most likely diagnosis

[K06100]

A 48-year-old man is brought to the emergency
department confused and disoriented. He reports
recent onset of nausea and has had several
episodes of emesis in the past 4 days. On further
questioning he also notes a metallic taste in his
mouth, frequent hiccups, and pruritus. On
physical examination there is a rough, Velcro like
sound heard across his precordium. Which
of the following is the most likely diagnosis?

(A) Addisonian crisis
(B) Fulminant hepatic failure
(C) Heroin withdrawal
(D) Renal insufficiency
(E) Vitamin B12 deficiency

[anomali]

would go for D........

[Anders]

Originally Posted by K06100

A 48-year-old man is brought to the emergency
department confused and disoriented. He reports
recent onset of nausea and has had several
episodes of emesis in the past 4 days. On further
questioning he also notes a metallic taste in his
mouth, frequent hiccups, and pruritus. On
physical examination there is a rough, Velcro like
sound heard across his precordium. Which
of the following is the most likely diagnosis?

(A) Addisonian crisis
(B) Fulminant hepatic failure
(C) Heroin withdrawal
(D) Renal insufficiency
(E) Vitamin B12 deficiency

Would go with D, uremic encephalopathy+ pericarditis

[cingulate.gyrus]

D) Renal insufficiency

[K06100]

The correct answer is D. Perhaps because of the
crucial role of kidneys in fi ltering toxins from the
plasma, renal dysfunction often pre sents with a
wide range of signs and symptoms. As uremic
toxins increase, patients will complain of pruritus,
nausea and vomiting, hiccups, and a metallic
taste in the mouth. Other signs include
uremic fetor (urine-like odor to breath), altered
sensorium, malaise, asterixis, and pericardial
friction rub in cases of uremic pericarditis (the
sound heard on physical examination in this
case). Signs and symptoms of altered volume status
may also be present, as renal failure can be
caused by hypovolemia (prerenal disease) or can
cause hypervolemic states (oliguria or anuria).
Answer A is incorrect. The most common
manifestation of acute adrenal insuffi ciency
is shock, but nonspecifi c symptoms may predominate
in the initial manifestations of the
syndrome. These include nausea and vomiting,
weakness, and abdominal pain. Changes
in arousal may also occur, ranging from fatigue
and lethargy to coma.
Answer B is incorrect. Symptoms of hepatic
failure include nausea, anorexia, jaundice, and
abdominal pain. Hepatic encephalopathy, if
present, can lead to asterixis, confusion, and
even coma.
Answer C is incorrect. Signs and symptoms
of opiate withdrawal are opposite to the effects
often associated with opiate use and abuse.
These include anxiety, tremor, and fl u-like
symptoms such as rhinorrhea, sneezing, nausea,
and vomiting. Other common symptoms
include papillary dilation, lacrimation, yawning,
and diarrhea.
Answer E is incorrect.Vitamin B12 defi ciency
is most often due to pernicious anemia, which
causes macrocytic anemia. Vitamin B12 defi
ciency may also lead to signs and symptoms
discernible on examination. Classically, mental
sluggishness, a shiny tongue, and a shuffl ing,
broad-based gait are associated with pernicious
anemia-induced vitamin B12 defi ciency. Patients
may also exhibit personality changes and
memory impairment. Other nonspecifi c neurologic
fi ndings due to damage to the posterior
and lateral spinal columns include loss of dexterity,
paresthesias, and weakness.