my case.02

ABDULMUNIM AL ABDULMUNIM AL FARSIFARSI

I CAN NOT HOLD A GLASS

CASE CASE PRESENTATIONPRESENTATIONCMECME

JULY. 13JULY. 13thth , , 20102010

CASE SCENARIO CASE SCENARIO

DIFFERENTIAL DIAGNOSIS ?DIFFERENTIAL DIAGNOSIS ?

MANAGEMENTMANAGEMENT

PITFALLSPITFALLS

TAKE HOME MASSAGETAKE HOME MASSAGE

OBJECTIVESOBJECTIVES OUTLINE OUTLINE

10.07.201010.07.2010

60+ yrs old gentleman .. presented with h/o 60+ yrs old gentleman .. presented with h/o tremortremor in his hands for > 1 month, associated in his hands for > 1 month, associated with slurred speech with slurred speech

CASE CASE SCENARIO SCENARIO

TRIAGE TRIAGE

AAirway: Patentirway: Patent

BBreathing: [spontaneous, RR:16/min, SPO2:99 reathing: [spontaneous, RR:16/min, SPO2:99 % in RA]% in RA]

CCirculation: [BP: 108/66 mmhg, P: 86/min, irculation: [BP: 108/66 mmhg, P: 86/min, regular] regular]

DDisability: [GCS:15 , reflo: 10.7 mmol, T: 37C]isability: [GCS:15 , reflo: 10.7 mmol, T: 37C]

EExposure: NADxposure: NAD


PRIMARY PRIMARY SURVEYSURVEY


HISTORYHISTORY

The pt was seen in LHC for this tremor The pt was seen in LHC for this tremor .. Told to have .. Told to have Parkinson disease Parkinson disease

Known to have Known to have - DM type II on insulin- DM type II on insulin- HTN on medication - HTN on medication - LV systolic dysfunction , EF=35%- LV systolic dysfunction , EF=35%- Mild renal impairment - Mild renal impairment - Known psychiatric problem .. f/u in Ibn Sina - Known psychiatric problem .. f/u in Ibn Sina hospitalhospital


HISTORY HISTORY

No h/o trauma, headache or blurred visionNo h/o trauma, headache or blurred visionNo h/o vomiting or feverNo h/o vomiting or fever

Ex-smoking, No alcohol consumption, No h/o Ex-smoking, No alcohol consumption, No h/o drug abusedrug abuse

h/o incoherent speech, and sleepiness h/o incoherent speech, and sleepiness No h/o chest pain , no SOB, No h/o chest pain , no SOB, No bowel or urine compliantNo bowel or urine compliant

CVSCVS: s1, s2, no murmur, no carotid bruits: s1, s2, no murmur, no carotid bruits

CHESTCHEST: b/l basal minimal: b/l basal minimal

ABDOMENABDOMEN: soft, non tender. no organomegaly: soft, non tender. no organomegaly


SECONDARY SECONDARY SURVEY SURVEY

CNSCNS::No meningeal signNo meningeal signAlert , oriented to time place and personAlert , oriented to time place and personLt eye cataract . Rt eye pupil reacting to Lt eye cataract . Rt eye pupil reacting to light , no nystagmuslight , no nystagmusfacial asymmetry Rt angle mouth drop facial asymmetry Rt angle mouth drop

UL: Tone: cogwheel rigidity, Power: 4/5 b/l, UL: Tone: cogwheel rigidity, Power: 4/5 b/l, Reflexes: 1+, Sensation: intact.Reflexes: 1+, Sensation: intact.

LL: Right/Left sided, Power 4+, Reflexes b/l LL: Right/Left sided, Power 4+, Reflexes b/l 1+, Sensation: intact1+, Sensation: intact

Gait ataxic,finger nose incoordination with Gait ataxic,finger nose incoordination with significant knee - heel incoordination.significant knee - heel incoordination. Romberg’s sign positive .. Planter reflex Romberg’s sign positive .. Planter reflex eqivocaleqivocal


SECONDARY SECONDARY SURVEY SURVEY

? Intracranial pathology ? Intracranial pathology

? Parkinson disease ? Parkinson disease

? …? …

? …? …


DIFFERENTIAL DIFFERENTIAL DIAGNOSIS DIAGNOSIS

What is your What is your NEXT STEPNEXT STEP ? ?


WORK-UP WORK-UP

ECGECG


WORK-UP WORK-UP

ECG: ECG: prolonged QTprolonged QT


WORK-UP WORK-UP

QTcQTc

Normal QT = 340 - 430 ms Normal QT = 340 - 430 ms Pathological QT > 450 msPathological QT > 450 ms

ABGABGpH= 7.38pH= 7.38pCOpCO22= 39.4= 39.4pOpO22= 41.5= 41.5HCOHCO33= 22.8= 22.8


INVESTIGATIONS INVESTIGATIONS

UE1UE1Na= 133Na= 133K= 4.8K= 4.8COCO22= 20= 20Urea= Urea= 14.114.1Cret= 222Cret= 222eGFR= 29eGFR= 29

BONEBONECaCa2+2+ = 2.4 = 2.4 albumin= albumin= 3838POPO44= 1.31= 1.31ALP= 180ALP= 180

CBCCBCHb = 11.2 Hb = 11.2 Plt= 232Plt= 232WBC= 8.8WBC= 8.8


INVESTIGATIONS INVESTIGATIONS

BRAIN ATROPHYBRAIN ATROPHYCT BRAIN CT BRAIN

NEXT STEP ?NEXT STEP ?


PROGRESS IN A/EPROGRESS IN A/E

HYDRATIONHYDRATION

Psychiatric medications:Psychiatric medications:LithiumLithium (Antimanic) (Antimanic)ChlorpromazineChlorpromazine (Antipsychotics) (Antipsychotics)

Differential diagnosis ?Differential diagnosis ?

Mediation:Mediation:Cavidelol , lisinopril, frusemide, aspirin, Cavidelol , lisinopril, frusemide, aspirin, simvastatin , insulin , psychiatry medicationssimvastatin , insulin , psychiatry medications


MANAGEMENT in MANAGEMENT in A/E A/E

NEPHROLOGY CONSULTATION NEPHROLOGY CONSULTATION

LITHIUM LEVEL LITHIUM LEVEL 3.2 mEq/l3.2 mEq/l

PLASMA LITHIUM LEVELPLASMA LITHIUM LEVELTOXICITYTOXICITY

1.5 - 2.5 mEq/L1.5 - 2.5 mEq/LMildMild

2.5 - 3.5 mEq/L2.5 - 3.5 mEq/LModerateModerate

> 3.5 mEq/L> 3.5 mEq/LSeverecSeverec

Neuromuscular excitability, irregular coarse tremors, Neuromuscular excitability, irregular coarse tremors, fascicular twitching, rigid motor agitation, muscle fascicular twitching, rigid motor agitation, muscle weakness, ataxia, sluggishness, delirium, nausea, weakness, ataxia, sluggishness, delirium, nausea, vomiting, diarrhea, leukocytosis, sinus bradycardia, and vomiting, diarrhea, leukocytosis, sinus bradycardia, and hypotension. hypotension.

Can lead to seizures, stupor, coma, and a 10% risk of Can lead to seizures, stupor, coma, and a 10% risk of permanent neurologic sequelae (such as dementia and permanent neurologic sequelae (such as dementia and ataxia)ataxia)

NephrologyNephrology Impression: ARF secondary to Impression: ARF secondary to LITHIUM LITHIUM TOXICITYTOXICITY


MEDICAL MEDICAL CONSULTATIONCONSULTATION

»»What are the indication of HD in this pt ?What are the indication of HD in this pt ?

» » Plan: Plan: HEMODIALYSISHEMODIALYSIS Lithium is the most dialyzable toxin Lithium is the most dialyzable toxin due to its: due to its: - low molecular weight- low molecular weight- negligible protein binding- negligible protein binding- volume of distribution similar to that - volume of distribution similar to that of waterof water

ADMISSION UNDER NEPHROLOGY TEAMADMISSION UNDER NEPHROLOGY TEAM


DISPOSITION DISPOSITION

Indications of Indications of HemodialysisHemodialysisHDHD is indicated if one or more of the following is is indicated if one or more of the following is present: present:

- A plasma lithium level is >4 mEq/L, regardless of the - A plasma lithium level is >4 mEq/L, regardless of the clinical status of the patient.clinical status of the patient.

- A plasma lithium concentration >2.5 mEq/L in a - A plasma lithium concentration >2.5 mEq/L in a patient who is markedly symptomatic or who has renal patient who is markedly symptomatic or who has renal insufficiency or other conditions that can limit urinary insufficiency or other conditions that can limit urinary lithium excretion (such as congestive heart failure or lithium excretion (such as congestive heart failure or cirrhosis)cirrhosis)

- If the plasma lithium level is between 2.5 - 4 mEq/L in - If the plasma lithium level is between 2.5 - 4 mEq/L in an asymptomatic patient and is not anticipated to be an asymptomatic patient and is not anticipated to be less than 0.6 mEq/L within 36 hours. less than 0.6 mEq/L within 36 hours.

There is relatively slow equilibration between There is relatively slow equilibration between extracellular and intracellularextracellular and intracellular

As a result, there is a As a result, there is a rebound increaserebound increase in in plasma lithium levels after the cessation of plasma lithium levels after the cessation of dialysis as intracellular lithium diffuses into dialysis as intracellular lithium diffuses into the extracellular fluid. the extracellular fluid.

Recommend extending the duration of dialysis Recommend extending the duration of dialysis to 8-12 hrs to minimize rebound and to repeat to 8-12 hrs to minimize rebound and to repeat dialysis as necessary until the plasma dialysis as necessary until the plasma lithium level remains at less than 1 mEq/L for lithium level remains at less than 1 mEq/L for 6 to 8 hours after dialysis6 to 8 hours after dialysis


FOLLOW-UP FOLLOW-UP

LITHIUM CLEARANCELITHIUM CLEARANCE

70 - 17070 - 170 ml/minml/min in hemodialysis in hemodialysis

10 - 40 ml/min10 - 40 ml/min in the urine in the urine (due to extensive proximal reabsorption) (due to extensive proximal reabsorption)

15 ml/min15 ml/min with peritoneal dialysis with peritoneal dialysis (because of the low blood flow associated with this (because of the low blood flow associated with this procedure) procedure)


FOLLOW-UP FOLLOW-UP

Medications history Medications history

HemodialysisHemodialysis

......


PITFALLS PITFALLS

Prolong QTProlong QT ? ?

Lithium toxicity Lithium toxicity hydration & hydration & hemodialysishemodialysis

PITFALLSPITFALLS TAKE HOME TAKE HOME MASSAGESMASSAGES

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