Cough / Pneumonia

Winter is here. In the ED, we’re not worried about whitewalkers. We’re worried about the influx of patients with the flu and other URIs. If you’re been in the ED recently, you know that it has already started. So, let’s do a bread-and-butter case.

A 50s M with a hx of prostate CA presents with “pneumonia”. He had a cough for a week with right sided chest pain. The patient went to an urgent care earlier in the day. A cxr was done and it showed a right-sided pneumonia. He was prescribed an antibiotic. He comes to the ED because he’s not feeling any better. His main complain is R sided rib pain when he coughs. There is no history of travel.

Vitals are HR 82, RR 14, BP 128 / 84, T 99.3, RA sat 100. His HEENT exam is normal. His lungs are mostly clear with occasional scattered rhonchi when he coughs. There is rib tenderness. He appears in pain. The rest of the exam is unremarkable. How do we treat this patient?

Do we repeat a CXR?
It’s November in the Eastern U.S. Do you do a flu swab?
Should we get blood cultures?
Should we send a lactate?

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Answer to the weird labs…

The unusual finding is a serum bicarb of 5, but the anion gap is only 18. In the ED, virtually all metabolic acidosis that we see are related to high anion gaps. The chemistries are suggestive of a non-AG metabolic acidosis.

Non-AG metabolic acidosis are caused by loss of bicarb from the body. The body loses bicarb in the urine and in the poop. Thus, the ddx includes RTA / renal causes and diarrhea / GI causes. In general, non-AG metabolic acidosis are not life-threatening emergencies…

Unless, you have a severe case of acidosis from laxative abuse. The patient’s pH on a vbg was 6.7. The treatment is relatively straightforward, put the bicarb back in the body; admit the patient. Because of the severe acidemia, most patients go to the icu.