Sponsored Links
Page 1 of 2 12 LastLast
Results 1 to 10 of 12
  1. #1
    Statia Graduate is offline Junior Member 510 points
    Join Date
    Apr 2009
    Location
    Midwest
    Posts
    98
    Downloads
    0
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts

    Hmmm, and another

    Advertisements



    74 year-old white female with COPD, HTN, HLD, DM presents complaining of severe SOB and cough. She has had progressive SOB for 2 days, and a persistent cough with minimal white sputum. She denies any fevers or chills, or sick contacts. She uses 2 liters O2 at home.

    On exam, sshe is alert and oriented, she appears slightly diaphoretic, and in moderate distress. She is breathing through pursed lips.

    Vitals: 158/92, HR: 112, RR: 30, O2: 90% on 100% nonrebreather, Temp 98.1

    (system-specific)
    CV: Tachy, regular, no murmurs, rubs or gallops
    Lungs: Diffuse expiratory wheezes heard in all lung fields, prolonged espiratory phase

    Labs:
    WBC: 8.2
    Hg/HCT: 12.8/39.1
    Plt: 218

    Na: 138
    Cl: 108
    Bicarb: 28
    BUN: 12
    Cr: 0.7

    ABG:
    pH: 7.2, PCO2: 80, PO2 90 Bicarb on ABG: 29

    CXR shows hyperinflation, no evidence for infiltrate

    The patient's baseline PCO2 is 42. What should you do next?
    A. Bipap
    B. Cont nonrebreather, and give nebs
    C. Cont nonrebreather, give nebs and steroids
    D. Intubate
    E. Cont nonrebreather, give nebs, steroids, and treat for community acquired pneumonia
    Last edited by Statia Graduate; 05-09-2009 at 09:49 AM.

  2. #2
    RussianJoo's Avatar
    RussianJoo is offline Ultimate Member
    Join Date
    Jun 2004
    Location
    Out Fishing
    Posts
    6,367
    Downloads
    7
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    Well COPD exacerbation. treatment for COPD is COPD= Cortico steriods, Oxygen, Prophylaxis, dilators (Beta2 agonists)

    she's in respiratory acidosis.

    my question is does she have bandemia i.e. left shift, and what's her pmn count?

    she doesn't have pneumonia but COPD exacerbations are commonly caused by an infection so if she has bandemia or like 98% nuetrophils and only 2% lymphs then i would pick choice E. but since there are no signs of infection i'll go with choice C as my answer.

    Servey says?
    Hollywood Upstairs School of Medicology, Class of 2010
    Due to the high volume of private messages, I can only answer questions that are posted in a forum. Private messages will be ignored.
    Hidden Content

    Hidden Content

  3. #3
    Statia Graduate is offline Junior Member 510 points
    Join Date
    Apr 2009
    Location
    Midwest
    Posts
    98
    Downloads
    0
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    Quote Originally Posted by RussianJoo View Post
    Well COPD exacerbation. treatment for COPD is COPD= Cortico steriods, Oxygen, Prophylaxis, dilators (Beta2 agonists)

    she's in respiratory acidosis.

    my question is does she have bandemia i.e. left shift, and what's her pmn count?

    she doesn't have pneumonia but COPD exacerbations are commonly caused by an infection so if she has bandemia or like 98% nuetrophils and only 2% lymphs then i would pick choice E. but since there are no signs of infection i'll go with choice C as my answer.

    Servey says?
    Correct, she has resp acidosis.

    I agree with your reasoning abou the bandemia. I frequently use that to determine my treatment, regardless of what the CXR shows.

    But, in this case, you need to treat her hypercapnic respiratory failure before you lose her. So, the answer is: A. Bipap

    You would call respiratory therapy for Bipap setup first, and order the usual nebs, steroids, +/- antibiotics.

  4. #4
    Statia Graduate is offline Junior Member 510 points
    Join Date
    Apr 2009
    Location
    Midwest
    Posts
    98
    Downloads
    0
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts

    The case progresses

    Your patient is now on full-face mask Bipap, and was tolerating well. She received nebs, solumedrol, and azithromycin. However, 45 minutes after starting bipap, she becomes drowsy. She is A&Ox1 to self only, and at times difficult to arouse.

    You originally placed her on bipap because you know it will improve her tital volumes and minute ventilation, and therefore improve her oxygenation and decrease her CO2. Repeat ABG shows:
    PH: 7.23
    PCO2: 76
    PO2: 155
    Bicarb on ABG: 28

    So, what to do now?
    A. Cont bipap and increase nebs to every hour
    B: Call for pulmonary consult
    C. Intubate
    D. Recheck CXR for possible pneumothorax
    E. Call Dr. Statia to complain about all these stupid questions

    And finally:
    We know the patient has hypercapnic respiratory failure. So, what do you diagnose her with once she develops mental status changes?
    A. Delirium, but not sure why, need more info
    B. CO2 narcosis
    C. Metabolic encephalopathy
    D. TIA
    E. The old lady is just plain crazy

  5. #5
    RussianJoo's Avatar
    RussianJoo is offline Ultimate Member
    Join Date
    Jun 2004
    Location
    Out Fishing
    Posts
    6,367
    Downloads
    7
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    you dropped her PCO2 which was her drive to breath, now she's not breathing as much and thus drowsy.. so C: intubate is my answer.


    2) hypoxic ischemic encephalopathy. so C is my answer..
    Hollywood Upstairs School of Medicology, Class of 2010
    Due to the high volume of private messages, I can only answer questions that are posted in a forum. Private messages will be ignored.
    Hidden Content

    Hidden Content

  6. #6
    RussianJoo's Avatar
    RussianJoo is offline Ultimate Member
    Join Date
    Jun 2004
    Location
    Out Fishing
    Posts
    6,367
    Downloads
    7
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    hey i have a question for you. i am reading kaplan peds book and in the GI section it specifically says that Crohn's is associated with more extraintestinal manifestations than UC.

    I thought it was the other way around? and I checked my Robbin's pathology book and it says the exact opposite.. that UC is associated with more extraintestinal manifestations. so I know i should trust Robbin's over Kaplan but the Robbin's book is old.. did something change in the last 2 years? or did kaplan just royally screw up?

    isn't UC associated more with HLA-B27 that gives you the Arthritic manifestations?

    which one has more of an autoimmine component?
    Hollywood Upstairs School of Medicology, Class of 2010
    Due to the high volume of private messages, I can only answer questions that are posted in a forum. Private messages will be ignored.
    Hidden Content

    Hidden Content

  7. #7
    Statia Graduate is offline Junior Member 510 points
    Join Date
    Apr 2009
    Location
    Midwest
    Posts
    98
    Downloads
    0
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    Quote Originally Posted by RussianJoo View Post
    you dropped her PCO2 which was her drive to breath, now she's not breathing as much and thus drowsy.. so C: intubate is my answer.


    2) hypoxic ischemic encephalopathy. so C is my answer..
    To intubate (choice C) is the correct answer. Explained more below.

    This patient has CO2 narcosis (choice B). She was at risk for this the moment she walked in the door. Her CO2 did not drop so much as to decrease her respiratory drive. Sometimes patients can handle the CO2, other times they can't. There is no way to predict it. Bipap will eventually correct her CO2 levels, but, her mental status is decreasing. I mentioned full-face bipap for a reason. Bipap not only forces air into the lungs, it can force air into the stomach. A patient with decreasing mental status on full-face bipap is at a HUGE risk for aspiration. Hence, the reason to intubate.

    On the medicine floors and in the ER, we have to decide whether or not to use bipap or intubate. The deciding factor is always mental status.

  8. #8
    Statia Graduate is offline Junior Member 510 points
    Join Date
    Apr 2009
    Location
    Midwest
    Posts
    98
    Downloads
    0
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    Quote Originally Posted by RussianJoo View Post
    hey i have a question for you. i am reading kaplan peds book and in the GI section it specifically says that Crohn's is associated with more extraintestinal manifestations than UC.

    I thought it was the other way around? and I checked my Robbin's pathology book and it says the exact opposite.. that UC is associated with more extraintestinal manifestations. so I know i should trust Robbin's over Kaplan but the Robbin's book is old.. did something change in the last 2 years? or did kaplan just royally screw up?

    isn't UC associated more with HLA-B27 that gives you the Arthritic manifestations?

    which one has more of an autoimmine component?
    From what I've heard, it would not be the first time Kaplan has printed something wrong. As far as I know, nothing about UC vs Crohns has changed in the last 2 years. And Robbin's is sort of the Bible, you know?

    Anyway, yes, UC is associated with extraintestinal manifestations over Crohns. The arguement continues on whether or not it is an autoimmune disease. Regardless, it is still treated like an autoimmune disease. And, yes, it is associated with HLA-B27.

    Crohn's disease is an autoimmune disease. Serum antibodies that are used to eval are anti-neutrophil cytoplasmic antibodies (ANCA) and anti-Saccroharomyces cerevisiae antibiodies (ASCA).

  9. #9
    RussianJoo's Avatar
    RussianJoo is offline Ultimate Member
    Join Date
    Jun 2004
    Location
    Out Fishing
    Posts
    6,367
    Downloads
    7
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    cool thanks a lot.
    Hollywood Upstairs School of Medicology, Class of 2010
    Due to the high volume of private messages, I can only answer questions that are posted in a forum. Private messages will be ignored.
    Hidden Content

    Hidden Content

  10. #10
    RussianJoo's Avatar
    RussianJoo is offline Ultimate Member
    Join Date
    Jun 2004
    Location
    Out Fishing
    Posts
    6,367
    Downloads
    7
    Uploads
    0
    Thanks
    0
    Thanked 0 Times in 0 Posts
    Quote Originally Posted by Statia Graduate View Post
    From what I've heard, it would not be the first time Kaplan has printed something wrong. As far as I know, nothing about UC vs Crohns has changed in the last 2 years. And Robbin's is sort of the Bible, you know?

    Anyway, yes, UC is associated with extraintestinal manifestations over Crohns. The arguement continues on whether or not it is an autoimmune disease. Regardless, it is still treated like an autoimmune disease. And, yes, it is associated with HLA-B27.

    Crohn's disease is an autoimmune disease. Serum antibodies that are used to eval are anti-neutrophil cytoplasmic antibodies (ANCA) and anti-Saccroharomyces cerevisiae antibiodies (ASCA).

    is ANCA and ASCA used to evaluate for UC as well? like isn't ANCA more associated with UC and ASCA more with Crohn's? so if you test for both and once is high and the other is low then you can pretty much say which it is but you still need a bipsy to make the official diagnosis.
    Hollywood Upstairs School of Medicology, Class of 2010
    Due to the high volume of private messages, I can only answer questions that are posted in a forum. Private messages will be ignored.
    Hidden Content

    Hidden Content

Page 1 of 2 12 LastLast

Similar Threads

  1. hmmm
    By rjh58 in forum SGU Veterinary School
    Replies: 3
    Last Post: 01-18-2007, 04:31 AM
  2. hmmm...
    By playarf in forum St. Christophers College of Medicine
    Replies: 144
    Last Post: 03-25-2005, 12:12 PM
  3. hmmm
    By dontyouwonder in forum St. Christophers College of Medicine
    Replies: 6
    Last Post: 01-03-2005, 12:07 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •