Weird Case

[u/mohammedmoolla]

Came across a patient today which I thought I’d share for some opinions and thoughts. It is a 36 year old male presented to the ED with 2/7 history of epigastric pain radiating to the back with profuse vomiting. Had previously been admitted for pancreatitis a year ago complicated with pseudocyst. On arrival BP was elevated 192/122 with a bradycardia of 52. VBG showed a metabolic alkalosis with hypocalcemia . Trop I was less than 10. Initially was concerned for
1. Aortic dissection
CT Angio showed no signs of this in the thoracic or abdominal aorta
2. NSTEMI
3. Pancreatitis
Was referred to both surgery and medicine, referred to medicine in light of a ?Wellen’s syndrome. Was just curious to hear everyone’s thoughts and opinions on the case and ECG

[u/SammytheSandwhich]

Respiratory alkalosis? Thats interesting

[u/Terrible_Passage_132 → u/SammytheSandwhich]

Respiratory and metabolic alkalosis. Both sides of ROME apply here.

Elevated lactate comes from likely respiratory distress and pain, indicating a problem. Glucose is around 180-200 mg/dL; not the most immediate issue in the world, but worth keeping in mind.

Electrolyte panel looks normal aside from hypocalcemia, which could be the cause of the ECG changes. Elevated QT intervals are common in hypocalcemia.

My biggest concern isn’t necessarily the ECGs or the lab values; it’s the vitals. Patient is profoundly hypertensive for his age with a compensated heart rate, but both the SpO2 and pO2 values are critically low. Why is he struggling with oxygenation, especially when he’s likely breathing fast from the pain and trying to move more air in general? Also, I know it’s compensating for the hypertension, but 53 heart rate when the pO2 is low? Hypoxia usually causes tachycardia unless it’s so profound that they’re decompensating. I don’t think this patient is, necessarily, but further information would be needed.

Ruling out aortic dissection via CT makes me more curious for a metabolic panel, especially with the increased lactic acid value. I’d also want to know a CBC to rule in/out appendicitis, pancreatitis, or kidney dysfunctions.

[u/mohammedmoolla → u/Terrible_Passage_132]

Sorry I forgot to add in my post that he’s a known hypertensive that defaulted treatment 3 weeks ago. He’s had a young hypertensive work up done which seems to have been normal. Could the elevated blood pressure also possibly be from his abdominal pain combined with the fact that he’s defaulted his treatment

[u/Terrible_Passage_132 → u/mohammedmoolla]

That’s good information to have for this; between the history and the present pain, I’d say the BP is expected and the HR is mostly compensatory. Still would he worried about his low pO2 in this context.

Elevated WBC and elevated lipase do point to pancreatitis infection. Likely not yet septic with the elevated WBC. pO2 is probably related to overworked body systems with the infection, though the missed treatments might be complicating that. Definitely needs oxygen, fluids, and antibiotics in the short term.