1/ #UncleBob discussed BMP on #VMR - spend #5goodminutes 2 analyze. Pt ~80 & weighs ~55kg (recent 5 kg wt loss). Sarcopenia Pt has orthostasis (HR & BP).
Na 134 K 4.7 Cl 99 HCO3 23 BUN 22 cr 1.2 nl glucose
tweetorial later today
Can these labs help?
@kidney_boy
@uabimres
Na 134 K 4.7 Cl 99 HCO3 23 BUN 22 cr 1.2 nl glucose
tweetorial later today
Can these labs help?
@kidney_boy
@uabimres
2/
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
Gregory (Scotland Yard detective): “Is there any other point to which you would wish to draw my attention?”
Holmes: “To the curious incident of the dog in the night-time.”
Gregory: “The dog did nothing in the night-time.”
Holmes: “That was the curious incident.”
3/
We have a patient with presumed simple intravascular volume contraction. Do the labs support that hypothesis?
The sodium is slightly low - volume contraction is definitely a potential cause of low sodium - if the patient is drinking fluids freely.
We have a patient with presumed simple intravascular volume contraction. Do the labs support that hypothesis?
The sodium is slightly low - volume contraction is definitely a potential cause of low sodium - if the patient is drinking fluids freely.
4/
If the problem is simply volume contraction - then we would expect a hypokalemic metabolic alkalosis. Volume contraction stimulates aldosterone and sodium reabsorption (to try to protect volume). We change the proximal tubular bicarb reabsorption threshold.
If the problem is simply volume contraction - then we would expect a hypokalemic metabolic alkalosis. Volume contraction stimulates aldosterone and sodium reabsorption (to try to protect volume). We change the proximal tubular bicarb reabsorption threshold.
5/
But the patient has a high K, and a low normal bicarbonate. Note the normal anion gap and we are told u/a is normal so likely no ketones. The BUN is quite high for some with decreased intake. The creatinine is very high for a patient with a BMI of 55 and sarcopenia.
But the patient has a high K, and a low normal bicarbonate. Note the normal anion gap and we are told u/a is normal so likely no ketones. The BUN is quite high for some with decreased intake. The creatinine is very high for a patient with a BMI of 55 and sarcopenia.
6/
So the labs look partly like routine volume contraction, but some things just don't fit. What else could give orthostasis?
Autonomic dysfunction can - but the appropriate pulse increased excludes the autonomic branch of the schema.
So the labs look partly like routine volume contraction, but some things just don't fit. What else could give orthostasis?
Autonomic dysfunction can - but the appropriate pulse increased excludes the autonomic branch of the schema.
7/
Then we learn that volume does no resolve the orthostatic BP & HR. Things are not what they appeared. Slightly low sodium, slightly high K and relative hypotension make one consider adrenal insufficiency.
Then we learn that volume does no resolve the orthostatic BP & HR. Things are not what they appeared. Slightly low sodium, slightly high K and relative hypotension make one consider adrenal insufficiency.
8/
I would have drawn a random cortisol at that point and given a dose of dexamethasone. The cortisol should be elevated given the BP and the tachycardia. If it is not elevated than a stimulation test will either support or exclude adrenal insufficiency.
I would have drawn a random cortisol at that point and given a dose of dexamethasone. The cortisol should be elevated given the BP and the tachycardia. If it is not elevated than a stimulation test will either support or exclude adrenal insufficiency.
9/
I choose dexamethasone because it is the only glucocorticoid that will not interfere with the measurements of the stim test.
In fact this patient did have adrenal insufficiency. I (and the wisdom of the chat) did not work through this analysis.
I choose dexamethasone because it is the only glucocorticoid that will not interfere with the measurements of the stim test.
In fact this patient did have adrenal insufficiency. I (and the wisdom of the chat) did not work through this analysis.
10/ We got there in a different way. On further reflection, the BMP which seemed rather unremarkable actually could have been a clue. Now that you know the diagnosis, the numbers make total sense.
@CPSolvers @DxRxEdu @rabihmgeha @3owllearning @MohitHarshMD @HannahRAbrams
@CPSolvers @DxRxEdu @rabihmgeha @3owllearning @MohitHarshMD @HannahRAbrams
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