Chief Complains:

1.SOB, aggravated in recent one week

2.L't lower leg cyanosis with pain in recent 2-3 days

Present Illness:

This 83 y/o male with chronic lung disease suffered from SOB (aggravated in recent one week) and L't lower leg cyanosis with pain in recent 2-3 days.

This time, he visited our ER because of above reason, and there CxR showed bil. emphsematous change. At usual time, he visited 田中仁和H. and taked medicines for controlling the chronic lung disease (for few years). Shortness of breath was noted in past few years, and SOB was more severe in recent one week. There was cough with sputum sometimes. L't lower leg cyanosis was noted and cold sensation over all extremities was noted.

Under the suspection of DVT and COPD with AE, he admitted for further evaluation and management on 89-8-16.

Personal History:

1. smoking(+): 1-2 PPD for more than 60 years

2. alcohol drinking(+)

3. Medication: drugs form 田中仁和H.

4. Allergy history: denied

Immunization:

1. Parainfluenza vaccination (-).

2. Pneumococcus vaccination (-).

Past History:

1. Denied major systemic disease such as diabetes mellitus, hypertension,etc.

2. Denied any major operation history.

3. COPD

Systems Review:

1. General conditions:

fever(-), general malaise(+), body weight loss(-), chills(-)

2. HEENT: normal

3. Neck:

JVE(-), lymph node(-)

4. Respiratory:

cough(+), sputum(+), chest pain(-), hemoptysis(-), dypnea(+), SOB(+)

5. CV:

palpitation(-), DOE(-), tachycardia(-), bradycardia(-),arrhythmia(-),

chest tightness(-), orthopnea(-)

6. GI:

anorexia(-), nausea(-), vomiting(-), diarrhea(-), constipation(-),

dysphagia(-), heartburn(-), hematemesis(-), abdominal pain(-),

abdominal tenderness(-), abdominal distension(-), melena(-)

7. GU:

frequency(-), urgency(-), incontinence(-), dysuria(-), nocturia(-),

hematuria(-), polyuria(-), oliguria(-), abnormal discharge(-)

8. Endocrine:

moon face(-), weight change(-), hirsutism(-), polydipsia(-),

decreased libido(-)

9. Musculoskeletal:

muscle atrophy(-), involuntary movement(-), L’t lower leg pain (+),

limitation of ROM (-)

10. Mental status:

swing of mood(-), anxiety(-), memory loss(-)

11. Hematological:

cyanosis(+), pale sclera(-). petechiae(-), ecchymosis(+)

12. Skin:

itching(-), rash(-), ulcer(-), abnormal pigmentation(-)

Physical Exam:

General appearance: chronic ill-looking, weakness(+)

Cons: clear, E4M6V5

Vital sign: TPR: 37/100/25 BP: 129/69mmHg

HEENT: Conj: mild pale Sclera: anicteric

Neck: supple, no LAP, no JVE

Thyroid: N.P.

Axillary: no LAP

Chest: symmetric expansion, breathing sound: bil. moderate wheezing

Heart: RHB without murmur

Abd: soft and flat, tenderness(-) , no rebounding pain

normoactive bowel sound, Liver/spleen: impalpable, no palpable mass

Inguinal area: no LAP

Ext: freely movable, no pitting edema

Impression:

1.R/O DVT

2.COPD with AE

Plan:

1.use heparin

2.keep airway: use bronchodilator, aminophylline and steroid

3.supprotive Tx

4.F/U ABG to decide O2 supplyment amount

Hospital course:

8/16 COPD - SOB - on endo - RICU

8/17 empiric antibiotics use

heparin for l't leg DVT

8/18 bed-side heart echo: mild TR,MR

thrombolytic therapy

fever r/o L't foot gangrene

8/21 拔foley

8/23 biopsy:L’t foot cellulitis with necrosis

8/28 ECG show:sinus tachycardia,tall T wave

8/31 fragmin used for L't leg gangrene

9/3 prokinetics used for ileus

L't foot gangrene s/p B-K amputation

9/5 A-K amputation of L't foot

9/6 Keep antibiotics with pipril+Tobromicin

9/10 no fever

9/11 Venturi mask used

hyponatremia

hyperkalemia cause?

9/13 出RICU, asthma attack

No used NSAID,ACEI,Aldactone since 8/16

Used heparin during 8/16~8/31

Lab Summary

BI

CS

8/16 Sputum: Haemophilus influenzae blood: no growth

8/17 Sputum: Gram stain G(+)Coccu urine: no growth

8/19 Pus: Enterococcus, Proteus mirabilis, Pseudomonas aeruginosa

8/31 Pus:Proteus mirabilis blood: no growth

HE

SC

UR

D/D of hyperkalemia

1.Pseudohyperkalemia

• Hemolysis

• Fist clenching在抽血的時候握拳過久

• Thrombocytosis(platelet>75萬)
• Leukocytosis(>50萬)

2.Transcellular K+ shift(Redistribution)

• Acidosis(PH降0.1，K+升高0.6mEq/L)
• Insulin deficiency, Diabetic hyperglycemia, and hyperosmotality
• b ₂-adrenergic blockade
• Arginine hydrochloride

• Succinycholine(Depolarizing muscle relaxants)

• Tissue damage(Burn,tumor lysis,Rhadomyolysis)

• Digitalis overdose
• Periodic paralysis

3.Oligouria renal failure ：Potassium retention (Ccr<20ml/min)

Male：Ccr=(140-age)*BW/72*Pcr

GFR<10-15ml/min

4.Assess K+ secretion(TTKG>10) TTKG=( Uk⁺ * Posm)/( Pk⁺ * Uosm)

TTKG=transtubular K+ concentration gradient

decreased distal flow

• Decreased effective circulating volume
• Low-protein diet(decrease urea)

當濾過物質減少，Na+濾過減少，則在遠端Na+濃度低，則Na+-K+交換inactive，K+loss減少

5. Assess K+ secretion(TTKG<5)

response to 9a -fludrocortisone

5-1 TTKG>10

• Primary hypoaldosteronism(high renin and low aldosterone)

• Adrenal insufficiency(Addison's disease)
• adrenal enzyme deficiency(21-hydroxylase,3b -hydroxysteroid dehydrogenase,corticosterone methyl oxidase)

• Secondary hypoaldosteronism

• Hyporeninemia( low renin and aldosterone)
• Drugs

• ACEinhibitors: block the conversion of angiotensionI to angiotensionII
• NSAIDs: inhibit renin secretion and the synthesis of prostaglandins
• Heparin: inhibits production of aldosterone

5-2 TTKG<10 Hypotension - high renin and aldosterone

• pseudohypoaldosteronism

• Drugs
• K+-sparing diuretics: Spironolactone(Aldactone), amiloride and triamterence
• Trimethoprim(blocking distal nephron Na+ reabsorption)
• Pentamidine

5-3 TTKG<10 Hypertension - low renin and aldosterone

• Gordon's syndrome(Cl- shunt)
• Cyclosporine nephrotoxicity

• Type 4 distal RTA
• Hyperchloremic metabolic acidosis
• Reduced NH4+ excretion
• Aldosterone is reduced
• Reduced urinary PH
• No aminoaciduria no PO4- encretion(No proximal tubule defect)

Anion gap: Na-Cl-HCO₃

Urine anion gap: U _NA+U _K-U _Cl >0 low urine NH₄+

9/12

Mild metabolic acidosis

TTKG=39.4*285/6.0*475=3.94

Anion gap=123-92-22.4=8.6

UAG=73+39.4-77=35.4

Suspect hypoaldosteronism(low BP,Na+ wasting)

R/o Primary adrenal insufficiency

R/o Type 4 RTA(low gap metabolic acidosis,positive urine AG,hyperkalemia)

Treatment

重度高血鉀: >7.5mEq/L

中度高血鉀: 6.5~7.5mEq/L

輕度高血鉀: 5.5~6.5mEq/L

1. 用鈣(calcium gluconate)來拮抗高K⁺造成的心率不整
2. Digitalis toxicity危險：用digitalis antidate--MgSO₄
3. 緩解後用Sodium polystyrene sulfonate(Kayexalate)，使Na+-K+交換 in the GI tract，加Sorbitol造成diarrhea加速K+從GI excretion
4. 若達透析標準，用透析降血K⁺
5. 用轉移的方式：Glucose + insulin / NaHCO₃
6. b 2-adrenergic agonists: promote cellular uptake of K+
7. loop and thiazide diuretics: may enhance K+ excretion if renal function is adequate
8. 排除藥物引起的，疾病引起的要限制飲食，矯正代謝性酸中毒。
9. mineralocorticoid replacement therapy(with fludrocortisone at a dose of 0.05 to 0.2 mg/day)for primary adrenal insufficiency

9/12 輕度高血鉀

Ca2+-gluconate

Kayxalate

insulin 10u + 50% G/W