Woman.pptx--------------------------------

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1. A sick young woman

2. Demographics * 25 years old woman who weighs around 60 kg * Admitted to the emergency department at the 24 th of Aug

3. Chief complain Severe diarrhea that got her dizzy and hypotensive Puffy eyelids were noticed

4. Reported history Recent hospitalization for a month with AKI Type 1 DM HTN Ulcerative colitis

5. Reported history * Information about her in-patient medications were obtained including Meropenem , Metronidazole & Levofloxacin

6. Past workup Echocardiogram that revealed non-significant findings Abdominal U/S that revealed gall bladder stones & slight hepatomegaly with normal renal structure

7. Initial provisional diagnosis Nephrotic syndrome UC flare-up

8. Lab values as a guiding torch At the day of transfer to the ICU, labs were withdrawn that revealed the following

9. Lab values as a guiding torch TLC: 17 * Plt : 540 Hb : 8.8 * RBG: 140 Albumin: 2.3 * BP: 90/60 Cr: 0.5 * CVP: +12 Ca : 1 UOP: 1620/2000

10. Approached management Cefobid 1 g q12hr * Antinal q8hr Midodrine q8hr * Colosalazine 500 mg q8hr Clexane 40 q24hr * Prednisolone 40 mg q12hr Flagyl 500 mg q8hr * Calcium q12hr Furosemide 20 mg q8hr Albumin q8hr

11. It kept developing… The troublesome diarrhea was persistent. And it kept the responsible team guessing She became less edematous as Furosemide was working wonders Negative balance was observed that noted the need to re-measure the CVP

12. It kept developing… Fecal Calprotectin and urine Albumin/ Creatinin ratio were ordered C. difficile infection was suspected Other measures were advised to be taken

13. Does it particularly help? General consensus is heading towards the usefulness of FC to, at least, differentiate between IBS and IBD Recommendations have proposed it as a utility to guide the clinician through the flare-up episode

14. Re-evaluating the diagnosis Urine ACR came back 106. That, alongside her blood pressure readings, subsequent normal Albumin values and acceptable response to diuretics, further rule out nephrotic syndrome diagnosis

15. Tweaking some juices Rifaximin 500 mg PO q12hr and Vancomycin PO were added Furosemide was withhold as her UOP response was more than enough IV Dexamethasone q8hr to tightly curb that flare-up trumped Prednisolone in choice

16. Tweaking some juices Her CVP reading was almost zero that warranted the addition of Ringer’s acetate to prevent the development of possible hypovolemic AKI Septicemia was suspected as some growth were observed around the central catheter

17. Tweaking some juices * Linozelid 600 mg q12hr and Pip- Tazo q6hr were added according to the sepsis protocol

18. It does not come up cheaply! Her random blood glucose has spiked to the four hundreds She reported tingling & stinging sensations in her periphery

19. Tweaking some juices * 10 units of Insulin glargine were added

20. Some remarks Metronidazole’s relatively long-term usage is the suspected culprit The continuation of both Metronidazole on top of Vancomycin would not make sense especially when the fulminant nature of the infection is ruled out Her troublesome below range CVP readings were in need of addressing as soon as possible

21. Our recommendations Oral Vancomycin should suffice in managing the suspected C. diff infection Weaning off Norepinephrine & Midodrine Addition of B12 ampoules to alleviate the neurological manifestations

22. Our recommendations Upping the units of long-acting insulin while adding pre-meal boluses Consult gastroenterology to review her out-patient UC maintenance medications Obtain blood culture to detect the nature of the targeted organism, whether it is Gram negative or positive

23. references https :// journals.lww.com/ajg/fulltext/2016/10001/the_utility_of_fecal_calprotectin_in_an_acute.683.aspx https:// bjgp.org/content/68/675/497 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3990145 / https:// www.mayoclinicproceedings.org/article/S0025-6196%2819%2930725-6/fulltext https:// www.uptodate.com/contents/evaluation-and-management-of-suspected-sepsis-and-septic-shock-in-adults#H1633281939 https://www.sciencedirect.com/science/article/abs/pii/S0924857917303321#:~:text=Most%20cases%20of%20metronidazole%E2%80%93associated,g%20or%20%E2%89%A44%20weeks .