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Morning Report

Sarah Todd, PGY-3


July 20, 2015

Previously healthy 15 year old


young man found down at home

HPI
-Vomiting for two days
-Abnormal gait, frequent falls
-Loud fall in the bathroom the evening
prior to presentation
-The next morning, he was found on
the floor of a siblings bedroom,
unresponsive but breathing

HPI
-Taken to an OSH ED
-Initial GCS was 3
-Intubated 2/2 impending respiratory
failure

HPI, per family


-Sick for about two weeks prior to
admission
-Poor energy and mood
-Dark urine
-Stumbling
-Not acting like himself

Past Medical/Surgical
History
-Headaches
-Depressed mood
-Occasional nausea
-No prior hospitalizations
-No prior surgeries

History continued
HOME MEDICATIONS: None
ALLERGIES: Allergy to a topical antibiotic, family
cannot recall name
FAMILY HISTORY: Father w/ MI in 40s,
grandparents with Type II DM, siblings healthy
SOCIAL HISTORY: Lives with mom and siblings.
Attends 9th grade. Plays lots of video games.

PHYSICAL EXAM
Vital Signs: Temp 36.4 HR 126 RR 27 BP 121/80 on arrival, then 80/30 normal sats
on vent (low settings, FiO2 0.4)
Weight: 90 kg
GEN: Large teenage boy examined lying in bed, intubated and unresponsive.
HEENT: NCAT. Pupils equal, 3 mm, sluggish. Ears with normal position/rotation. Lips
dry. ETT taped at lip.
CV: Tachycardic for age. RR. No murmur. Central and upper extremity pulses
appropriate, pedal pulses difficult to palpate. Cap refill 5 sec.
LUNGS: Normal RR on vent. Does not over-breathe vent. Lungs clear bilaterally.
Small breaths. No signs of increased WOB.
ABD: Obese abdomen. Soft, non-tender. No obvious masses but exam limited by
body habitus.
EXT: No cyanosis, clubbing or edema.
GU: Did not examine. Foley in place.
NEURO/PSYCH: No response to pain. No spontaneous movements or eye-opening.
Pupils reactive.
SKIN: Diffuse acne and acne scars. Striae on back and abdomen. Bruising on
buttocks and dependent legs.
MSK: No obvious deformities

Previously healthy 15 year old young man found


unresponsive at home, now intubated 2/2 impending
respiratory failure

DIFFERENTIAL?

Differential Diagnosis
CV
Heart failure
Arrthymia
Hypertensive
encephalopath
y
Endocarditis
ID
Meningitis
Encephalitis
Sepsis
Syphilis
Malaria
Cerebral
abscess

RESP
Respiratory
failure
Hypoxia
Hypercapnea
GI
Hepatic
encephalopath
y

ENDO
DKA
HHS
Hypoglycemia
Hypothyroidis
m
Adrenal insuff.
METABOLIC
Electrolytes
abnl
Uremia
Hypothermia
Hyperthermia
Wernickes

Other
Drugs
Alcohol
Toxic ingestion
Carbon
Monoxide
NEURO
Stroke
Hemorrhage
Post-ictal state
Ischemia
Non-convulsive
status
Concussion
Hydrocephalus
Tumor
ADEM

Work-up
CMP: Na 126 K 4.7 Cl 98 HCO3 <5 AG 23 BUN 66 Cr 4.01 Gluc 1909 iCa
10.1 Pro 7.5 Alb 4.1 Bili 0.3 Alk phos 383 ALT 13 AST 20
Serum Osm: 428
CBC: WBC 40.6 HGB 15.6 HCT 52.8 PLAT 558 Bands 15% Neut 71%
Lymph 7% Mono 6% ANC 34.9
ABG: 6.85/24/127/4/-30
UA: gluc >1000, Ketones 1+, Nit neg, hgb small, pro 1+, leuk est neg
WBC 1 RBC 1 Epi 0
Lactate: 3.2
Imaging:
Head CT: normal
ECHO: Normal structure and function
CXR: ETT in midthoracic trachea. Lungs appear clear.

Hyperosmolar Hyperglycemic State


vs. DKA
HHS

SEVERE DKA

Glucose >1000
pH >7.33
HCO3 >18
Urine ketones: absent to small
Serum Osm >320
Anion gap varies
Stuporous/coma

Glucose 350-500
pH < 7
HCO3 >10
Urine ketones: positive
Serum Osm varies
Anion Gap > 12
Drowsy/stuporous

Management Principles
-IV fluid resuscitation
-Insulin
-Electrolyte management
-Close monitoring of mental status
-Close monitoring of serum Osms,
electrolytes and glucose
-Serum Osm = 2(Na) + (BUN/2.8)+
(gluc/18)

Initial resuscitation
-Art line placed
-Started on epi, nor-epi and vasopressin
- > 10 L fluid resuscitation
-Insulin drip
-Hypertonic saline
-Ceftriaxone
-Stress-dosed with hydrocortisone
-Electrolyte replacements
-Blood gluc q 1h, BMP and CBGs q 2h, serum
OSMs and Na q 2h, lactate q 4h

Hospital course
-Prolonged hospital course
-DCFS involved 2/2 concerns about
parental neglect
-Discharged home early this spring