Whats your

diagnosis, doc?
DR EMMA WEISS
NOVEMBER 2016
Warming up for the
CASE 1
Male, 45 years old

ER:
- fever
- chills
- pain in the lower part of the right thorax

Symptom onset acutely, 2 days ago

Male, 45 years old

Medical history

Diagnosed with multiple sclerosis - 1 month ago

He was admitted treatment: Prednison, 1 mg/kgc 2 weeks

 Fever - 39C

Pulmonary:
Dullness lower part of the right thorax with decreased breath sounds
Crackles

Normal BP
Tachycardia (100/min)
Q1. What would be your next test to establish
the diagnosis?

1. HLG

2. Chest X Ray

3. Inflammation tests

4. Echocardiography

5. EKG
Chest X Ray
Blood tests

Leucocitosis -17500/mmc
ESR - 125mm/h
Fibrinogen - 1210mg/dl

ECG Tachycardia, no other abnormalities

Q2. What is your diagnosis?

1. Right pulmonary tumour

2. Right pneumonia and pleural effusion

3. Pericarditis

4. Acute pulmonary edema

5. COPD
Q3. What is the next step?

1. Chest CT

2. Bronchoscopy

3. Pleural biopsy

4. Sputum culture and antibiogram

Q4. Whats the first line treatment?

1. Imipenem i.v.

2. Rifampicin p.o.

3. Amoxicilin/clavulanic acid + Gentamicin i.v

4. Ampicilin p.o.

5. Linezolid i.v.
TREATAMENT

1. Antibiotic Amoxicilin/clavulanic acid +

Gentamicin

2. Anti inflammatory (NSAIDs)

3. Antithermal

4. Vitamin C

5. Mucolytics
CASE 2
Male, 45 years old

Non-smoker

Heavy alcohol drinker

HTN stage 2

Discharged 2 days previously where he was admitted for

5 days history of distal lower limb DVT - diagnosed Doppler US
treated with heparin and acenocumarol afterwards
Admitted

Right calf pain and swelling after his bus trip to Bucharest

Clinical exam:
BP 130/80 mmHg, HR 85 bpm
SaO2 98% in room air
Pulmonary - normal
Right calf and thigh
Swollen,painfully, Hommans + (sensitivity 10-
54%, specificity 39-89%)
Tenderness and redness of the overlying skin
Normal pulses
 Q5. What is the cause?

1. Venous insufficiency/post-thrombotic syndrome

2. Thigh haematoma / oral anticoagulant overdose

3. Muscle rupture

4. Recurrent deep vein thrombosis - now with proximal involvement

5. Acute lower limb ischemia

6. Lower limb cellulites

7. Gonarthrosis, Bakers cyst - acute inflammation

Q6. What tests do we need?

1. Knee X ray

2. Soft tissue echography

3. Thigh CT scan

4. Venous Doppler US

5. Arterial Doppler US

6. Abdominal US

7. Thigh MRI
Lower limb venous ultrasound

Proximal deep vein thrombosis femural and popliteal involvement

How can we explain this?

Bus trip after the previous hospital discharge sitting position for a long time
Short term anticoagulation? (5 days)
? Guideline recommendation
Anticoagulation not efficient? (but INR 2,34)
Hypercoagulable status thrombophilia genetic or acquired (neoplasia)?
Risk factors for VT/PE ESC Guidelines 2016
OR 10 OR 2-9 OR < 2
Arthroscopic surgery
Blood transfusion
Central iv line
Fracture lower limb Erythropoietin stimulating agents Age
Postpartum
Knee/hip surgery Arterial hypertension
IV Fertilization
Major trauma Diabetes mellitus
Oral Contraceptives
Spinal cord injury Hormone replacement therapy Obesity
Acute heart failure Inflammatory bowel disease Laparoscopy
Autoimmune disease
STEMI < 3 months Pregnancy
Infections (UTI, pneumonia, HIV)
Previous VTE Venous insufiiciency with varicose veins
Congestive HF/Respiratory failure
Paralythic Stroke
Thrombophilia
Superficial VT
Bed rest > 3 days
Prolonged sitting
 Q7. Therapy

1. Heparin 5000 u every 6 h iv

2. Unfractioned Heparin continuous infusion aPTT guided

3. Continue acenocumarol, but with an INR between 3-4

4. Switch acenocumarol with dabigatran

5. Fibrinolysis

6. Add antiplatelet agent (Aspirin/ Clopidogrel)

Treatment and disease course

Heparin 5000 UI bolus, then continuous infusion

Therapeutic aPTT 50-70 s (2-3x UNL)
Duration - 5-7 days;
concomitant administration of oral anticoagulant - min 2 days of therapeutic INR
Then acenocumarol

Course
Swelling remission, pain improvement, normal skin colour
Anticoagulation options
Unfractioned Heparin iv bolus 80UI/kg, then
18UI/kg/h
Low Molecular Weight Heparin
Enoxaparin 1mg/kg every 12h
Dalteparin 100UI/kg every 12h
Nadroparin 86UI/kg every 12h
Fondaparinux 5 mg (<50 kg) every 24h
7.5mg (50-100 kg)
10 mg (>100kg)
Oral therapy acute phase
Rivaroxaban 15mg every 12h, 3 weeks
20mg every 24h
Apixaban 10mg every 12h, 1 week
5mg every 12h
 Disease course

Severe abdominal pain mostly in the left upper quadrant

Tachicardia
Tachipnea
Hypoxemia - SO2 in room air 90%

Cyanosis in the extremities

Changes in lung examination

lower part of the left thorax - dullness on percussion and coarse
crackles at auscultation
What are your differential diagnosis?
Which one is the probable cause?

1. Acute pancreatitis

2. Pulmonary embolism

3. Hospital acquired pneumonia

4. Spleen rupture

5. Sepsis
ECG
Q8. So? What is it?

1. Acute coronary syndrome

2. Pericarditis

3. Pulmonary embolism

4. SVPT

5. Atrial flutter

6. Right bundle branch block

S1Q3T3 + Sinus tachycardia PE
Chest X Ray
 PE
A 22 mm thrombus in left PA and left lobar PA
Pulmonary infarctions and small accumulation of pleural fluid
 Why PE under anticoagulant treatment?

Resistance to anticoagulant treatment (AT III deficit)?

Inefficient anticoagulation (aPTT 31 sec)?

Hypercoagulative state (neoplasia)?

Non-adherance to therapy Frequent disconnection from the syringe

pump?
 What should we do now?

Continue heparin - with an aPTT at the upper therapeutic

limit 70 sec
Acenocumarol after 6 days of heparin
Acenocumarol and heparin together min 2 days of INR >2
Cancer screening (sounds stupid)
Conclusions

Even though rare PE can appear even under anticoagulant

treatment

Abdominal pain can be misleading it can be a basal pulmonary or

disphragmatic pleural disease
Its never too early
CASE 3
M, 24 yrs

student (exam period), sedentary

CV Risk factors:
Overweight
Dyslipidemia
Heavy Smoker

Occasionally alcohol drinker

Coffee
Presents to the ED for

Epigastric pain and dyspnea for 1 week

Apparently he had 1 syncope at home

This morning (4 am) resting pain appears and he comes to the ER

Q10. What do you think?

1. Anxiety

2. Dyspepsia/ulcer

3. STEMI

4. NSTEMI

5. All of the above

Clinical exam

BMI 26 kg/m2 (overweight)

BP 170/90 mmHg, HR 80 bpm

No pulmonary rales

Normal cardiac examination

Paraclinic evaluation
ECG: SR, HR 90 bpm, without ST abnormalities

Normal chest X ray

AST 112 IU/L (3-45 IU/L)

ALT 87 IU/L (5-35 IU/L)

GGT 227 IU/L (<45 IU/L)

ALP 384 IU/L (10-95 IU/L)

The patient leaves the ER without the doctors approval

5 Days later

Syncope 112
Monitor: FV CPR SR
Transported to the hospital admitted to the ICU

ECG normal when admitted

Cardiac US Normal EF, no wall motion abnormalities

Next morning: 7:30 am
Epigastric painagain
Q11. What do you see on the ECG?

1. STEMI

2. Subendocardial ischemia

3. Sinus bradicardia

4. Hiperkalemia
10 min later
The patient becomes cyanotic, with dyspnea and sweating
Thenon the monitor

Spontaneous conversion to supraventricular

tachycardia and then SR
Q12. Whats your diagnosis?

1. STEMI

2. Sick sinus syndrome

3. Vasospastic angina

4. Stable angina
Coronary angiography

No atherosclerotic lesions

Vasospasm Right coronary artery remission when NTG is injected

 Diagnostic

Prinzmetal Angina / Vasospastic Angina

Cuteness gone bad
CASE 4
True story!

F, 88 years
Family calls 112 for loss of counciousness
Patient brought to ER
GCS 3, bradypnea 10resp/min
OTI + MV (IOT + VM)
Q13. What would you do next?

1. Cerebral CT
2. Chest X-ray
3. Clinical examination
4. Chest CT
5. Blood tests (HLG, liver and renal tests, inflammation etc)
Were gonna scan anyway, dont you
wanna chest CT?
General

Unconscious, afebrile, dehydrated

asthenic, BMI~ 15-20kg/cm2

Lungs
OTI&MV (IOT+VM), SaO2
diminished breath sounds, predominantly right hemithorax 85%
absent breath sounds MV 1/4 lower right hemithorax
inotropic support+
BP 80/40mmHg
Cardiac
HR 150/min arrhythmic
arrhythmic heart sounds, no murmurs, no stasis AFib

When intubated no
Abdomen
secretions
Unremarkable, apparently not tender, no signs of peritoneal irritation,
liver prehepatic 16 cm, consistency hard, edge sharp and regular
Q14. What would you do next?

1. History taking ask the family

2. Abdominal CT
3. Pacient is in a severe state admit in ICU preferably cardiology
(hemodynamic instability)
4. Cerebral CT
 The family tells us

Previous conditions Past 48h

Stroke 15 years ago 3 episodes of loss of counsciousness lasting for ~ 10-
15 mins
Difficulty walking & maintaining ortostatism
HTN controlled with
perindopril and indapamid No fever/chills, no chest pain, no pain
No cough

Liver cysts diagnosed on

routine echo 8 years ago Actuallyno complaints lately

Diagnosticsheep-related liver cystshaha

Q15. Whats your suspicion?

1. Repetead TIAs, eventualy stroke neurologic coma

2. Bronchopneumonia acute respiratory failure, imminent
respiratory arrest (before ventilation support)
3. Hepathic encephalopathy
4. Acute aortic dissection
Q16. Whats the next test you call for?

1. Liver MRI
2. Chest Xray & abdominal US, blood tests
3. Cerebral CT, preferably full body CT
Lab Tests

Hb 10.9 g/dl Abdominal US

Leucocytes 40.000 x 10^3 /m^3
Hepatic cysts with hypoechoic
(85% neutrophilia)
content and one hyperechoic
mass segment VII, possibly
AST 128
central necrosis
ALT 140
GGT 113 Large
pleural effusion right
hemithorax
Serum Creatinine 2.75 mg/dl
How do we explain this?
Lets discuss it till we receive the
chest Xray from radiology
Chest Xray

Why the arrows, what do you see?

Q17. What next?

1. We have our Dx, admit to ICU

2. Cerebral, lung and abdomen CT
3. Cerebral CT
4. Lung CT
5. Thoracentesis

Dr. Chase
Dr. House
We could do a full body scan.
We hate full body scans.
Dr. Foreman We also hate it when patients die before we

figure out what's wrong with them.
Dr. House ...Do the scan...
Full body
CT scan
 Q18. What do you think fits best?

1. Hydatid cysts, fistulization of liver abscess, massive right pleural empyema

2. Necrotizing liver tumor, right pleural effusion secondary to acutely
decompensated HF
3. Hydatid cysts, bronchopneumonia
4. Essential cysts, pulmonary embolism with secondary pleural effusion
Can we help?

1. Respiratory support
2. Inotropic support
3. Rehydration
4. Large spectrum AB
5. Thoracenthesis 3L pyogenic liquid
Septic shock - death

SIRS criteria (2 of)

Temperature <36C or >38C Source of infection
Heart rate >90/min Pyogenic hydatid cyst
Respiratory rate >20/min or pCO2 < 32mmHg
WBC <4000/mm3 or >12000/mm3,
or >10% immature bands

Hepatic and lung hydatidosis

Pyogenic hydatid cyst fistulization to the pleura Hemodynamic instability
Massive right pleural empyema
Grab your phone and get
QxCalculate to work for you
Unde dai si unde crapa
CASE 5
The expected
F, 65 years
2 months previously biological prosthetic aortic valve & ascending aortic prostethis for
severe aortic regurgitation and ascending aorta aneurysm
Permanent Atrial Fibrillation
Hyperthyroidism & hormone therapy

Fever, rest dyspnea, cough with purulent sputum

Lab tests
Inflammation, INR 11
Chest X ray: bronchopneumonia

ICU Large spectrum AB

Q18. 48h later seizures & right motor
deficit
1. Stroke
2. Seizures secondary to fever
3. Intracerebral Hemorrhage
4. Cerebral septic embolization
48h later seizures
Cerebral septic/neoplastic embolization

Full body scan

Bilateral bronchopneumonic condensation
Bilateral pleural effusion
No tumors or metastasis
Therapy
1. Antibiotic
2. Antifungal
3. Antithermal
4. Anticonvulsant
5. Fresh frozen plasma

Meanwhile:
Tumor markers
TOE (transesophageal cardiac US) vegetations? Any sign of
endocarditis?

All negative TSH 0.(0)1

Check-up CT scan 2w later

Clinical status significantly better, no fever, no seizures, SaO2 in ra 96%, normal breath
sounds, no murmurs
BP 140/86 mmHg, HR 90/min (AF)

Brain MRI added no other significant information

Why no biopsy?

1. Fear high surgical risk

2. Patient refusal
3. Hypertiroidism contraindicates surgery
3 months later

Cerebral angiography no aneurysms

 Significant cognitive decline
9 months later MMSE 16/30 = moderate dementia
No motor deficits, few seizures

Cerebral MRI numerous bilateral cortical microbleeds

CEREBRAL AMYLOID ANGIOPATHY

Ce e un studiu dublu orb?
Doi cardiologi intr-o burta
CASE 6
The case

F, 65 yrs, HTN, newly diagnosed DM 1 month previous

Home therapy Perindopril 5mg, Metformin 850mg x 2/day (well controlled
glycemia)
Moderate alcohol consumption

Diffuse severe continuous non-colicative abdominal pain (10/10)

Onset 2 months, same intensity
No fever, no changes in bowel movements, no nausea/vomiting
No dysuria, a bit dark colored urine
Many hospital visits, usual pain killers no results
Clinical exam

BP 170/90 mmHg, HR 95 bpm regular, SaO2 98%, BMI 30 kg/m2, afebrile

Warm, perspirated skin
Lung and CV exam no significant findings
Abdomen is diffusely tender spontaneously and pain does not change
on palpation
No signs of peritoneal irritation, no palpable masses
Giordano absent
Testing
ECG: SR, HR 90 bpm, no ST changes

Normal Chest X ray & abdominal US

HLG normal
Glycaemia 70 mg/dl
AST & ALT normal
Creatinine 0.96 mg/dL
(eGFR 62 ml/min/1.73m2)

Urine test
+ leucocytes, + erythrocytes
Suspicion?

1. Acute pyelonephritis
2. Acute porphyria
3. Diabetic neuropathy
4. Mesenteric ischemia
Pain management

Algifen (metamizol + pitofenona), Perfalgan (paracetamol 1g pev)

no improvement
NSAIDs (ketoprofen) no improvement
Neodolpasse (diclofenac + orphenadrine) temporary improvement
Other tests

Re-check abdominal US OK

Urine culture: Klebsiella spp. Urinary tract infection (cystitis?

Symptomatic? Arguments for pyelonephritis?) specific AB
Q19. In the absence of efficient
pain management
1. Colonoscopy, endoscopy, abdominal CT
2. Lumbar MRI
3. EMG (diabetic neuropathy)
4. Varicella zoster virus IgM
Results

Abdominal CT: no tumors, no adenopathy, no peritoneal fluid, no

signs of mesenteric ischemia
Colonoscopy: normal
endoscopy: chronic gastritis
Q20. Diagnosis?

1. Irritable bowel syndrome

2. Porphyria
3. Nevrosis
4. Celiac disease
Final Diagnostic
Severe, constant pain, with only slight and temporary decrease in intensity
(orphenadrine) despite usual antalgic therapy
In the absence of an obvious organic cause functional pain?

Uro- & coproporphyrins urine/24h 2245 g/24h (15-50 g/24h normal)

Late onset porphyria

Associated
with (secondary to) decreased carbohydrate intake and
hypoglycemic episodes after initiation of DM therapy (HbA1c 6.9%)
Prolonged fasting
Hypoglucidic diets
Perioperatively

Glycemia

ALAS

Hem
Q21. Quiz

1. Development of DM may decrease frequency and severity of

porphyria attacks
2. The association of DM + porphyria increases the risk to develop
HCC
3. In the case of a diabetic patient th administration of iv glucose in a
porphyria attack is contraindicated
Q22. Which of the following can not
precipitate porphyria?
1. Hormone therapy
2. Infections
3. High carbohydrate intake
4. Drugs
You might find it obvious
CASE 7
Triple poison cant be good

F, 68 years, AFib, CHD MI 2 BMS (2009), HTN, COPD

Metoprolol 100mg/day, Ramipril 10mg/day, Indapamid 1.5mg/day, Acenocumarol
non-compliant to medical thrapy, no INR testing
Smoker 40PY, alcohol consumption 20g/day
Colecistectomy (1998)

Diffuse, intense abdominal pain, waking her up in the middle of the night
Accompanied by nausea, vomiting and inability to maintain ortostatic
posture
2 watery stools, dark brown
 Clinical exam

Altered clinical state, t 37.4C, BMI 19 kg/m2

BP 100/60 mmHg, HR 120 bpm, arrhythmic, SaO2 93% in ra, RR 22 rpm
No lung rales; no heart murmurs, no stasis
Slightly distended abdomen, mild tympanism, tender upon palpation of upper abdomen
and periumbilical area
No masses, no signs of peritoneal irritation
Normal stool aspect on rectal exam
Lab tests

ECG: AFib, HR 120 bpm, LVH with secondary ST changes

Chest Xray cardiomegaly

Plain abdominal Xray: no hydroaeric phenomena

Abdomen US
Intestine wall with stasis, free peritoneal fluid ~ 8mm

Mild inflammation (leucocytosis 10500/mm3, ESR 40mm/h)

INR 1.37
Hb 12.5 g/dL
Lipase, AST, ALT, Creatinine, Urea normal
What do you think?

1. Gastric ulcer - perforation

2. Acute pancreatitis
3. Upper GI tract bleeding
4. Ulcerative colitis
5. Mesenteric ischemia

Not in her case, but what is this?

Q23. To confirm diagnosis

1. Endoscopy
2. Colonoscopy
3. Chest & abdomen CT
4. AngioCT
AngioCT results

Thrombus in the upper mesenteric artery

Intestinal pneumatosis
Q24. Treatment

1. Oral anticoagulation is sufficient if the target INR is kept around 2-3

2. Rehydrate, control HR and antibiotics
3. Intra-arterial thrombolysis
4. The patient has multiple CV risk factors and comorbidities. Any
intervention would be highly risky and therefore it is wiser to wait
and see and ensure symptom relief
The old man didnt mind much
CASE 8
Anuric de 3 zile

B, 75 ani, hipertensiv
Aspenter 75mg/zi, Nifedipine 30mg/zi

Durere abdominala constanta (necolicativa)

De 6 saptamani, agravata progresiv
Scadere ponderala ~ 10kg in ultima luna
Afirmativ anurie de 3 zile, anterior polachi- si nicturie
Greata marcata in ultima saptamana cu intoleranta digestiva pentru solide si
lichide
Obiectiv

TA 210/100 mmHg, AV 100 bpm ritmic, SaO2 98% in aa

Pulmonar MV prezent bilateral, fara raluri

Zgomote cardiace ritmice, fara sufluri, jugulare neturgescente

Edeme gambiere importante, moi, pufoase, ce lasa godeu

Abdomen destins, sensibil la palpare in hipogastru si periombilical, moale, mat la percutie

fara semne de iritatie peritoneala

Bradilalic, OTS, fara semne neurologice de focar

Q25. Clinica sugereaza

1. Ascita in tensiune
2. Glob vezical
3. Colica abdominala
4. Pneumoperitoneu
Paraclinic

Ecografie abdomen
glob vezical gigant, prostata marita de volum ce face compresie pe colul urinar

HLG normala

Na 130 mEq/L (136-145 mEq/L)

Cr 21.2 mg/dL (0.6-1.2 mg/dL)

Uree 260 mg/dL
RFGe 3ml/min/1.73m2
Q26. Diagnostic

1. Neoplasm renal
2. Uropatie obstructiva
3. Anevrism de aorta rupt
4. Stenoza de artera renala
In continuare
Examenul CT confirma hipertrofia prostatica, fara adenopatii sau
mase intra-abdominale

Dupa sondare urinara se evacueaza 2200 ml urina hipercroma

Se clampeaza sonda si dupa 1h se evacueaza inca 1700 ml urina hipercroma
Se administreaza pev de rehidratare, cu monitorizarea diurezei
Valorile Cr si uree au revenit la valori normale in urmatoarele zile, cu RFG 55
ml/min/1.73m2. Valorile TA se stabilizeaza ~ 145/90 mmHg
SU intens pozitiv pentru leucocite, nitriti si eritrocite
Concluzii

Insuficienta renala acuta prin obstructie post-renala,

remisa
Hipertrofie de prostata
Hipertensiune arteriala grad III
Boala cronica de rinichi stadiul III
Q27. La externare pacientului i se
interzic urmatoarele medicamente
1. Betablocantele, Tramadolul si plasturii cu nicotina
2. Paracetamol, Aspirina si AINS
3. Antibioticele cu excretie renala
4. Inhibitorii de enzima de conversie
Fara saren bucate
CASE 9
La admisie in UPU

89 ani, alterarea starii generale din cursul diminetii

Somnolenta, greu responsiva
CGS 3 la domiciliu

La UPU
DTS, greu cooperanta, raspunde la stimuli verbali
SaO2 88% in aa, corectata la 96% sub O2/masca
TA 126/76 mmHg, AV 76/min (FiA pe monitor, ritm electrostimulare)
Anamneza familiei & documente
medicale
In urma cu 1 luna
internare FiA cu AV rapida, debut incert
Angina de repaus
Dispnee de repaus
In urma cu 2 saptamani
Sincope repetate
Pauze sinusale, TV nesustinuta
Implantare cardiostimulator VVI
Externata in urma cu 5 zile, nedeplasabila
Paraclinic

Hb 13 g/dl
Leu 18.000/mm3
Neu 73%

Na 114 mmol/L
(135-145 mmol/L)

pH 7.49
pO2 57 mmHg
pCO2 46 mmHg
HCO3 30 mmol/L
Q28. ECG?

1. Tahicardie supraventriculara cu frecvente ESV, HVS

2. Ritm sinusal cu ESV
3. Fibrilatie atriala, ritm electrostimulat, bataie de fuziune, complexe de baza
4. NSTEMI
Anamneza familiei & documente
medicale
In urma cu 1 luna
internare FiA cu AV rapida, debut incert
Angina de repaus
Dispnee de repaus
In urma cu 2 saptamani
Sincope repetate
Pauze sinusale, TV nesustinuta
Implantare cardiostimulator VVI
Externata in urma cu 5 zile, nedeplasabila
Examen clinic Right Left

Constienta, cooperanta, greu responsiva

Echimoze 2-3 cm periombilical
Echimoza hemitorace drept anterior 7 cm
Plaga suturata recenta, aspect curat fara
complicatii, 3 cm hemitorace stang

MV absent hemitorace drept Abdomen

foarte rare raluri crepitante hemitorace stang bazal

Fara sufluri, fara semne de staza

Fara semne neurologice de focar

Q29. De ce are echimoze & plagi?
1. Coagulare intravasculara diseminata
2. Tratament cu Heparina cu Greutate Moleculara Mica, implantare cardiostimulator
3. Supradozaj anticoagulante orale
4. Semn Cullen + (hemoperitoneu)

Q30. What else do you need for your Dx?

1. Rx pulmonar
2. CT craniu
3. CT torace
4. Nimic momentan, am explicatie pentru starea pacientei
Q31. What to do? What to do?

1. Furosemid iv administrare continua pentru ameliorarea stazei pulmonare

2. Fibrinoliza pentru TEP bazal stang
3. Drenaj pleural aspirativ
4. Antibioterapie cu spectru larg pneumonie stanga nosocomiala
Pneumotorax post-implantare?
<1% complicatiile implantarii de pace-maker
Se obisnuieste Rx control dupa implantare
Teoretic, nu este necesar in cazurile necomplicate
Diagnostic final

Insuficienta respiratorie acuta

Pneumotorax masiv drept
Encefalopatie hiponatremica
Boala binodala cardiostimulare permanenta VVI
Fibrilatie atriala permanenta
Who me? Id never!
CASE 10
B, 62 ani

Locuieste singur, fumator, neaga consum alcool

Adus de vecin (!) pentru dispnee
Diabetic controlat prin dieta (?)

Examen clinic
Stare generala Mizerie fiziologica
Afebril
Pulmonar FR 35/min, SaO2 78% in aa corectata la 93% sub admisie O2
MV abolit hemitorace stang
MV diminuat hemitorace drept
Raluri crepitante si ronflante inferioara bilateral
TA 140/80 mmHg AV 100/min
EAB arterial
pH 7.2
pO2 45 mmHg Glicemie 152 mg/dl
pCO2 65 mmHg
HCO3 8 mmol/L
BE -4 mmol/L
Q32. Diagnostic?

1. Insuficienta respiratorie acuta cu alcaloza metabolica

compensata respirator
2. Insuficienta respiratorie acuta cu acidoza mixta
3. Acidoza metabolica compensata respirator (tahipnee
compensatorie)
4. Cetoacidoza diabetica
Pe sectie

Evolutie buna in primele 24h sub tratament antibiotic cu

spectru larg (levofloxacina + cefoperazona)

Ulterior devine agitat, refuza repausul la pat

EAB arterial
In 48h gasit in coma CGS 5, status mental alterat pH 7.06
IOT+VM pO2 50 mmHg
pCO2 50 mmHg
Transferat in STI
HCO3 4 mmol/L
Glicemie 250 mg/dl
Gaura anionica 18 mEq/L
Q33. Ce se intampla?
1. Coma diabetica
2. Acidoza metabolica severa cu gaura anionica mare
3. Insuficienta respiratorie acuta hipercapnica cu acidoza
respiratorie severa
Thank you!