an obscure acidosis…

The Case.

64 year old male attends your ED with a complaint for 3 months of progressive weakness, however over the past 7 days he has had multiples falls secondary to his ‘legs just completely giving way’.  You note on the hospital records that he has a history of alcoholism (150-250 grams per day). After a long & drawn out discussion (think, blood from a stone) in an attempt to elaborate his history, you gain the knowledge that …

  1. he has had some chronic worsening, low back pain
  2. he has not eaten a proper meal for over a week (and no alcohol in that time either)
  3. he has lost a ‘decent amount of weight’, but cannot objectify it any further.

He has no known past medical history & takes no regular medications.

He looks crook. Pale, diaphoretic and clammy. Tachycardic (@120/min) and hypertensive (165/110 mmHg). He is afebrile however. No murmurs, chest clear. Tender hepatomegaly. No midline back pain. Normal power, sensation and reflexes to both legs (with good peripheral pulses).

Here is his venous blood gas and accompanying chemistry….

VBG01

What are your thoughts ?
Differential diagnoses ??
What are you going to do next ???

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headache for all…

The Case.

A 28 year old female presents to your ED at 2am. She left the hospital 12 hours earlier with her newborn first child who is now 2 and half days old. Her main complaint is that of profound lethargy, fatigue, severe worsening bifrontal headache and breathlessness.

She is normally fit and well, takes no regular medications & has no significant past medical history. Her pregnancy was uneventful, but her delivery (at 39 weeks) was slightly hair-raising with foetal distress & decelerations due to an obstructive labour (requiring a ventouse).

She looks lethargic and is laying quietly in bed, but is speaking in full sentences. Her observations are within normal limits, but her BP catches your eye at 154/89. Her cardiorespiratory exam is unremarkable (specifically, her chest is clear, there are no murmurs & I cannot see a JVP). Her belly is soft with a palpable uterus, midway between  umbilicus & pubic symphysis. She has no peripheral oedema. Her GCS is 15 with reactive pupils and normal cranial nerves. She has impressively brisk reflexes (you don’t need your tendon hammer) and her power/tone/sensation appear symmetrical & normal.

Her bloods are completely normal! (FBC, LFTs, PLTs, even the CRP) !!

Now what ??

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a poison puzzler…

23 year old female is bought to ED by her family after an intentional overdose of ~ 100 ‘diet tablets’ which she ingested 1.5-2 hours earlier.

She is agitated, anxious, tremulous and profoundly diaphoretic.
P 170. BP 123/70. Sats 100%. RR 32. Temp 36.8*C.
Patent airway. Chest clear. Soft, non-tender abdomen.
Pupils 4mm (equal & reactive).
Normal tone & power in all 4 limbs.
5-6 beats of inducible clonus at the ankles.

BSL 13.1
ECG. Sinus tachycardia @ 170/min (confirmed by increasing paper-speed to 50mm/sec).
VBG.

 

What do you think she took ?

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iatrogenic acceleration…

The Case.

A 46 year old restrained passenger in a high-speed MVA rolls into the resus bay. She is intubated & sedated [easily ventilated & oxygenated, no evidence of chest trauma], persistently tachycardic @ 160/min with a systolic BP of 90mmHg & has a very postive FAST exam….

She spends less than 15 minutes in your ED (extra IV access, blood transfusion continued, limbs splinted) before heading for a trauma laparotomy. She has a liver laceration (repaired) and capsular haematoma, complete bladder rupture (repaired) and splenic haematoma (managed conservatively). Post-op she goes via radiology for a ‘pan-scan’….

Her post-operative ICU stay is a rocky one, marked by ongoing transfusion, coagulopathy and persistent tachycardia (still around 160 beats per minute). Some 6 hours later with her haemoglobin & INR stable, she remained tachycardic at 150-60 (still sinus) & has developed a temperature of 38.6*C.

What are your thoughts ??

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