Food for Thought

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 Food for Thought

Real life frequently involves complex decisions

The time to make decisions is often short
Sometimes these situations involve a clinical dilemma

We are going to present a case that will stop at various stages of
complex decision-making
The participants will reflect upon these issues and discuss them tomorrow

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 Clinical Case: History

 34 year-old woman

 PMH: Meningitis at 8 months resulting in Mental retardation and Deafness; Obesity; Type
1 DM diagnosed at age 31y – on insulin.

 05/11/2022: Fever, vomiting, abdominal pain in the lower quadrants and dysuria.
 Treated with Co-trimoxazole.

 07/11/2022: evaluated in the ED with the same symptoms.

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 Clinical case: Physical Exam

 General: Drowsy. Dehydrated. Tachypneic.

 Axillary Temp: 38.5ºC; BP: 100/60 mmHg; HR: 115 bpm; Resp: 28 bpm.

 HEENT: No neck stiffness

 Lungs and heart: normal.
 Abdomen: Soft, depressible, but painful on palpation of right iliac quadrant (no pain on
release)

 GU: Urinary catheter: 500mL, pyuria

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 Clinical Case: Lab Values

 Capillary blood glucose > 500 mg/dl Diagnosis:

 Urinary Ketones ++++

 pH: 7.25  Sepsis

 PaO2: 98 mmHg (13 Kpa) Complicated UTI
 PaCO2: 28 mmHg (3.73KPa)
 HCO3-: 13.1 mEq/L
 Ketoacidosis
 Lactate: 2.5 mmol/L
 SaO2: 97%
 FiO2: 21%

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 Clinical Case: Additional Lab Values

 Hb: 13 g/dL Initial treatment(s)?

 Leukocytes: 13.4 x103/μL (91% PMNs)
 Platelets: 244 x103/ μL
 2L Ringer lactate
 Glucose: 849 mg/dL (47.6 mmol/L)
 Urea: 159 mg/dL (8.83 mmol/L)  Insulin IV gtt
 Creatinine: 3.5 mg/dL (301µmol/L)  Meropenem
 Na+: 130 mEq/L; K+: 6.7 mEq/L

 TGO (AST): 18 U/L; TGP (ALT): 23 U/L 4hrs later…

 Total bilirubin: 1.3 mg/dL (144 µmol/L)
 Direct Bilirubin: 0.9 mg/dL (80 µmol/L)

 CRP: 12.4 mg/dL (124 mg/L)

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 Clinical Case: Follow-Up

 More awake. Renal US

 Temp 37ºC; BP 122/70 mmHg;
 atrophic left kidney.
HR 110 bpm
 Enlarged right kidney with
emphysematous pyelonephritis,
 Diuresis 50 ml/h, pyuria
without associated urinary
obstruction
 Blood glucose 292 mg/dL (16.2
mmol/L)
CT scan:
 ABG: pH: 7.33; PaO2: 98 mmHg
(13 Kpa); PaCO2: 30 mmHg (4
KPa); HCO3-: 15.4 mEq/L; SaO2:
97% on room air

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 CT: Emphysematous Pyelonephritis

What to do next?
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