some rheumatologic syndrome. Just for fun, what does the echo show?
She has noticed her sugars creeping up. She does not vary her insulin intake.
Some labs are coming back. Her cardiac enzymes are not elevated. Her white blood cell count is mildly elevated at 12.0. Her Sodium is 132, potassium 6.9, BUN 73, Cr 2.5 (all were normal last month). Blood glucose is 574. Rest is still pending.
It appears that she has the Diabeetus like myself.
Kidney failure. (K,Bun,Creat all up). With that Potassium, you need to take action fast. What is her bicarb level?
Has anyone done a ward test for urine? I suspect she has sugar and ketones in her urine, indicative of very out of control high blood sugar levels.
A finger prick blood glucose can be taken while waiting for the lab sugar to come back.
I suspect she has severe ketoacidosis (too much sugar in the blood because of the poorly controlled diabetes) and cardiomyopathy (weak floppy overworked heart) maybe due to congestive cardiac failure.
As the blood sugar is corrected her heart will be put further at risk by rapid swings in blood electolytes.
Not an MD, but in layman’s opinion, think di’s on to something – kidney failure due to poorly controlled diabetes. Disrupted EPO production leads to anemia leads to the lightheadedness and general weakness; screwed-up electrolyte balance accounts for the bradycardia.
Give her regular insulin to get the blood sugar back down. The potassium will probably shift back to intracellular area on it’s own. Elevated potassium the reason for the abnormal ekg? Needs fluids to rehydrate. She gets to spend the night in the hospital and the ER doc has handled the crisis and passed the other crap on to the hospitalist.
OK, urinalysis showed moderate leukocyte esterase, 3+ glucose, trace ketones, trace blood.
The patient, btw, has no edema (oedema).
I’ve intentionally passed on describing therapy in favor of diagnosis. You folks are pretty damned good, especially the non-doctors. So here’s the deal.
Symptomatic bradycardia (the patient’s low heart rate that made her dizzy) can have many causes, including medications, intrinsic heart problems, etc. In this case it was an electrolyte imbalance (high potassium). The high K+ was caused by dehydration, kidney failure and high blood glucose levels. The high glucose levels were caused by a urinary tract infection.
The patient received insulin, calcium, and intravenous fluids, and the heart rate corrected quickly. She was sent home on oral antibiotics.
That’s when the next problem occurred.
“That’s when the next problem occurred.”
~Told you she should have spent the night in the hospital. 😉
That’s when the next problem occurred.
And in the next episode…?
Allergic reaction to the antibiotics? Secondary infection? Hypoglycemic coma when she forgets to readjust her insulin after the infection is cured?
Did her BUN/Cr go back to normal after the infection resolved? For that matter, did the infection resolve and did her potassium stay down? Insulin and calcium are fast acting, but not long lasting, ways to correct the potassium. I think Bill’s right: she should have stayed in the hospital overnight.
I guess I should clarify that she did stay in house a few days. Her BUN/Cr returned to normal. Her K+ was fine once she was rehydrated and had her glucose controlled—no need to remove it from her body, just coaxed it back into the cells, as suggested above.
She was discharged home on a fluroquinolone antibiotic.
When she came to see me later in the week, she didn’t have diarrhea thankfully, but she still had white cells in her urine. Her culture was back and it grew out Pseudomonas resistant to FQs.
“It appears that she has the Diabeetus like myself.
Posted by: Wilford Brimley”
LOL. I just saw that. That’s funny.
Thanks PalMD. This is fun. I hope we see more of these.
What does that mean please?
oh, sorry, just reread your last post, flouroquinolone.
So- what are here symptoms now? confusion? collapse?
What are her obs on admission?
No admission for a patient with heart block in the ER did seem a little extreme, even for the US–I should have assumed that the patient was admitted for a few days. Anyway, my concern about the K was that she’d go home, still with a UTI, not take enough insulin, get sugar in her urine, and the whole thing could start again, rather than that the total body K was high. (In an alternate scenario, she could have gone home with an insulin dosage adjusted for infection, forget or not know to decrease it when the infection resolved and get into hypoglycemia…diabetes is an obnoxious illness.) It sounds like she did go home on what turned out to be ineffective abx but fortunately everyone was now more on top of the situation so things didn’t go as far. What were her abx in the hospital? Was she essentially partially treated?
This is fun. Do you have any more cases for us?
My guess would be that Cipro was given initially and, when the C&S came back, it was switched to whatever it showed the bug was sensitive to.
? I thought we were still on the same case, as the lady had re-presented at ED. ? No?
I don’t think she came back to the ED. I understood that she had a followup with her PCP (PalMD) later in the week.
Can this be at least a once per week thing? It is pretty awesome and makes me almost happy about taking step 1 in a little over a month!
This was fun because it was a good virtual recreation of an actual clinical experience, at least from my point of view.
A colleague asks me a question about a patient and I make a couple of ill-considered suggestions off the top of my head. Then I go off shift and don’t think about this patient until I walk into the hospital the next morning. That’s when I think about her and the two most common outcomes: 1) she needed some fluid and a little adjustment of her blood sugar before being sent home, or 2) she’s been admitted to ICU with uncontrolled cardiac arrhythmia and is currently circling the drain.
My only interaction with most patients that pass through the building is with their charts. This was just like work. On my day off. Yay!
It was fun for me, because I spend a great deal of my time playing this game in real life. I have 40+ elderly at my assisted living facility. I escort each one of them to the ED when the need arises. The reason being, I know them better than whoever is at the ED. Many are past being accurate historians. Many have family that are more of a hindrance than a help. I try to provide the information necessary for the physician and other staff to do their jobs effectively.
One of the hardest parts of my job is distinguishing between what does and does not constitute an emergency. Do we call for an ambulance, go to the ED im my car or will this wait until tomorrow and see the PCP? Is this person that is complaining of chest pain going to need medical attention? Is it the hiatal hernia acting up again? Is it a new onset of cardiac problems? That is a big part of my job. After 7 years of doing this, 24/7, I think I am getting pretty good at it, but there are always a few that are difficult. What about the lady that fell on her bottom walking down the sidewalk Saturday afternoon and now has vaginal bleeding? Is this an emergency or should we wait until Monday and call her PCP? (I spent 5 hours with her in our local ED last night waiting on a simple pelvic exam, just to return to our facility with instructions to follow up with a urologist.)
I, however, have the advantage of seeing these people regularly. I also have the distinct advantage of playing armchair quarterback once I get to the ED and basically hand off responsibility. I try to keep my opinions to myself or, when it is so obvious that I can’t do so any longer, I speak to the doctor in private and ask questions.
It was refreshing to get to “shout out” my guesses instead of sitting back and watching others go through what seems like a painfully slow process of sleuthing out the answers.
I hope to see more of these soon.
Interesting to read your perspective and experience. You have a lot of responsibility there.
From a nurses’ pov, a pulse and blood pressure reading on the two ladies you mention would help indicate how urgent their problems are. Is that something you could do?
Just wanted to make an observation about the difference between denialism and genuine science, given that this thread is in a blog about “denialism”.
In this thread, nearly every post consisted of people posting QUESTIONS. Intelligent questions, often quite a few of them in a single post. Significantly, they weren’t rhetorical questions – they were genuine questions seeking information to inform the process of thinking through a problem to its solution.
The contrast between this mode of examining reality and that of denialists and pseudoscientists is striking. Denialists rarely ask questions because their primary interest is trying to make reality fit their own preconceived beliefs, – this is the opposite of science.
Snout: Another difference between science and denialism: the willingness to change hypotheses when the data doesn’t support the old one any longer. For example, I was initially suspicious of some sort of anticholinergic ingestion, possibly without the patient’s awareness. But when the K value came back, I abandoned that idea in favor of potassium induced heart block. Denialists tend to try to make the data fit the hypothesis rather than the other way around…
…and one reason to do cases is to show people how real science/medicine operates. It has a very different “feel” than pseudoscience.
I agree, science does have a very different “feel” than pseudoscience. In my limited experience, P-science seems to be very reactionary. They are always trying to “fight against great opposition”. In the case of science, it’s just too hard to oppress indefinitely because the truth is always there, glaring us in the face.
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