{"id":2764,"date":"2021-06-09T06:56:37","date_gmt":"2021-06-09T06:56:37","guid":{"rendered":"https:\/\/www.kauveryhospital.com\/ima-newsletters\/?p=2764"},"modified":"2025-04-11T04:05:15","modified_gmt":"2025-04-11T04:05:15","slug":"diagnostic-dilemma-of-a-complex-case","status":"publish","type":"post","link":"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-june-2021\/diagnostic-dilemma-of-a-complex-case\/","title":{"rendered":"Diagnostic dilemma of a complex case"},"content":{"rendered":"

[vc_row][vc_column][vc_column_text]<\/p>\n

A common encounter in ER<\/strong><\/h2>\n

Case presentation:<\/strong><\/h2>\n

A 75-year old lady came with c\/o shortness of breath NYHA grade IV sudden onset since 12hrs, associated with reduced urine output since 1 day.<\/p>\n

C\/o generalized fatigue and tiredness since 3 days<\/p>\n

No H\/o fever, vomiting, loose stools, nausea, abdominal pain, cough, chest pain, palpitation,\u00a0 sweating, and altered sensorium<\/p>\n


\nPast medical history:<\/strong><\/h3>\n

The patient is known to have diabetes, hypertension, CAD with normal LV function with chronic AF, hypothyroid and dyslipidemia, severe PAH and OSA – on intermittent domiciliary CPAP.<\/p>\n

On examination:<\/strong><\/h3>\n

The patient was conscious, oriented, afebrile, dehydrated ++
\nHR – 150 \/ min
\nBP – 130\/90 mmHg
\nRR – 30 \/ min
\nTemp – 98.4 F
\nGCS – 15\/15
\nCBG – HIGH
\nSPO2- 91 % RA
\nBilateral pitting pedal edema ++
\nJVP – mildly elevated<\/p>\n

Systemic examination:<\/strong><\/h3>\n

CVS : S1S2 + No murmur
\nJVP – elevated
\nRS : B\/L AE + B\/L basal crepts
\nP\/A – Soft, BS + non tenderness , no organomegaly
\nCNS – Slightly drowsy but easily arousable (GCS – E3-4, V5, M6) NFND, moving all 4 limbs<\/p>\n


\nBedside investigations done:<\/strong><\/h3>\n

\"\"<\/strong><\/p>\n

ECG:<\/strong><\/h3>\n

Initial ECG:<\/p>\n

\"\"<\/p>\n

Is this ventricular tachy arrhtyhmia or SVT with aberrancy?<\/p>\n

But subsequent ECG within 2 mins:<\/strong><\/h3>\n

\"\"<\/em><\/p>\n

Showed:<\/strong><\/h3>\n

\u2022 Non sinus rhythm – irregular rhythm
\n\u2022 Left axis deviation
\n\u2022 Rate – 150 bpm
\n\u2022 Wide qrs complex
\n\u2022 Tall t wave noted
\n\u2022 St depression lead 1 , avl
\n\u2022 Sine wave pattern – in 2nd ecg<\/p>\n

Probably features of severe hyperkalemia in background of chronic atrial fibrllation with fast ventricular rate<\/p>\n


\nProvisional diagnosis:<\/strong><\/h3>\n

\u2022 Hyperglycemic state – Diabetic keto acidosis vs hhs
\n\u2022 Severe hyperkalemia – seocndary to aki
\n\u2022 Chronic atrial fibrillation with fast ventricular rate – Sepsis-induced
\n\u2022 Severe sepsis – focus – Urosepsis
\n\u2022 Acute kidney injury – Pre renal – secondary to dehydration
\n\u2022 Dyselectrolytemia<\/p>\n


\nFurther investigations revealed the following:<\/strong><\/h3>\n

\u2022 CBC – Leucocytosis with neurtrophilic predominance (TC – 23100, N84.5%, L6%),
\n\u2022 Mild anemia (Hb : 9.3),
\n\u2022 Platelets – 2.21lakhs
\n\u2022 CRP – elevated (305.13)
\n\u2022 Urea: 114.9
\n\u2022 Creatinine: 3.19<\/p>\n

Urine routine:<\/strong><\/h3>\n

\u2022 Protein ++
\n\u2022 Blood +++
\n\u2022 Glucose ++
\n\u2022 Pus cells – plenty
\n\u2022 Epithelial cells : 8to 10
\n\u2022 RBCs- plenty
\n\u2022 Urine ketone : negative
\n\u2022 Nitrite – negative<\/p>\n

Echo done:<\/strong><\/h3>\n

\u2022 Normal lv function, ef – 60%
\n\u2022 Dilated ra\/rv
\n\u2022 Severe pah
\n\u2022 ? Features of cor pulmonale<\/p>\n

CT chest and abdomen:<\/strong><\/h3>\n

\u2022 Features of cardiomegaly with CORADS 3
\n\u2022 Features of left-side perinephric fat stranding – probable left pyelonephritis<\/p>\n

CT abdomen images showing left-sided perinephric fat stranding – left pyelonephritis<\/strong><\/p>\n

\"\"<\/h2>\n

Discussion:<\/strong><\/h2>\n

Treatment challenges we faced in ER – diagnostic dilemmas encountered worth discussion:<\/strong><\/p>\n

1) What to treat first? – hyperkalemia? hyperglycemia? AF with fast ventricular rate
\n2) Do we give fluid boluses to this patient considering patient was in fluid overload status?
\n3) Concomitant sepsis treatment<\/p>\n

A) As patient had severe hyperkalemia of 7.2 meq with sine wave pattern, which is precursor for ventricular arrhythmias like vf\/vt, which can be life-threatening, we chose to treat the hyperkalemia first.<\/p>\n

Treatment given:
\n<\/strong>
\n1) Injected calcium gluconate 30 ml iv stat –> repeat dose of 20 ml calcium gluconate after 20 min
\n2) Injected insulin 12 units iv stat, dextrose deferred as cbg more than 700 mg\/dl
\n3) Asthalin nebulizer 10 mg stat given<\/p>\n

ECG changes seen in hyperkalemia include:<\/strong><\/p>\n

\u2022 Peaked T waves
\n\u2022 P wave widening \/ flattening
\n\u2022 PR prolongation
\n\u2022 QRS widening with bizarre QRS morphology
\n\u2022 Conduction blocks (bundle branch block,fascicular blocks)
\n\u2022 Bradyarrhythmias :: sinus bradycardia, high grade AV block with slow junctional and ventricular escape rhythms , slow AF<\/p>\n

B) Secondly, we started treatment for hyperglycemia:<\/p>\n

Insulin infusion @ 8 units\/hour as per dka protocol, with hourly cbg monitoring<\/p>\n

Diagnostic criteria for DKA<\/strong><\/p>\n

\u2022 Sr. glucose – >250
\n\u2022 Arterial PH – < 7.3
\n\u2022 HCO3 – <15
\n\u2022 Urine ketone – ++
\n\u2022 Sr.ketones – +++
\n\u2022 Anion gap – > 10
\n\u2022 Develops over hours to days
\n\u2022 Most common in type 1 diabetes mellitus
\n\u2022 Mental status – Alert \/ drowsy \/ stupor \/ coma
\n\u2022 Sr.osmolarity – variable<\/p>\n

Diagnostic criteria for HHS<\/strong><\/p>\n

\u2022 Sr. glucose – > 600
\n\u2022 Arterial PH – >7.30
\n\u2022 HCO3 – >15mmol \/l
\n\u2022 Urine ketone – negative
\n\u2022 Sr.ketones – Negative
\n\u2022 Anion gap – <12mmol\/l
\n\u2022 Develops over hours to weeks
\n\u2022 Most common in type 2 Diabetes mellitus
\n\u2022 Mental status – Alert \/ drowsy \/ stupor \/ coma
\n\u2022 Sr.osmolarity – > 320mmol\/kg<\/p>\n

In our patient:<\/strong><\/p>\n

\u2022 Urine ketone was negative, thereby ruling out dka
\n\u2022 Considering she had altered mentation with sugars more than 700, serum osmolality was calculated, which was found to be 285 mmol\/l , thereby ruling out hhs
\n\u2022 Hence, we continue treatment for hyperglycemia as per sliding scale for insulin infusion<\/p>\n

C) After initial hyperkalemia correction -hr settled from 160 to 140 bpm. Now a diagnosis of atrial fibrillation with fast ventricular rate was more obvious as it was unmasked by the decerase in heart rate. As patient was constantly still slightly drowsy and had borderline bp of 90\/60 mmhg, chemical cardioversion with inj amiadarone 300 mg inufusion over 1 hour was given slow iv. Heart rate after initial iv bolus of amiadarone was reduced further to 110-120 bpm. Hence, the patient was continued on inj amiadarone infusion @ 900 mg over 24hrs.
\n
\nECG features of atrial fibrillation:<\/strong><\/p>\n

\u2022 Irregularly irregular rhythm
\n\u2022 No p waves
\n\u2022 Absence of an isoelectric baseline
\n\u2022 Variable ventricular rate
\n\u2022 Qrs complexes usually < 120ms unless pre-existing bundle branch block , accessory pathway , or rate-related aberrant conduction
\n\u2022 Fibrillation waves may be present and can be either fine (amplitude < 0.5mm) or coarse (amplitude > 0.5mm)
\n\u2022 Fibrillatory waves may mimic p waves leading to misdiagnosis<\/p>\n

D) Finally the patient was dehydrated, but fluid overload, iv fluids as per dka protocoal was initiated, and ivf – ns 500 ml iv boolus was given. Considering ivc was collapsing and the patient had normal lv function with ef of 60%, but also keeping in mind the underlying cardiac abnormality, deranged kidney functions, and fluid overload status, guarded ivf ns 250 ml bolus was given followed by 100 ml\/hr.<\/p>\n

E) As all of the above was triggered by an underlying sepsis with source being left pyelonephritis – iv antibitoics was initiated with inj magnex forte 3 gm iv stat followed by 1.5 gm iv bd.
\n
\nOld diagnostic criteria for sepsis : systemic inflammatory response syndrome (sirs):<\/strong><\/p>\n

\u2022 Temp – < 36\u2019c or > 38 \u2018c
\n\u2022 Rr – > 20\/min
\n\u2022 Hr – >90
\n\u2022 Wcc – <4000 or >11000<\/p>\n

New diagnostic criteria for sepsis: quick sequential organ failure assessment score (qsofa):<\/strong><\/p>\n

\u2022 Systolic bp < 100mmhg
\n\u2022 Rr – > 22\/min
\n\u2022 Altered mental status
\n\u2022 Lactate – >2 mmol<\/p>\n

Goal in sepsis:<\/strong><\/p>\n

\u2022 Iv antibiotics within first hour
\n\u2022 Fluid resuscitation
\n\u2022 Mean arterial pressure > 65mmhg
\n\u2022 Urine output > 0.5ml\/kg\/h
\n\u2022 Treatment for the underlying sepsis, hyperkalemia, hyperglycemia, and atrial fibrilaation was initiated simulateneously within 1st hour of presentation, and the patient was treated subsequently under cardiology team and after obtaining diabetologist\u2019s and nephrologist\u2019s opnion. She was discharged with normal hemodynamics after 48 hrs.
\n\u2022 Thereby, I would like to end by saying though this is a very common challenge we face in the emergency department every day, diagnosing a patient along with concomitant initiation of complex treatments is a skill we need to develop as what we do here directly in the emergency department is seen to directly impact the patient\u2019s outcome.<\/p>\n

References:<\/strong><\/h3>\n

\u2022 Tintinalli\u2019s Emergency Medicine \u2013 9th Edition
\n\u2022 RCEM guidelines<\/p>\n

 <\/p>\n

\"\"Dr. Noor Akbar<\/strong>
\nMRCEM Resident \u2013 Dept. of Emergency Medicine
\nKauvery Hospital, Chennai[\/vc_column_text][\/vc_column][\/vc_row]<\/p>\n","protected":false},"excerpt":{"rendered":"

[vc_row][vc_column][vc_column_text] A common encounter in ER Case presentation: A 75-year old lady came with c\/o shortness of breath NYHA grade IV sudden onset since 12hrs, associated with reduced urine output<\/p>\n","protected":false},"author":2,"featured_media":2765,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[30],"tags":[],"class_list":["post-2764","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-ima-journal-june-2021"],"yoast_head":"\nDiagnostic dilemma of a complex case<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.kauveryhospital.com\/ima-journal\/ima-journal-june-2021\/diagnostic-dilemma-of-a-complex-case\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta 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