You are asked to see a 73-year-old female on the ward. She was admitted to the Emergency Department in a dishevelled state.
She has the following vital signs and investigation results:
Temperature: 34.5°C
Blood pressure: 80/40 mmHg
Glasgow Coma Score: 11
Parameter |
Patient Value |
Adult Normal Range |
Fi02 |
0.28 |
|
pH |
7.26* |
7.35 - 7.45 |
P02 |
62 mmHg (8.3 kPa) |
|
PC02 |
37.0 mmHg (4.7 kPa) |
35.0 -45.0 (4.6 - 6.0) |
sp02 |
92% |
|
Bicarbonate |
16.0 mmol/L* |
22.0 - 26.0 |
Base Excess |
-10.0 mmol/L* |
_2.0 _ +2.0 |
Lactate |
3.1 mmol/L* |
0.5 - 1.6 |
Sodium |
128 mmol/L* |
135 - 145 |
Potassium |
3.1 mmol/L* |
3.5 -5.0 |
Chloride |
90 mmol/L* |
95- 105 |
Glucose |
3.2 mmol/L* |
3.5 -6.0 |
Urea |
13.0 mmol/L* |
3.0 - 8.0 |
Creatinine |
132 umol/L* |
45 — 90 |
Creatinine Kinase |
1500 U/L* |
55 - 170 |
Haemoglobin |
80 g/L* |
120 - 160 |
White Cell Count |
15.0 x 109/L* |
4.0 - 1 1.0 |
Platelet count |
250 x 109/1- |
150 - 350 |
a) Comment on the acid base status and ECG abnormalities
(ECG show below)
(30% marks) b) List the two most likely differential diagnosis. (20% marks)
a)
Primary metabolic acidosis
Associated respiratory acidosis, or inadequate compensation
Increased anion gap. (22)
Delta ratio 1.2 –pure high anion gap acidosis
ECG: low voltage
Relative bradycardia
Prolonged QT
b)
Myxoedema coma.
Sepsis
Acid base status, in detail:
ECG abnormalities
Overall, the ECG is consistent with hypothermia. Which the patient has. And with ... one other thing.
So... those two most likely differentials?
Well. One of them HAS to be myxoedema coma.
How can one be so confident? It's easy, when the college lifted their ECG directly from the LITFL page on ECG changes in hypothyroidism. Which is excellent: as that work is covered by the Creative Commons license, this offers the author a rare opportunity to reproduce the original college image without fear of the CICM intellectual property stormtroopers.
The other differential could easily be sepsis, MI, acute kidney injury due to prolonged lie and rhabodomyolysis, and so on.
Zhang, Yiyi, et al. "Thyroid hormones and electrocardiographic parameters: findings from the third national health and nutrition examination survey." PloS one 8.4 (2013): e59489.