Case 85 – update 1

Thank you for all your help so far on the medical admissions unit.

Assessment
Our patient was initially assessed using an ABCDE approach:
A) Snoring, requiring an airway adjunct (nasopharangeal airway)

B) RR16, chest clear to auscultation, sats 97% room air

C) HS I+II+0, HR 90 regular, BP 150/95, Cap refill 2 secs, no urine output

D) Unresponsive. BM 7. Pupils 2mm equal, reactive to light. Apyrexial

E) Soft abdomen, no obvious tenderness. No obvious trauma/bleeding/injuries/rash
We then discussed some initial investigations. You correctly identified that this was an emergency situation in which we had extremely limited background information about our patient.

First steps
Initial blood tests were taken
An urgent non-contrast CT head was requested
Critical care were contacted to review our patient

Investigations
The lab struggled with our patient’s samples and reported that they were ‘breaking the analyser’ as they were ‘too thick’, an ABG could not be processed; which made us question whether this could be a presentation of hyperviscosity syndrome.

The FBC came back relatively quickly and you notice that the requested blood film looked very blue compared to other samples – which you correctly identified could be a sign of a paraproteinaemia.

You pointed out that we need to be cautious with regard to top-up blood transfusions if we are considering a diagnosis of hyperviscosity syndrome, as this can further increase plasma viscosity and be dangerous for our patient.

Hb 73 

MCV 102.8 

Plt 123

WCC 5.87 

Neut 4.08 

CRP 60

 PT 12 

APTT 30

Fib 3.7

Na 140 

K 4.8 

Ur 23 

 Creat 204

 Co2 19

Total protein 115 

Albumin 37 

 Mg 1.0

 IgA 53

IgG 1.3

IgM 0.13

Paraprotein 45g/L

 Ad. Ca 4.33 

Phosphate 1.36 

                                                           
CT Head (non-contrast) No evidence of bleed/mass/infarct. Lytic lesions noted throughout skull

Next steps…
We have transferred our patient to a level 2 bed on HDU for monitoring, as he remains unresponsive and is tolerating an airway adjunct. We now have a bag of intravenous saline running in an attempt to dilute his hyperviscous blood.

We have summarised his current issues

1) Severe hypercalcaemia

2) Likely hyperviscosity syndrome

3) AKI (no know urine output at present)

4) Possible new underlying diagnosis of IgA Myeloma (serum immunofixation, lytic lesions on CT head)

Questions
· What do you know about the causes and symptoms of hypercalcaemia?

· What do you know about the causes and symptoms of hyperviscosity syndrome?

· What could be the causes of an AKI in this case?

· How would you prioritise the next steps in his management?

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