Intern Report Case 1.13

intern-report

Presented by Amy McCroskey, MD

History and Physical

A 4-year-old boy presented to the emergency department with difficulty in breathing for about 3 hours.  The mother provided the history, because the patient was unable to answer questions, due to his difficulty in breathing.  She stated that for the past 5 days he had a nonproductive cough, sneezing, and nasal drainage, without a fever.  Also, he had been vomiting for the last 3 days about 3 to 4 times a day, no blood or bile present.  He had diarrhea and was urinating more frequently.  She did not know the quantity or color of his bowel movements or urine.  He had diffuse abdominal pain.  Mom noticed a decrease in his appetite and he had not been able to tolerate any food for the past day, but he was tolerating fluids.  She thought that he was loosing weight, and that he appeared to be more thirsty than normal.  She said that his symptoms have progressively worsened, and today she noticed he was having difficulty breathing.  She did not give him any medications, and denied any possible ingestion.  She denied that the boy had ever had a similar illness, and she denied any sick contacts.

Past Medical History: ED visit 2 months prior foreign body removed from nose
Past Surgical History: None
Medications: none
Allergies: none
Social history: up-to-date immunizations, stays at home with mother and does not attend day care
Family History: Uncle- diabetes on dialysis, mother hypertension

Physical Exam
VS: BP 104/62 HR 120 RR 38 Temperature 37.0  Oxygen Sat 100% on room air, weight 14.1 kg (weight 2 months prior 18 kg)
General: Patient was alert, not speaking, but looking at people when they talked to him, and he would respond by nodding his head. He appeared to be in mild respiratory distress, and appeared weak while lying on the stretcher.
HEENT: Head: Normocephalic, atraumatic Ears: tympanic membrane clear  Eyes: pupils are equally round and reactive to light, & extraocular eye movements are intact Nose: minimal nasal discharge  Throat: dry mucous membranes, saliva foaming at corners of the mouth, no tonsillar erythema, exudate or enlargement
Neck: supple
Lungs: Clear to auscultation bilaterally.  No wheezing or crackles.  Good air entry bilaterally. Labored, irregular breathing pattern.   Using abdominal, and accessory muscles to breath.
Cardiovascular: Tachycardic, normal S1& S2, no murmurs
Abdomen: Soft, nontender on palpation, mildly distended, bowel sounds present, no guarding or rigidity
Extremities: Able to move all extremities without any difficulty, movements were sluggish.
Skin: No bruising, rashes, or petechiae
Neurologic exam: Not answering questions, decreased response to pain (noticed when IV was inserted), and responded to verbal stimuli with eye opening

Laboratory Results

Capillary blood gas: pH 7.00 / PCO2 19.3 / PO2 64.9 / bicarb 4.5 / K 6.0 / Lactate 3.5
ED blood glucose meter >600
Urinanalysis:

Color: clear, yellow

Epithelial cells <5
Glucose 3+

Leukocyte Esterase Negative
Ketone 3+

WBC <5
pH 5.0

RBC 2-5
Urine Specific Gravity 1.039

Bacteria none
Blood 1+

Nitrite negative
CBC: WBC 36.8 Hemoglobin 16.5 Hematocrit 44.4 platelet count 332
Lytes: Na 137 K 4.9 Cl 100 CO2 <5 BUN 13 Cr 0.8 Ca 9.4 Mg 2.2
Phos. 4.3 Glucose 770
Acetone 2+
Osmolarity 342

ECG

ECG

Questions

1.    What is the most likely diagnosis?
a.    Dehydration secondary to gastroenteritis
b.    Sepsis
c.    Toxic ingestion
d.    Diabetic ketoacidosis
e.    Acute respiratory failure

2.    What is the estimated fluid deficit in this patient, and how should this deficit be managed?
a.    Estimated fluid deficit 2%, give initial bolus of 1 mL/kg of 0.9 NaCl
b.    Estimated fluid deficit 20%, give initial bolus of 10 mL/kg of 0.9 NaCl
c.    Fluid deficit 5-10%  initial 10-20 mL/kg bolus of 0.9 NaCl
d.    Fluid deficit of 10%, give initial bolus of 10-20 mL/kg of lactated ringers
e.    Fluid deficit of 15-20%, give initial bolus of 10 mL/kg of 0.45 NaCl and start and insulin infusion

3.    What treatment can lead to volume overload, accelerated hypokalemia, hypernatremia, and paradoxical CNS acidosis, and associated with a fourfold increase in the development of cerebral edema
a.    insulin
b.    bicarbonate
c.    potassium replacement
d.    0.9 NaCl fluid resuscitation
e.    Phosphate

Please submit your answers to the questions in the “leave a reply” box or click on the “comments” link.  Your submission will not immediately post.  Answers with a case discussion will post on Friday.  If you have any difficulty, please contact the site administrator at arosh@med.wayne.edu. Thank you for participating in Receiving’s: Intern Report.

28 Responses

  1. 1. What is the most likely diagnosis?
    d. Diabetic ketoacidosis

    2. What is the estimated fluid deficit in this patient, and how should this deficit be managed?
    d. Fluid deficit of 10%, give initial bolus of 10-20 mL/kg of lactated ringers

    3. What treatment can lead to volume overload, accelerated hypokalemia, hypernatremia, and paradoxical CNS acidosis, and associated with a fourfold increase in the development of cerebral edema
    d. 0.9 NaCl fluid resuscitation

  2. DBB

  3. 1. A
    2. C
    3. B

  4. Of note, the Osmolar gap is 21 msom/L. Does this mean that you have to evaluate for ethylene glycol or methanol? Where are those extra osms coming from?

    Ketones also elevate the osmolarity. This is one of the reasons that the serum osmolality is a very poor test for characterizing a patient’s acidosis.

  5. 1.D
    2.C
    3.B

  6. 1.) D

    2.) C

    3.) B

  7. 1. c
    2. c
    3. d

  8. 1) D
    2) C
    3) B

  9. 1. D
    2. C
    3. A

  10. 1) D
    2) B
    3) B

  11. d, c, b

  12. d c b

  13. D C A

  14. 1. d
    2. c
    3. b

  15. 1. d
    2. c
    3. b

  16. 1. d
    2. e
    3. a

  17. 1-c
    2-a
    3-b

  18. 1. D
    2. C
    3. A

  19. d,b,b

  20. 1. D
    2. Don’t agree with these answers. You give a 20cc/kg bolus of .9NS, then start insulin and then adjust your fluids accordingly(.45NS, add glucose, K, PO4, etc. as needed) I could be wrong of course……
    3. D

  21. D
    B
    B

  22. 1.) D
    2.) C
    3.) D

  23. 1. D
    2. C
    3. B

  24. 1. D
    2. C
    3. B

  25. Answers!
    1. D DKA
    2. B
    3. B bicarb

  26. d,e,a

  27. 1. d. dka
    2. c. Fluid deficit 5-10% initial 10-20 mL/kg bolus of 0.9 NaCl
    3. b. bicarbonate

  28. 1-d
    2-c
    3-d

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