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Multiple medical concerns to consider… September 28, 2012

Posted by Andy Jagoda, MD in : Hematologic/Allergic/Endocrine Emergencies , trackback

An 88-year-old woman with history of moderate dementia presents via ground ambulance for irritability and increased weakness after having 2 weeks of cough and vomiting at her extended care facility. She was found febrile and confused during morning nursing rounds. Her past medical history is significant for recent cerebrovascular accident with residual left-sided weakness and chronic kidney disease. Current medications include metformin, hydrochlorothiazide, metoprolol, and aspirin. Her vital signs on arriving in the ED are blood pressure 98/63 mm Hg, pulse 95 beats per minute, respiratory rate 24 breaths per minute, oral temperature 38.3C, and oxygen saturation 95% on 2 L nasal cannula. On physical exam, she is frail and appears dehydrated, with intermittent confusion. Her pulmonary exam is remarkable for crackles at the right base with mild diffuse abdominal discomfort. Her chest x-ray shows right middle lobe pneumonia. Blood is obtained, and a serum chemistry panel shows sodium 152 mEq/L, potassium 4.0 mEq/L, chloride 108 mEq/L, bicarbonate 14 mEq/L, BUN 55 mg/dL, creatinine 1.7 mg/dL, and glucose 131 mg/dL. The nurse asks you what IV fluids you want and how fast

What’s your diagnosis? And how do you proceed?

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Comments»

1. liu kui - September 29, 2012

this woman had pneumonia. And she have been coughing and vomiting for 2 weeks. the chemistry showed that bicarbonate was 14 mEq/L. So the diagnosis is Metabolic acidosis. And the irritability and increased weakness was attributed to Metabolic acidosis.

2. doug - October 1, 2012

metformin lactic acidosis ???

3. Dr. JV - October 1, 2012

I will give plain lactated ringer solution 60cc/hr, start antibiotic, get abg, do CT scan to rule out new onset of stroke. My initial impression:
Community acquired pneumonia, high risk with possible concomitant aspiration
Acute renal failure on top of CKD secondary to dehydration
T/c Metabolic encephalopathy
Moderate dementia
Post stroke with residual hemiparesis, r/o new onset of stroke

4. Gabriele Di Giammarco - October 1, 2012

metabolic acidosis due to metformine adverse effect as it is almost contraindicated in chronic renal failure.
therapy: rehidratation by normal saline

5. Ken Kleinsteuber - October 1, 2012

She has a RML pneumonia, is dehydrated on top of chronic renal disease. Would start IVF of NS at 100 ml/hr.She needs SSI, hold Metformin as countraindicated in her renal state. She will need ABx’s, neb treatments, and monitoring closely. would hold HCTZ and ASA and cover with Lovenox.

6. James Flanagan - October 1, 2012

Bolus 0.9 normal saline.

7. geno - October 2, 2012

NS/ Antibiotics (Zosyn + vanco). She is very sick.
Pneumonia(Aspiration) + CVA+ Metabol. Acidosis+ sepsis

8. saifaldeen - October 25, 2012

the patient had hypernatremic dehydration and metformin induced lactic acidosis??? so the the proper managrment:
1, G/w 5% infusion ..and given slowly to avoid cerebral oedema
2. antibiotic against strept. and staph
3.chart for( urine output, pr.bp)

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