Medical instincts – the denouement


Category : General, Medical Rants

As many readers surmised, the bicarbonate was elevated secondary to hypoventilation. This patient’s ABGs (on 4 L) revealed a pH of 7.3, pCO2 74, pO2 66. He has the classic Pickwickian syndrome.

To flesh out the story, the patient suffers with PTSD. He had CPAP prescribed, but he was unable to tolerate it psychologically. He also has depression, which led to a marked weight gain over the past year – resulting in his obstructive sleep apnea.

We have 4 options which we presented to him:

1. CPAP – this just will not work
2. Weight loss, either through diet or gastric bypass – he says he can lose weight
3. Uvoloplasty – we have arranged an ENT consultation
4. If all else fails, he will eventually need a tracheotomy.

The key teaching point on the wards was that the bicarbonate level gave us a huge clue as to the extent of his hypoventilation syndrome. As readers understood, he had a more complex sleep apnea, not the simple garden variety type, but the full blown syndrome. The housestaff knew that sleep apnea was a problem. Obtaining the ABG demonstrated the severity of the syndrome.

Thanks for all the comments. I assume from the comments that I should repeat this type of post periodically.

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Comments (4)

There is another case of Pickwickian syndrome with ABGs and other labs on the Clinical Cases and Images website.

The best teaching is through practice, so your idea is definitely worth repeating or even becoming a regular feature.

As a non-medical type I did not understand the labs. This does give us a talking point with friends who are over weight and have sleep apnea to offer some positive reinforcement to loose weight and exercise.

I, too, was not immediately familiar with the labs. As an Army medic, and an applicant to medical school, I understand a lot of the chemistry and biochemistry behind them, but I don’t immediately know the normal ranges.

However, some quick Google searches were able to get me up to speed on what the ranges should be.

I do really appreciate the academic exercise these offer. Thank you, very much, DB.

What is the patient’s apnea-hypopnea index? Judging from your description of him it is likely above 60. If this is the case, uvulopalatopharyngoplasty alone is unlikely to turn the disease process around. As harsh as it may sound, the best option might be tracheostomy. This certainly would eliminate his obstructive events and may even improve his energy level to the point where weight loss is possible.

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