Clinicopathologic

Conference
Internal Medicine
EVMC Group D1 EVMC Group D2
Abieras Loyola
Bianes Mazo
Marcellones Navales
Peñ aflor Pelicano
Sabalberino Perez-Gamboa
Sebanes Verunque
 
 

UPM-SHS
Dacaya
Ingcog
Inocencio
Yogyog
Objectives:
• To present the case protocol of this clinicopathologic conference
• To formulate a differential diagnosis based on the case
Chief Complaint

•Difficulty of Breathing
 History of Present Illness

Recurrent productive cough

Body weakness
Decreased appetite
Nausea and vomiting
No consult done nor
medications taken
 History of Present Illness

Recurrent productive cough

Body weakness Weakness became
Decreased appetite persistent and
Nausea and vomiting progressive  can no
No consult done nor longer ambulate
medications taken
 Difficulty of breathing
Consult at a tertiary hospital
Decreased sensorium
Desaturation of 64%
Psychosocial History

Smoker
Factory worker

Sick grandmother Alcoholic beverage drinker

Physical Examination
On Admission

Vital signs:
BP: 120/80mmHg
HR: 109 bpm
RR: 23 cpm
Temp: 37.5 ⁰C
O2 Sat: 99% (intubated)

Height: 168 cm
Weight: 50kg
BMI: 17.7 (Underweight)
Physical Examination

Decreased bilateral breath sounds

Neurologic Exam

• Motor of 2/5, left lower and upper extremities

• Weak grip

• DTRs 2+

• No sensory deficits

• CN – not mentioned
Complete Blood Count (Day 1)
Parameter Result Reference range Remarks
Hemoglobin 180 140-170 g/L High
Hematocrit 0.513 0.42–0.52
WBC 29.7 4.8-10.8 x 109/L High
Segmenters 0.89 0.43-0.65 High
Lymphocytes 0.08 0.20-0.45 Low
Monocytes 0.03 0.05-0.12 Low
Platelets 259 150-400 x 109/L

Neutrophil-Lymphocyte Ratio: 11
Blood Chemistry (First Hospital Day)

Parameter Result Reference range Remarks

BUN 18.3 2.9-9.3 mmol/L High
Creatinine 346.8 80-115 umol/L High
Sodium 131.5 135–148 mmol/L Hyponatremia
Potassium 1.03 3.5–5.3 mmol/L
Hypokalemia -
Severe
Chloride 96.3 98-107 mmol/L Hypochloremia
Troponin I 0.13 0-0.6 µg/L
Urinalysis
Parameter Actual Normal value
Color Yellow, slightly cloudy
Specific gravity 1.025 1.016 – 1.022
pH 5.0 4.6 – 8
Glucose Negative Negative
Protein Trace Negative
RBC 0-1 0-5/hpf
WBC 1-2 0-5/hpf
Epithelial cells Few
Arterial Blood Gas
Parameter Result Reference range Remarks
pH 7.010 7.35–7.45 Acidotic
pCO2 49.1 35–48 mm Hg Acidotic
pO2 342.0 83–108 mm Hg High
HCO3 12.1 18-23 mmol/L Low
O2 sat 99.5% 95–98 mmHg

Anion Gap = Na – (HCO3 + Cl)

= 131.5 – (12.1 + 96.3)
= 23.1
Anion Gap: High

Interpretation:
High Anion Gap Metabolic Acidosis with Respiratory Acidosis, Hyperoxemia
Interpretation:
ECG
Sinus rhythm, Normal rate
No axis deviation
No chamber enlargement
No ischemic changes
Presence of U-waves
Chest Xray (PA view)

Upon Admission
• Fed via NGT
• IVF line with KCL side drips
• KCL tab TID
• Omeprazole 40mg/IV OD
• NaHCO3 tab OD
• Piperazillin-Tazobactam
IVTT q6
2nd Day of (+) Febrile Episodes
Admission (+) Dyspnea
(+) Awake, alert, agitated but follows commands
VS:
 BP: 110/70 mmHg (normotensive)
 HR: 130 mmHg (Tachycardic)
 RR: 30s-40s cpm (Tachypneic)
 T: 38.2C (Febrile)
 O2 Sat: 99% (intubated)
(+) Minimal coffee ground secretions per NGT
(-) Secretions per ET

Continuation of Medications with Calcium Gluconate 1 vial via SIVP,

RTC Paracetamol IVTT
Complete Blood Count

Parameter Day 1 Day 2 Reference range

Hemoglobin 180 H 118 L 140-170 g/L
Hematocrit 0.513 0.333 L 0.42–0.52
WBC 29.7 H 10.7 4.8-10.8 x 109/L
Segmenters 0.89 H 0.82 H 0.43-0.65
Lymphocytes 0.08 L 0.13 L 0.20-0.45
Monocytes 0.03 L 0.05 0.05-0.12
Platelets 259 1.71 150-400 x 109/L
Arterial Blood Gas

Parameter Day 1 Day 2 Reference range

7.010
pH 6.995 (Acidotic) 7.35–7.45
(Acidotic)
pCO2 49.1 (Acidotic) 35.3 35–48 mm Hg
pO2 342.0 (High) 137.5 (High) 83–108 mm Hg
HCO3 12.1 (Low) 8.5 (Low) 18-23 mmol/L
O2 sat 99.5% 97.2% 95–98 mmHg
Anion Gap = Na – (HCO3 + Cl)
= 154.7 – (8.5 + 120.5)
= 25.7
Anion Gap: High

Interpretation: High Anion Gap Metabolic Acidosis

Blood Chemistry
Parameter Day 1 Day 2 Reference range
131.5 154.7 (Hypernatremia)
Sodium 135–148 mmol/L
(Hyponatremia)
1.03 (Hypokalemia - 3.67
Potassium 3.5–5.3 mmol/L
Severe)
120.5 (Hyperchloremia)
Chloride 96.3 (Hypochloremia) 98-107 mmol/L
Magnesium 0.93 0.74–1.03 mmol/L
Calcium   1.39 (Hypercalcemia) 1–1.3 mmol/L
 
Phosphorus   0.81–1.49 mmol/L
27 (Hypoalbuminemia)
Albumin   35–50 g/L
TSH      
Troponin I 0.13   0-0.6 µg/L
AST   15-41 U/L
ALT     17-63 U/L
Parameter Day 1 Day 2 Reference range
671.2 H
Creatinine 346.8 H 80-115 umol/L
38.0 H
BUN 18.3 H 2.9-9.3 mmol/L

18 ml/min/1.73  
m2 8 ml/ min/1.73 m2
 
eGFR (Stage IV Severe (Stage V – Kidney
 
loss of kidney Failure)
function)  

BUN:Crea Ratio 1: 18.9 1:17.66  

3rd Day of (+) Febrile Episodes
Admission (+) Dyspnea
(+) Awake, alert, when stimulated but appears lethargic
 BP: 70/40 mmHg (Hypotensive)
 HR: 141bpm (Tachycardic)
 RR: 30s cpm (Tachypneic)
 T: 41.8C (Febrile)
 O2 Sat: 99-100% (intubated)
(+) Minimal coffee ground secretions per NGT
(-) Secretions per ET

CBGs: 94g/dL
ECG: Sinus tachycardia
Leptospirosis IgG, IgM – Negative

Started NE Drip (0.5mkm at 50kg), KCl tab shifted to K Citrate tab q6,
Cont. Omeprazole Drip, Piperacillin Tazobactam IVTT q6h, NAHCO3
Drip and Paracetamol RTC IVTT
Blood Chemistry
Parameter Day 1 Day 2 Day 3 Reference range
131.5 154.7 168.1 (Hypernatremia)
Sodium (Hypernatremia) 135–148 mmol/L
(Hyponatremia)
1.03 (Hypokalemia - 3.67 4.76
Potassium 3.5–5.3 mmol/L
Severe)
96.3 120.5 130.3 (Hyperchloremia)
Chloride (Hyperchloremia) 98-107 mmol/L
(Hypochloremia)
Magnesium 0.93 1.08 0.74–1.03 mmol/L
Calcium   1.39 (Hypercalcemia) 1.42 (Hypercalcemia) 1–1.3 mmol/L
  3.91
Phosphorus   (Hyperphosphatemia) 0.81–1.49 mmol/L
27 25 L
Albumin   (Hypoalbuminemia) 35–50 g/L

TSH     0.047 L  
Troponin I 0.13     0-0.6 µg/L
AST   751 H 15-41 U/L
ALT     179 H 17-63 U/L
 Day 3
Parameter Day 1 Day 2 Reference range
671.2 H 1092 H
Creatinine 346.8 H 80-115 umol/L
38.0 H 47.6 H
BUN 18.3 H 2.9-9.3 mmol/L

18
ml/min/1.73 5 ml/ min/1.73 m2  
m2 8 ml/ min/1.73 m2  
 
eGFR (Stage IV (Stage V CKD by (Stage V CKD by  
CKD by CKD- CKD-EPI creatinine) CKD-EPI
EPI creatinine)  
creatinine)

BUN:Crea
1: 18.9 1:17.66 1:22.94  
Ratio
 Referred to General Surgery:
IJ catheter and CV line insertion
Cardiopulmonary arrest
Expired.
PIVOT: Weakness

Weakness

45 y/o
Male
Factory Worker

SSx:
 Body weakness
 Difficulty moving all extremities
Syndrome of:  Decrease in appetite
Hypokalemia  Nausea and vomiting
 Decreased bilateral breath sounds
 Serum Electrolytes: K+ 1.03 (Dec. Severe)
 Presence of U waves
 Low Plasma HCO3

Castro D, Sharma S. Hypokalemia. [Updated 2021 Jul 20]. In: StatPearls [Internet]. Treasure Island (FL):
StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482465
  Body weakness
 Difficulty moving all extremities
Syndrome of:  Decrease in appetite
Hypokalemia  Nausea and vomiting
 Decreased bilateral breath sounds
 Serum Electrolytes: K+ 1.03 (Dec. Severe)
 Presence of U waves
 Low Plasma HCO3

Diuretic Use?
Chronic Diarrhea? Laxative Use?
Previous colon surgery? Salicylate Use?

No
No

GASTROINTESTINAL LOSSES IATROGENIC

RENAL POTASSIUM LOSS

  Body weakness
 Difficulty moving all extremities
Syndrome of:  Decrease in appetite
Hypokalemia  Nausea and vomiting
 Decreased bilateral breath sounds
 Serum Electrolytes: K+ 1.03 (Dec. Severe)
 Presence of U waves
 Low Plasma HCO3

Diuretic Use?
Chronic Diarrhea? Laxative Use?
Previous colon surgery? Salicylate Use?

No
No

GASTROINTESTINAL LOSSES IATROGENIC

RENAL POTASSIUM LOSS

 RENAL POTASSIUM LOSS

Proximal Renal Tubular Thyrotoxic Conn’s Syndrome/ Cushing’s

Acidosis (Type II) Periodic Paralysis/ Primary Syndrome
Hyperthyroidism Hyperaldosteronism

Risk Factor: Risk Factor: Risk Factor: Risk Factor:

(+) Factory Worker – [inadequate 45 y/o 45 y/o 45 y/o
information – possible Chronic Male Male Male
Heavy Metal Exposure] Asian
Rule In: Rule In:
Rule In: Rule In: (+) Syndrome of Severe (+) Hypercortisolism is
(+) Syndrome of Severe (+) Hypokalemia Hypokalemia correlated with potassium
Hypokalemia (+) Low BMI (+) Muscle weakness depletion  hypokalemia
(+) Muscle weakness (+) Body Weakness (+) N/V
(+) N/V (+) Appetite Changes (+) Respiratory Rule Out:
(+) Respiratory (+) Decrease in TSH Depression (-) Characteristic symptoms
Depression (+) U waves of Cushing Syndrome (Moon
(+) U waves (-) Edema Face, Obesity)
(+) Urine pH of <5.5 (5.0) Rule Out: (+) Patient is underweight
(+) Plasma HCO3 Depletion  (-) Palpable neck mass Rule Out: BMI 17.7
Metabolic Acidosis (-) Dysphagia (-) No HTN (-) No Hypertension
(-) Polydipsia, Polyuria (-) Does not explain HCO3 (-) Does not explain HCO3 Does not explain HCO3
(-) Hypertension Depletion Depletion Depletion
TPP usually presents with
Normal Acid-Base Balance
Rule Out:
Cannot totally rule out Cannot totally rule out
without complete thyroid
panel

Renal Tubular Acidosis: The
Clinical Entity
Juan Rodríguez Soriano
JASN Aug 2002, 13 (8) 2160-
2170; DOI: 10.1097/01.ASN.0000
023430.92674.E5
Proximal Renal Tubular Thyrotoxic
Acidosis (Type II) Periodic Paralysis/
Hyperthyroidism
Risk Factor: Risk Factor:
(+) Factory Worker – [inadequate 45 y/o
information – possible Chronic Male
Heavy Metal Exposure] Asian
Rule In: Rule In:
(+) Syndrome of Severe (+) Hypokalemia
Hypokalemia (+) Low BMI
(+) Muscle weakness (+) Body Weakness
(+) N/V (+) Appetite Changes
(+) Respiratory (+) Decrease in TSH
Depression
(+) U waves
(+) Urine pH of <5.5 (5.0) Rule Out:
(+) Plasma HCO3 Depletion  (-) Palpable neck mass
Metabolic Acidosis (-) Dysphagia
(-) Polydipsia, Polyuria (-) Does not explain HCO3
(-) Hypertension Depletion
TPP usually presents with
Normal Acid-Base Balance
Rule Out:
Cannot totally rule out Cannot totally rule out
 Proximal Renal Tubular Thyrotoxic Conn’s Syndrome/
Acidosis (Type II) Periodic Paralysis/ Primary
Hyperthyroidism Hyperaldosteronism

Risk Factor: Risk Factor: Risk Factor: Risk F

(+) Factory Worker – [inadequate 45 y/o 45 y/o 45 y/o
information – possible Chronic Male Male Male
Heavy Metal Exposure] Asian
Rule In: Rule I
Rule In: Rule In: (+) Syndrome of Severe (+) Hy
(+) Syndrome of Severe (+) Hypokalemia Hypokalemia correla
Hypokalemia (+) Low BMI (+) Muscle weakness deplet
(+) Muscle weakness (+) Body Weakness (+) N/V
(+) N/V (+) Appetite Changes (+) Respiratory Rule O
(+) Respiratory (+) Decrease in TSH Depression (-) Cha
Depression (+) U waves of Cush
(+) U waves (-) Edema Face, O
(+) Urine pH of <5.5 (5.0) Rule Out: (+) Pat
(+) Plasma HCO3 Depletion  (-) Palpable neck mass Rule Out: BMI 17
Metabolic Acidosis (-) Dysphagia (-) No HTN (-) No
(-) Polydipsia, Polyuria (-) Does not explain HCO3 (-) Does not explain HCO3 Does n
(-) Hypertension Depletion Depletion Deplet
TPP usually presents with
Normal Acid-Base Balance
Rule Out:
Cannot totally rule out Cannot totally rule out
Lam L, Nair RJ, Tingle L. Thyrotoxic periodic
without complete thyroid
paralysis. Proc (Bayl Univ Med Cent).
panel
2006;19(2):126-129.
doi:10.1080/08998280.2006.11928143
 Thyrotoxic Conn’s Syndrome/ Cushing’s
Periodic Paralysis/ Primary Syndrome
Hyperthyroidism Hyperaldosteronism

Risk Factor: Risk Factor: Risk Factor:

45 y/o 45 y/o 45 y/o
Male Male Male
Asian
Rule In: Rule In:
Rule In: (+) Syndrome of Severe (+) Hypercortisolism is
(+) Hypokalemia Hypokalemia correlated with potassium
(+) Low BMI (+) Muscle weakness depletion  hypokalemia
(+) Body Weakness (+) N/V
(+) Appetite Changes (+) Respiratory Rule Out:
(+) Decrease in TSH Depression (-) Characteristic symptoms
(+) U waves of Cushing Syndrome (Moon
(-) Edema Face, Obesity)
Rule Out: (+) Patient is underweight
(-) Palpable neck mass Rule Out: BMI 17.7
(-) Dysphagia (-) No HTN (-) No Hypertension
(-) Does not explain HCO3 (-) Does not explain HCO3 Does not explain HCO3
Depletion Depletion Depletion
TPP usually presents with
Normal Acid-Base Balance
Parmar MS, Singh S. Conn Syndrome. [Updated 2021 Sep 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls
Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459197/
 Conn’s Syndrome/ Cushing’s
sis/ Primary Syndrome
sm Hyperaldosteronism

Risk Factor: Risk Factor:

45 y/o 45 y/o
Male Male

Rule In: Rule In:

(+) Syndrome of Severe (+) Hypercortisolism is
Hypokalemia correlated with potassium
(+) Muscle weakness depletion  hypokalemia
(+) N/V
(+) Respiratory Rule Out:
Depression (-) Characteristic symptoms
(+) U waves of Cushing Syndrome (Moon
(-) Edema Face, Obesity)
(+) Patient is underweight
Rule Out: BMI 17.7
(-) No HTN (-) No Hypertension
O3 (-) Does not explain HCO3 Does not explain HCO3
Depletion Depletion
ith
nce
Primary Impression:
• Renal Tubular Acidosis (Type II)
 RTA Type II

K+ Depletion HCO3 Depletion

K+  1.03 (Severe)
Presence of U waves in
Severe Renal Injury
pH: 7.06.995
ECG Hypokalemia HCO3  12.1 8.5
Metabolic Acidosis

Hyperpolarization Uremia
of Cell membranes

(+) Vomiting
Impaired Neural Reduced Neural Reduced (+) Changes in Sensorium
(+) Body Weakness
Conduction to Conduction to Neural (+) Dyspnea/ Respiratory
Muscles Respiratory Conduction to Distress
Muscles ENS (+) Elevated BUN
(+) Elevated Crea

(+) Weakness
(+) Inability to Respiratory GI Paralysis/
Ambulate Depression Ileus

Inability to
Decreased Breath Sounds Protect Airway
Hypoventilation
CO2 Nausea, Vomiting
Dyspnea
Retention Decreased Appetite
Desaturation
Decreased Sensorium Metabolic Acidosis
Mental Status Changes Persisting despite
Respiratory Acidosis
treatment
Increased Risk for Pneumonia
Possible Aspiration Component

(+) Cough
CXR: Infiltrates
Right Middle Lobe
Sepsis

Degradation of Dec. Inc.

Gastric Mucosal Prostaglandin Cortisol Shock
Barrier Synthesis Levels
BP: 70/40 mmHg
HR: 141 bpm
RR: 30s cpm
T: 41.8C

Stress SIRS Criteria 3/4

Gastropathy
Death

Coffee Ground
NGT Secretions
 RTA Type II

HCO3 Depletion

re Renal Injury
pH: 7.06.995
lemia HCO3  12.1 8.5
Metabolic Acidosis

Uremia

(+) Vomiting
ral Reduced (+) Changes in Sensorium
(+) Body Weakness
to Neural (+) Dyspnea/ Respiratory
y Conduction to Distress
ENS (+) Elevated BUN
(+) Elevated Crea
 RTA Type II

K+ Depletion HCO3 Depletion

K+  1.03 (Severe) Severe

Presence of U waves in pH: 7.06.995
ECG Hypokalemia HCO3  12.1 8.5
Metabolic Acidosis

Hyperpolarization
of Cell membranes

(+)
Impaired Neural Reduced Neural Reduced (+)
(+)
Conduction to Conduction to Neural (+)
Muscles Respiratory Conduction to Dist
Muscles ENS (+)
(+)

(+) Weakness
(+) Inability to
 K+ Depletion HCO3 Depletion

K+  1.03 (Severe)
Presence of U waves in
Severe
pH: 7.06.995
ECG Hypokalemia HCO3  12.1 8.5
Metabolic Acidosis

Hyperpolarization
of Cell membranes

(+) Vom
Impaired Neural Reduced Neural Reduced (+) Cha
(+) Bod
Conduction to Conduction to Neural (+) Dys
Muscles Respiratory Conduction to Distres
Muscles ENS (+) Elev
(+) Elev

(+) Weakness
(+) Inability to Respiratory GI Paralysis/
Ambulate Depression Ileus

Inability to
Decreased Breath Sounds Protect Airway
Hypoventilation
 Presence of U waves in pH: 7.06.995
ECG Hypokalemia HCO3  12.1 8.5
Metabolic Acidosis

Hyperpolarization
of Cell membranes

(+) Vomi
Impaired Neural Reduced Neural Reduced (+) Chang
(+) Body
Conduction to Conduction to Neural (+) Dyspn
Muscles Respiratory Conduction to Distress
Muscles ENS (+) Eleva
(+) Eleva

(+) Weakness
(+) Inability to Respiratory GI Paralysis/
Ambulate Depression Ileus

Inability to
Decreased Breath Sounds Protect Airway
Hypoventilation
CO2 Nausea, Vomiting
Dyspnea
Retention Decreased Appetite
Desaturation
Decreased Sensorium Metabolic Acidosis
Mental Status Changes Persisting despite
Respiratory Acidosis
treatment
Increased Risk for Pneumonia
Possible Aspiration Component
 Inability to
Decreased Breath Sounds Protect Airway
Hypoventilation
CO2 Nausea, Vomiting
Dyspnea
Retention Decreased Appetite
Desaturation
Decreased Sensorium Metabolic Acidosis
Mental Status Changes Persisting despite
Respiratory Acidosis
treatment
Increased Risk for Pneumonia
Possible Aspiration Component

(+) Cough
CXR: Infiltrates
Right Middle Lobe
Sepsis

Degradation of Dec. Inc.

Gastric Mucosal Prostaglandin Cortisol Shock
Barrier Synthesis Levels
BP: 70/40 mmHg
HR: 141 bpm
RR: 30s cpm
T: 41.8C

Stress SIRS Criteria 3/4

Gastropathy
Death

Coffee Ground
NGT Secretions
Final Diagnosis

• Multifactorial Shock From:

1. Metabolic Acidosis from Acute Kidney
Injury from Renal Tubular Acidosis Type II
2. CAP-HR with Aspiration Component
Thank You!