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Hyperglycemia and Illness

11/27/2012

A 5-year-old girl is brought is by her mother for two days of nausea, vomiting, diarrhea, and fever. She has multiple sick contacts at home with the same. She has no abdominal pain, change in behavior, or rash. The girl is unable to tolerate a PO trial in the ED after antiemetics. Her VS T 39.3 C HR 150 RR 22 BP 98/60. She is well appearing but tired and moderately volume depleted on exam. Her exam is otherwise normal.

IV fluids are given and a chemistry panel is drawn: Na 140 K 3.6 Cl 110 HCO3 22 BUN 18 Cr 0.8 Glucose 180.

She has no history of diabetes mellitus in the family, and has been well until this recent illness. Her urinalysis shows no evidence of infection, a normal specific gravity, and no ketones. After therapy, she feels much better and is now tolerating fluids and solids.

Regarding her hyperglycemia, which of the following is the BEST answer:

       A. This is likely her first presentation of diabetic ketoacidosis (DKA)
       B. This child likely has pre-diabetes
            C. Her hyperglycemia is due to her fever and viral syndrome
            D. This is a spurious result and will not require further testing

In the meantime, a quote -- "The physician can do all he has to do with speed and precision, but he must never appear to be in a hurry, and never absent-minded." -Theodor Billroth 1829-94

Answer

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Acute Headache

11/18/2012

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A 32-year-old man with no past medical history is brought in for slurred speech and left-sided weakness. He was having intercourse when he had acute onset headache, slurred speech, and slumped over with weakness of left arm and left leg. In the field, HR 88 BP 170/80 RR 20 100% O2, blood glucose 72.

On arrival, this patient is not alert but arousable to voice, looking to the right with left-sided neglect, pupils reactive 4 mm to 3 mm OU, left upper extremity 2/5 motor response to painful stimulus, left lower extremity 3/5 motor response to same. There is no sensation to the left upper extremity. He has no evidence of trauma, no murmur, and is in normal sinus rhythm on the monitor.

CT non-contrast is performed immediately:

On arrival from the radiology suite, the man has complete resolution of signs and symptoms and has a completely normal repeat neurologic exam.

Regarding his presentation and management, which is the BEST answer:

    A. Obtain emergent neurosurgery consultation for possible coil embolization
    B. Initiate titratable anti-hypertensive agent to target systolic blood pressure
         of 140 mmHg
    C. Give alteplase 0.9 mg/kg actual body weight o a maximum of 90 mg/kg
    D. Give aspirin 325 mg PO

In the meantime, a quote --

"You medical people will have more lives to answer for in the other world than even we generals."

-- Napoleon Bonaparte

Answer

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Failure to Thrive

11/13/2012

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A three-week-old boy born full-term, normal spontaneous vaginal delivery without complication is brought in by his father because he received a letter in the mail that he did not understand about some laboratory tests for his son. The father is not sure about the baby’s eating habits, but states that “he’s a crier”, and sometimes vomits before feedings. He is afebrile and his vital signs are normal. The physical exam is significant for a sleepy newborn with a hyperpigmented scrotum. His weight is 3.7 kg, the same as his birth weight. What is the most appropriate management?

A.   Do a head-to-toe exam looking for causes of “increased crying”, and, if negative and tolerates fluids by mouth, refer to his pediatrician.
B.   Check the baby’s blood glucose, and if normal and eating in the ED, refer to his pediatrician.
C.   After a thorough history and physical, if negative, refer to Failure to Thrive clinic
D.   Draw blood for serum chemistry

In the meantime, a quote -- "In the presence of the patient, Latin is the language." -Medieval medical saying

Answer

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Unresponsive

11/5/2012

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A 52-year-old woman with diabetes mellitus type II, hypertension, and obesity arrives to the ED complaining of total body pain, palpitations, and fatigue over the past few weeks.

While waiting for evaluation she becomes anxious, diaphoretic, and slumps down into the gurney. She appears to be unresponsive.

Regarding her immediate management, which of the following is the BEST answer:

    A.     Initiate BLS maneuvers with “look, listen, and feel”
    B.     Take her pulse for up to 30 seconds and extrapolate beats per minute – this may be extreme bradycardia
    C.     Call for help and start compressions now
    D.     When another provider arrives, initiate ratio of 15 compressions to two breaths

In the meantime, a quote -- "All diagnoses are provisional formulae for action." Henry Cohen, MD Lancet 1:23-25, 1943

Answer

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Hyperglycemia and Illness

Acute Headache

Failure to Thrive

Unresponsive

Timothy Horeczko, MD, MSCR, FACEP, FAAP

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