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Case conference
-- Conscious disturbances
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性別: 女
Age: 47 y/o
Date of Admission:94年7月31日
Date of Discharge:94年8月1日
Con’s: AVPU
Vital signs: TPR:37.6/119/16
BP:100/63mmHg
• Triage I
Chief complaints
• Consciousness change at home
Present Ilness
• A case of hepatic adenocarcinoma s/p
TAE diagnosed at 2005.3
• Just discharged from GI ward on
2005.7.20 with initial presentation of
abdominal pain and consciousness
change
• Gradual onset of drowsy consciousness in
recent 2 days
• Fever was noted.
Past history
• Allergy : penicillin
• Hepatic adenocarcinoma s/p TAE
Physical Examination
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Con’s: slow response E4V6M5
HEENT: grossly normal
Lung: clear BS
Heart: RHB
Abd: soft and flat, tenderness(+), mild
distention
• Ext: freely movable, jaundice(-)
• Neurological: EOM:full pupil:3+/3+
• What you else?
• What is your differential diagnosis?
D/D of Altered Level of Conscious
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A ( Alcohol , abuse)
E ( Electrolyte, encephalopathy)
I ( Infection)
O ( Overdose ingestion)
U (Uremia)
T ( Trauma)
D/D of ALOC
• I ( Insuline, intussuception, inborn error of
metabolism)
• P (Psychogenic)
• S (Shock, stroke, seizure)
• What will you do next?
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O2
IV
Monitor
A
B (Kussmaul , Cheyne-Stokes)
C
D
E
Order(7/31)
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CBC/DC PT/aPTT
Panel I, iCa
GPT T/D bilirubin
Ammonia
N/S run 60cc/hr
B/C xII
ABG
F/S (104mg/dl)
U/A
EKG: NSR
Lab data(7/31)
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WBC:12600 S/L:84/8
BUN/Cr:15/0.7
Na/K:129/4.8
T/D bilirubin: 1.4/0.7
AST/ALT: 87/16
NH3: 111
CRP: 6.7
iCa: 7.48
ABG(R.A)
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pH : 7.428
pCO2: 36mmHg
pO2: 72.3mmHg
HCO3- : 23.9mmol/L
Sat : 94.8%
Diagnosis
• Hypercalcemia, HCC related
• Hepatic adenocarcinoma s/p PEIT
• Hyponatremia
• What will you do next with this
impression?
Order (8/1)
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Fleet enema
Lactulose 30cc tid x2D
Stool OB
排GI住院
轉EC
補P
• What is will you do next with after
seeing the lab data?
Order
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Bonfos 2# po tid and st
NS 500cc st
Zometa 1 vial in N/S 100cc run 30 mins
F/U iCa
Burinex 1 amp iv st and q12h x 1 D
Record Urine output
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Burinex 1 amp 改 iv q6h
F/U iCa at 10 a.m -> iCa:8.13
N/S 改run 200cc/hr
On CVP
F/U CXR
Consult總值for ICU admission
Haldol 1 amp im q4h
Patient AAD
Paraneoplastic syndromes
• Definition: caused by factors produced by
cancer cells that act at a distance from
both the primary cancer site and its
metastasis.
• 3 major classes of hormones are steroids,
monoamines, and peptides/proteins.
Hypercalcemia
• Hypercalcemia with cancer-Humoral
hypercalcemia with malignancy (HHM)
• Caused by local osteolytic hypercalcemia
(LOH)
• PTHrP causes nearly all cases of
malignancy
• Binds to receptors in bone and kidney and
causes increased bone resorption.
• The cancers associated with HHM are
non-small cell lung cancers
• Breast cancers
• Renal cell carcinoma
• Head and neck cancer
• Bladder cancer
• Myeloma
• S/S Hypercalcemia
Initial symptoms (calcium level
≧2.6mmol/L)-anorexia, malaise, fatigue,
confusion, bone pain, polyuria, polydipsia,
weakness, constipation
Neurologic symptoms (calcium level
≧3.5mmol/L)-confusion, lethargy, coma
and death.
Diagnosis
• Normal level of PTH level and a low serum
phosphate level in the absence of bone
metastases support the diagnosis of HHM
• A normal PTHrP level and normal
phosphorus in a pt with bone metastases
suggest LOH.
Treatment
• Moderate hypercalcemia
Pamidronate 90mg iv with Diuretics
2-4 L of normal saline
• Severe hypercalcemia
Calcitonin 4-8 U/kg IM or SC q12h