1. Case conference -- Conscious disturbances

2. 性別 : 女 Age: 47 y/o Date of Admission:94 年 7 月 31 日 Date of Discharge:94 年 8 月 1 日 Con’s: AVPU Vital signs: TPR:37.6/119/16 BP:100/63mmHg Triage I

3. Chief complaints Consciousness change at home

4. Present Ilness A case of hepatic adenocarcinoma s/p TAE diagnosed at 2005.3 Just discharged from GI ward on 2005.7.20 with initial presentation of abdominal pain and consciousness change Gradual onset of drowsy consciousness in recent 2 days Fever was noted.

5. Past history Allergy : penicillin Hepatic adenocarcinoma s/p TAE

6. Physical Examination Con’s: slow response E4V6M5 HEENT: grossly normal Lung: clear BS Heart: RHB Abd: soft and flat, tenderness(+), mild distention Ext: freely movable, jaundice(-) Neurological: EOM:full pupil:3+/3+

7. What you else? What is your differential diagnosis?

8. D/D of Altered Level of Conscious A ( Alcohol, abuse) E ( Electrolyte, encephalopathy) I ( Infection) O ( Overdose ingestion) U (Uremia) T ( Trauma)

9. D/D of ALOC I ( Insuline, intussuception, inborn error of metabolism) P (Psychogenic) S (Shock, stroke, seizure)

10. What will you do next?

11. O2 IV Monitor A B (Kussmaul, Cheyne-Stokes) C D E

12. Order(7/31) CBC/DC PT/aPTT Panel I, iCa GPT T/D bilirubin Ammonia N/S run 60cc/hr B/C xII ABG F/S (104mg/dl) U/A EKG: NSR

13. Lab data(7/31) WBC:12600 S/L:84/8 BUN/Cr:15/0.7 Na/K:129/4.8 T/D bilirubin: 1.4/0.7 AST/ALT: 87/16 NH3: 111 CRP: 6.7 iCa: 7.48

14. ABG(R.A) pH : 7.428 pCO2: 36mmHg pO2: 72.3mmHg HCO3- : 23.9mmol/L Sat : 94.8%

16. Diagnosis Hypercalcemia, HCC related Hepatic adenocarcinoma s/p PEIT Hyponatremia

17. What will you do next with this impression?

18. Order (8/1) Fleet enema Lactulose 30cc tid x2D Stool OB 排 GI 住院 轉 EC 補 P

19. What is will you do next with after seeing the lab data?

20. Order Bonfos 2# po tid and st NS 500cc st Zometa 1 vial in N/S 100cc run 30 mins F/U iCa Burinex 1 amp iv st and q12h x 1 D Record Urine output

21. Burinex 1 amp 改 iv q6h F/U iCa at 10 a.m -> iCa:8.13 N/S 改 run 200cc/hr On CVP F/U CXR Consult 總值 for ICU admission Haldol 1 amp im q4h Patient AAD

22. Paraneoplastic syndromes Definition: caused by factors produced by cancer cells that act at a distance from both the primary cancer site and its metastasis. 3 major classes of hormones are steroids, monoamines, and peptides/proteins.

23. Hypercalcemia Hypercalcemia with cancer-Humoral hypercalcemia with malignancy (HHM) Caused by local osteolytic hypercalcemia (LOH) PTHrP causes nearly all cases of malignancy Binds to receptors in bone and kidney and causes increased bone resorption.

24. The cancers associated with HHM are non-small cell lung cancers Breast cancers Renal cell carcinoma Head and neck cancer Bladder cancer Myeloma

25. S/S Hypercalcemia Initial symptoms (calcium level ≧ 2.6mmol/L)-anorexia, malaise, fatigue, confusion, bone pain, polyuria, polydipsia, weakness, constipation Neurologic symptoms (calcium level ≧ 3.5mmol/L)-confusion, lethargy, coma and death.

26. Diagnosis Normal level of PTH level and a low serum phosphate level in the absence of bone metastases support the diagnosis of HHM A normal PTHrP level and normal phosphorus in a pt with bone metastases suggest LOH.

27. Treatment Moderate hypercalcemia Pamidronate 90mg iv with Diuretics 2-4 L of normal saline Severe hypercalcemia Calcitonin 4-8 U/kg IM or SC q12h