By AbdelMumain

1. ABDULMUNIM AL FARSI I CAN NOT HOLD A GLASS CASE PRESENTATION CME JULY. 13 th , 2010

2.  CASE SCENARIO  DIFFERENTIAL DIAGNOSIS ?  MANAGEMENT  PITFALLS  TAKE HOME MASSAGE OBJECTIVES OUTLINE

3. 10.07.2010 60+ yrs old gentleman .. presented with h/o tremor in his hands for > 1 month, associated with slurred speech CASE SCENARIO TRIAGE

4. A irway: Patent B reathing: [spontaneous, RR:16/min, SPO2:99 % in RA] C irculation: [BP: 108/66 mmhg, P: 86/min, regular] D isability: [GCS:15 , reflo: 10.7 mmol, T: 37C] E xposure: NAD CASE SCENARIO PRIMARY SURVEY

5. CASE SCENARIO HISTORY The pt was seen in LHC for this tremor .. Told to have Parkinson disease Known to have - DM type II on insulin - HTN on medication - LV systolic dysfunction , EF=35% - Mild renal impairment - Known psychiatric problem .. f/u in Ibn Sina hospital

6. CASE SCENARIO HISTORY No h/o trauma, headache or blurred vision No h/o vomiting or fever Ex-smoking, No alcohol consumption, No h/o drug abuse h/o incoherent speech, and sleepiness No h/o chest pain , no SOB, No bowel or urine compliant

7. CVS : s1, s2, no murmur, no carotid bruits CHEST : b/l basal minimal ABDOMEN : soft, non tender. no organomegaly CASE SCENARIO SECONDARY SURVEY

8. CNS : No meningeal sign Alert , oriented to time place and person Lt eye cataract . Rt eye pupil reacting to light , no nystagmus facial asymmetry Rt angle mouth drop UL: Tone: cogwheel rigidity, Power: 4/5 b/l, Reflexes: 1+, Sensation: intact. LL: Right/Left sided, Power 4+, Reflexes b/l 1+, Sensation: intact Gait ataxic,finger nose incoordination with significant knee - heel incoordination. Romberg’s sign positive .. Planter reflex eqivocal CASE SCENARIO SECONDARY SURVEY

9. ? Intracranial pathology ? Parkinson disease ? … ? … CASE SCENARIO DIFFERENTIAL DIAGNOSIS

10. What is your NEXT STEP ? CASE SCENARIO WORK-UP

11. ECG CASE SCENARIO WORK-UP

12. ECG: prolonged QT CASE SCENARIO WORK-UP QTc Normal QT = 340 - 430 ms Pathological QT > 450 ms

13. ABG pH= 7.38 pCO 2 = 39.4 pO 2 = 41.5 HCO 3 = 22.8 CASE SCENARIO INVESTIGATIONS UE1 Na= 133 K= 4.8 CO 2 = 20 Urea= 14.1 Cret= 222 eGFR= 29 BONE Ca 2+ = 2.4 albumin= 38 PO 4 = 1.31 ALP= 180 CBC Hb = 11.2 Plt= 232 WBC= 8.8

14. CASE SCENARIO INVESTIGATIONS BRAIN ATROPHY CT BRAIN

15. NEXT STEP ? CASE SCENARIO PROGRESS IN A/E HYDRATION Psychiatric medications: Lithium (Antimanic) Chlorpromazine (Antipsychotics) Differential diagnosis ? Mediation: Cavidelol , lisinopril, frusemide, aspirin, simvastatin , insulin , psychiatry medications

16. CASE SCENARIO MANAGEMENT in A/E NEPHROLOGY CONSULTATION LITHIUM LEVEL 3.2 mEq/l Neuromuscular excitability, irregular coarse tremors, fascicular twitching, rigid motor agitation, muscle weakness, ataxia, sluggishness, delirium, nausea, vomiting, diarrhea, leukocytosis, sinus bradycardia, and hypotension. Can lead to seizures, stupor, coma, and a 10% risk of permanent neurologic sequelae (such as dementia and ataxia) Severec > 3.5 mEq/L Moderate 2.5 - 3.5 mEq/L Mild 1.5 - 2.5 mEq/L TOXICITY PLASMA LITHIUM LEVEL

17. Nephrology Impression: ARF secondary to LITHIUM TOXICITY CASE SCENARIO MEDICAL CONSULTATION » What are the indication of HD in this pt ? » Plan: HEMODIALYSIS Lithium is the most dialyzable toxin due to its: - low molecular weight - negligible protein binding - volume of distribution similar to that of water

18.  ADMISSION UNDER NEPHROLOGY TEAM CASE SCENARIO DISPOSITION Indications of Hemodialysis HD is indicated if one or more of the following is present: - A plasma lithium level is >4 mEq/L, regardless of the clinical status of the patient. - A plasma lithium concentration >2.5 mEq/L in a patient who is markedly symptomatic or who has renal insufficiency or other conditions that can limit urinary lithium excretion (such as congestive heart failure or cirrhosis) - If the plasma lithium level is between 2.5 - 4 mEq/L in an asymptomatic patient and is not anticipated to be less than 0.6 mEq/L within 36 hours.

19. There is relatively slow equilibration between extracellular and intracellular As a result, there is a rebound increase in plasma lithium levels after the cessation of dialysis as intracellular lithium diffuses into the extracellular fluid. Recommend extending the duration of dialysis to 8-12 hrs to minimize rebound and to repeat dialysis as necessary until the plasma lithium level remains at less than 1 mEq/L for 6 to 8 hours after dialysis CASE SCENARIO FOLLOW-UP

20. LITHIUM CLEARANCE 70 - 170 ml/min in hemodialysis 10 - 40 ml/min in the urine (due to extensive proximal reabsorption) 15 ml/min with peritoneal dialysis (because of the low blood flow associated with this procedure) CASE SCENARIO FOLLOW-UP

21. Medications history Hemodialysis ... CASE SCENARIO PITFALLS

22.  Prolong QT ?  Lithium toxicity  hydration & hemodialysis PITFALLS TAKE HOME MASSAGES