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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