jdumoch Posted February 22, 2014 Share Posted February 22, 2014 Thought I'd post this on here.. I have a few ideas but thought i'd get some input. 46 y/o uninsured female presents to urgent care clinic with one episode of vomiting this morning and nausea with diffuse abdominal cramping throughout the day. Severe body aches and subjective fevers. Husband w/ GI bug 3 days ago. No recent travel or antibiotics. Pulse 90, normal BP. Exam benign- abdomen soft, contender non distended. Responds well to ODT zofran in the office. I order a urine hcg which is negative, and my MA runs a dipstick along with it and finds 2+ ketones. In house chem-8 shows mild hyponatremia, glucose 116, normal anion gap. has been eating normally the past week with no alterations in diet, and only had the one episode of vomiting. why the ketonuria? Link to comment Share on other sites More sharing options...
rcdavis Posted February 22, 2014 Share Posted February 22, 2014 Starvation (relative) ketosis and dehydration Though co2 is normal, has shifted from aerobic to anaerobic metabolism. Check lipase to assure no pancreatitis and maybe serum lactate. Rehydrate with 1 liter back and 1 liter d5rl.. I'll bet the ketosis resolves. Link to comment Share on other sites More sharing options...
Acebecker Posted February 22, 2014 Share Posted February 22, 2014 What he said. Ketonuria is common with GI bugs. Link to comment Share on other sites More sharing options...
jdumoch Posted February 22, 2014 Author Share Posted February 22, 2014 it was my understanding ketonuria in GI bug was from starvation and wouldn't really be occurring within the first 5-6 hours, especially with only a single episode of vomiting Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 22, 2014 Share Posted February 22, 2014 For any students, where does ketosis come from (metabolically)? For the EMS types, remember what you were taught about HHNS? Link to comment Share on other sites More sharing options...
tariesen Posted February 22, 2014 Share Posted February 22, 2014 Breakdown of fat. Not enough CHOs in diet or diabetic. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 22, 2014 Share Posted February 22, 2014 ^^^ And there's your answer. Link to comment Share on other sites More sharing options...
jdumoch Posted February 23, 2014 Author Share Posted February 23, 2014 i guess I'm missing something. i'm fully aware that ketones come from breakdown of fat.. but this particular patient had been sick for less than 6 hours, vomited only once, was able to sip water throughout the morning without vomiting, and had been eating a normal diet right up until the day I saw her. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 23, 2014 Share Posted February 23, 2014 I've personally seen it in early morning specimen collections in preparation for fasting lab work since initiation of fasting just before midnight. Link to comment Share on other sites More sharing options...
Guest Paula Posted February 23, 2014 Share Posted February 23, 2014 So what did you do? Link to comment Share on other sites More sharing options...
bradtPA Posted February 23, 2014 Share Posted February 23, 2014 i guess I'm missing something. i'm fully aware that ketones come from breakdown of fat.. but this particular patient had been sick for less than 6 hours, vomited only once, was able to sip water throughout the morning without vomiting, and had been eating a normal diet right up until the day I saw her. And this uninsured patient may have socioeconomic issues contributing, like a poor diet.... Link to comment Share on other sites More sharing options...
jdumoch Posted February 23, 2014 Author Share Posted February 23, 2014 with a normal metabolic panel I gave her zofran, told her to go home and drink and return for repeat urine and glucose.. she came back in today feeling better and no ketones. sugar of 80. still diffuse crampy abdominal pain but overall resolved. Link to comment Share on other sites More sharing options...
Guest JMPA Posted February 23, 2014 Share Posted February 23, 2014 do not treat numbers, treat patients Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 23, 2014 Moderator Share Posted February 23, 2014 with a normal metabolic panel I gave her zofran, told her to go home and drink and return for repeat urine and glucose.. she came back in today feeling better and no ketones. sugar of 80. still diffuse crampy abdominal pain but overall resolved. Well done! Could have gone through a million dollar work up for not...... I am time and time again reminded of "a tincture of time" is worth a lot..... Just because we CAN order additional testing does not mean we should.... do not treat numbers, treat patients Oh so true - I refer to it as the sniff test - unless the patient looks really bad think twice about just ordering things based on a lab finding.... did anyone else read that article about the variance that is present between labs and even with in one lab? It is huge and this compiled with the fact that the normal ranges for labs are merely statically created an not foolproof... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 23, 2014 Share Posted February 23, 2014 Dang ventana, don't start going all statistical and talking common sense stuff now ;-). Next thing you know you'll start thinking like I do that CBCs are basically worthless and that in a lot of cases, the best prescription is no prescription at all! Shoot, that should be an additional "House of God" rule. You know, we ought to come up with our own HOG PA rules. Here's the first one, in honor of EMEDPA: 1) The best rural ED SP is NO SP. Link to comment Share on other sites More sharing options...
tariesen Posted February 23, 2014 Share Posted February 23, 2014 As a medical lab scientist who's starting PA school this May (yippee!), we occasionally come across reference range variations between institutions. A lot of it has to do with different methodology (e.g. a chem analyzer from company A vs analyzer from company B). Typically, the variance is minor because patients often get lab work from a variety of sources. However, in a situation where a patient that is getting PSA testing following PCa, it's always best to continue to use the same lab if possible to avoid the minor differences (minor changes in numbers, in this case, can equate to scares). Generally, the reference ranges for a particular establishment are based on the patient population of that institution. So yes, there are minor changes from hospital A in Delaware and hospital B in California. Overall, though, a serum sodium run in DE should not vary much from the same test done in CA. Link to comment Share on other sites More sharing options...
cinntsp Posted February 23, 2014 Share Posted February 23, 2014 Oh so true - I refer to it as the sniff test - unless the patient looks really bad think twice about just ordering things based on a lab finding.... did anyone else read that article about the variance that is present between labs and even with in one lab? It is huge and this compiled with the fact that the normal ranges for labs are merely statically created an not foolproof... Normal ranges are created by using control samples and a large number of donor or patient samples. The data is used to establish a mean, cv, and sd. Controls are run every day to make sure the analyzer is functioning as it should by assuring results are produced within the established standard deviation. Like any machine, these analyzers will have occasional anomalies due to reagent problems, bubbles in a sample, clots, etc and the result is an erroneous value. This is why it's important for providers to order tests as verification rather than just hoping to find something, or know when something doesn't look right. They need to recognize the value as abnormal and request a repeat. There should not be a lot of variation within one lab for most tests if controls are run properly. We liked our cv under 10%, but there are some assays that require something higher. Sent from my Nexus 7 using Tapatalk Link to comment Share on other sites More sharing options...
Febrifuge Posted February 24, 2014 Share Posted February 24, 2014 it was my understanding ketonuria in GI bug was from starvation and wouldn't really be occurring within the first 5-6 hours, especially with only a single episode of vomiting Is the patient fit? Thin? Fat? Maybe started doing Paleo a month or two ago? Plenty of the current popular diets are lower-carb (which is generally good), and a smidge of keto isn't uncommon really. An acute period of vomiting or diarrhea might bump it up to +2. Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 24, 2014 Moderator Share Posted February 24, 2014 I am not sure if this is the one that I was remembering.... The point is that there is a fairly big variation between labs, and even within the same lab ....... yup the human body is a variable organism and trying to take an honest "still picture" of it with a lab draw is not a great idea at times... http://www.thrombosisjournal.com/content/11/1/6 Link to comment Share on other sites More sharing options...
tariesen Posted February 24, 2014 Share Posted February 24, 2014 Can you repost the link? It doesn't seem to be working. Link to comment Share on other sites More sharing options...
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