Patient Preparation and Counseling, Therapeutic plasma exchange, Clinical Pathology - Full Vignette скачать в хорошем качестве

Patient Preparation and Counseling, Therapeutic plasma exchange, Clinical Pathology - Full Vignette

A 60-year-old man with complex cardiac, pulmonary, and gastrointestinal history is admitted to the ICU for confusion and agitation during his first therapeutic plasma exchange, subsequently developing perioral tingling, carpopedal spasms, and arrhythmias. What clinical features and laboratory findings should guide your evaluation of his sudden symptoms during plasma exchange? Which aspects of the presentation are crucial for narrowing the differential diagnosis in this critical care setting? VIDEO INFO Category: Patient Preparation and Counseling, Therapeutic plasma exchange, Clinical Pathology Difficulty: Easy - Basic level - Suitable for medical students Question Type: Diagnosis - Identify conditions based on clinical presentation Case Type: Critical Condition Explore more ways to learn on this and other topics by going to https://endlessmedical.academy/auth?h... QUESTION A 60-year-old man with a history of hypertrophic cardiomyopathy (recently reclassified as dilated cardiomyopathy on follow-up), silicosis, vesicoureteral reflux, chronic fatigue syndrome, hearing loss, laryngopharyngeal reflux, and prior gastric adenocarcinoma (resected; immunohistochemistry CK7+, HER2-, pMMR) is admitted to the ICU with agitation and confusion. He has a sedentary lifestyle, occasionally uses marijuana, and is in treatment for opioid use disorder (on methadone).... OPTIONS A. Symptomatic hypocalcemia from citrate anticoagulation during albumin-replacement TPE, presenting with perioral tingling, carpopedal spasm, and ventricular ectopy despite stable blood pressure and oxygenation. B. Immediate hypersensitivity to 5% human albumin, causing anaphylaxis with hypotension, bronchospasm, and urticaria during the exchange. C. Air embolism from central venous access, causing abrupt hypoxemia, chest pain, and a drop in end-tidal CO2 with cardiovascular collapse. D. Sepsis from catheter-related infection, causing fever, rigors, hypotension, and rising lactate within minutes of starting the exchange. CORRECT ANSWER A. Symptomatic hypocalcemia from citrate anticoagulation during albumin-replacement TPE, presenting with perioral tingling, carpopedal spasm, and ventricular ectopy despite stable blood pressure and oxygenation. EXPLANATION This patient develops classic citrate toxicity during albumin-replacement TPE: perioral tingling, carpopedal spasm, and ventricular ectopy, with documented low ionized calcium (0.88 mmol/L) and concurrent mild respiratory alkalosis (pH 7.47, PaCO2 31 mm Hg), which further lowers ionized calcium. Citrate in ACD-A chelates ionized calcium in the extracorporeal circuit and, when returned to the patient, transiently reduces systemic ionized calcium until hepatic metabolism clears citrate. Even if albumin-corrected total calcium looks near-normal, ionized calcium best correlates with symptoms. Prompt intravenous calcium (often calcium gluconate) and magnesium repletion abort symptoms and mitigate arrhythmias; slowing the citrate load or increasing prophylactic calcium infusion can prevent recurrence. Alternative diagnoses do not fit the pattern and timing. Immediate hypersensitivity to 5% albumin would more often show hypotension, bronchospasm, urticaria, or flushing, which are absent. Air embolism typically causes sudden hypoxemia, chest pain, a drop in end-tidal CO2, and hemodynamic collapse-not present here with PaO2 110 mm Hg on low-flow oxygen. Sepsis within minutes of starting an exchange is implausible; fever, rigors, hypotension, and rising lactate are not reported.... Further reading: Links to sources are provided for optional further reading only. The questions and explanations are independently authored and do not reproduce or adapt any specific third-party text or content. --------------------------------------------------- Our cases and questions come from the https://EndlessMedical.Academy quiz engine - multi-model platform. Each question and explanation is forged by consensus between multiple top AI models (i.e. Open AI GPT, Claude, Grok, etc.), with automated web searches for the latest research and verified references. Calculations (e.g. eGFR, dosages) are checked via code execution to eliminate errors, and all references are reviewed by several AIs to minimize hallucinations. Important note: This material is entirely AI-generated and has not been verified by human experts; despite stringent consensus checks, perfect accuracy cannot be guaranteed. Exercise caution - always corroborate the content with trusted references or qualified professionals, and never apply information from this content to patient care or clinical decisions without independent verification. Clinicians already rely on AI and online tools - myself included - so treat this content as an additional focused aid, not a replacement for proper medical education. Visit https://endlessmedical.academy for more AI-supported resources and cases. This material can not be treated as medical advice...