Tuesday, 12 February 2008

A Challenge For You All

Dear Bloggers

I have in the past presented cases and posed questions for you to answer. Today's challenge is very interesting and I would like you to post your answers on my blog for all to see and so everyone can learn.

The case has been anonymised for confidentiality as always.

A man was admitted with reduced conscious level.

He had been transferred from another hospital following a cardiac arrest on their ward. The reason for the initial admission had been vomiting and the patient was being investigated for the underlying cause. The vomiting had been occurring for several weeks following the commencement of a new Parkison's disease drug, the name of which was unknown, although that drug was eventually stopped. However the vomiting continued and the patient was developing regular vomiting of stomach contents each lunch time. The patient had never complained of much even when he had been ill in the past, so the family were unaware if he had any body pains.

The patient had a long history of constipation and had been taking medication for some time resulting in 5-6 episodes of diarrhoea daily.
The patient had not complained of any chest or abdominal pain. There was no haematemesis, malaena or haematochezia (fresh rectal bleeding). There was no complaint of any visual disturbance e.g. blurred vision, or headache (consideration of raised ICP). It is unknown whether there were any symptoms of gastroesophageal reflux (GERD).

Previous medical history included Parkinson's Disease, Constipation, Dementia, Depression and a Cerebral Infarction.

He was receiving anti-PD drugs (names unknown), Sennoside (for constipation), a tricyclic anti-depressant and Aricept.

He was a non-smoker and had previously drunk alcohol in moderation. The patient's ADLs were impaired because of the severity of the PD and he was limited to walking a few yards. However, he was nevertheless able to feed and wash himself.

The examination at the other hospital is unknown but they were investigating the suspected cause of an ileus.
The patient underwent a gastroscopy which revealed undigested food but no other abnormalities. A CT abdominal scan was also performed which revealed dilated loops of bowel but no mass lesion.

On the day of the cardiac arrest, the patient had been initially alert but soon became increasingly unconscious and then stopped breathing. A cardiac arrest ensued and he was found to be in an asystolic rhythm. He was effectively resuscitated and transferred to the current hospital. Arterial blood gas prior to the cardiac arrest revealed the following: PaO2 132mmHg, PCO2 105 mmHg, pH 7.33, HCO3 53.3, BE 23.5 (after 10L O2).

On transfer to the new hospital, his physical examination revealed the following:

JCS 300, Afebrile, pulse 50 beats per minute and regular, BP 80/60mmHg, SpO2 95% on 10L O2. Reduced skin turgor and dry mouth. No anaemia. Dark coloured, low volume urine in the catheter bag.

CVS: regular rhythm, good volume pulse, JVP not raised. Heart Sounds 1 + 2. No murmurs or added sounds.

RESP: RR 8/min, no tracheal tug or use of accessory muscles. Trachea central. Poor excursion of chest. Percussion resonant and reduced air entry throughout. No wheeze or crepitations (crackles).

ABDO: Distended, non-tender. No bowel sounds. No obvious masses. No rebound or guarding. Tympanic sound throughout on percussion. No renal angle tenderness. No abdominal hernia seen. Rectal examination-- no stool present, no mass lesion.

CNS/PNS: Pupils equal and reactive to light. Unable to perform other movements.
Moving upper and lower limbs spontaneously. Reduced muscle tone and reduced reflexes. Babinski sign negative bilaterally. Unable to test sensory or cerebellar function. Fundoscopy was not performed.

Lab Data revealed the following:

BUN 16, Creat 1.2, K 1.1, Na 134, Mg2+ 2.3, Ca 6.9, Alb 2.7, PO4 0.6, CK 850, ALT 102, AST 103, Bil 1.5, ALP 320, gamma GT 24.
WBC 38.2, Hb 9.0, MCV 82, Plt 20.0, INR 1.2

Urine revealed >100 WCC/hpf, 30-49 RBCs/hpf, 1+ protein, negative ketones, negative to glucose, 4+ bacteria.

CXR was normal apart from a raised right hemidiaphragm due to dilated bowel pushing up from below. AXR was abnormal showing loops of bowel distended with gas. No stool could be visualised on the Xray.


1) Why did this patient develop CO2 retention?

2) Which two simple cardiac tests would you perform and why?

3) Identify as many possible reasons why this patient developed a cardiac arrest?

4) Which one urine test would you perform to investigate the cause of possible ensuing renal failure in a patient with this clinical history?

5) Taking into account the entire history, list as many causes as possible for this patient developing an ileus. Is there a Syndrome that encompasses all of these features??

6) What does the arterial blood gas show and why do you think it occurred?

Please send in your answers and in 1 week, I will publish the answers! This is not an easy case but please try and have a go-- you might just be right!

Happy sleuthing.

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