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Diagosis me
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airtones
Pregnancy occured to me, but its not something I've covered in a clinical environment yet. Would you expect a pregnant woman to have a sustained episode like this?
The thing that made me doubt pregnancy was the duration of the encounter. Shes fallen down, most likely passed out then gotten to A&E, but her resps and pulse are still high. Is this common in pregnancy? I would have thought it would be short lived. Without a CBC, especially the white blood cell count, its hard to tell but this sounds like theres a good chance its a cytokine storm.
The thing that made me doubt pregnancy was the duration of the encounter. Shes fallen down, most likely passed out then gotten to A&E, but her resps and pulse are still high. Is this common in pregnancy? I would have thought it would be short lived. Without a CBC, especially the white blood cell count, its hard to tell but this sounds like theres a good chance its a cytokine storm.
Cytokine storm?!?
Tachycardia, tachypnea, and a pale female patient who has had a collapse.
You need to make sure she isn't pregnant because its good practice, and because you will look and idiot if you start diagnosing weird stuff like cytokine storms or putting it down to anxiety and she turns out to have an ectopic pregnancy that is bleeding.
The funny thing about this entire thread is that in most scenarios there is a set way of managing it. A pre-syncopal episode is one of those. You need to know what you are doing and why.
You also need to know you can't possibly let someone leave the ED department with obs like that.
airtones
Pregnancy occured to me, but its not something I've covered in a clinical environment yet. Would you expect a pregnant woman to have a sustained episode like this?
With a normal healthy pregnancy, no. With a ruptured ectopic or other problems, yes (though usually there would be pain too).
Not to mention the fact that if you're going to be x-raying her you want to exclude pregnancy first.
Think I've got all the questions covered, yell if I've missed
(collapse actually happened outside the hospital, so probably only 10-15 minutes previously). Felt fine until just before the collapse when felt faint, palpitations and removed from what was happening (as if underwater). Now fully aware of what is happening
Abdomen soft, no obvious bleeding
BMI - 18
Doesn't think she's pregnant (on OCP) - provides urine sample, negative
She's been tired since having pneumonia 4 months previously, is taking FeSO4 for anaemia but GP didn't say what the level was (GP in a different trust and not open for another 2 hours) no previous fainting episodes. On a course on antibiotics for a chest infection but that seems to have cleared (1 day left of course)
Sats 99%
Blood sugar - 4.2 (breakfast eaten approx 1 hour previously)
No postural hypotension - BPs pretty much the same both lying and standing
Venflon sited (after several attempts)
FBC
Hb - 5.5
WBC - 3
Platelets - 70
MCV - 100
(collapse actually happened outside the hospital, so probably only 10-15 minutes previously). Felt fine until just before the collapse when felt faint, palpitations and removed from what was happening (as if underwater). Now fully aware of what is happening
Abdomen soft, no obvious bleeding
BMI - 18
Doesn't think she's pregnant (on OCP) - provides urine sample, negative
She's been tired since having pneumonia 4 months previously, is taking FeSO4 for anaemia but GP didn't say what the level was (GP in a different trust and not open for another 2 hours) no previous fainting episodes. On a course on antibiotics for a chest infection but that seems to have cleared (1 day left of course)
Sats 99%
Blood sugar - 4.2 (breakfast eaten approx 1 hour previously)
No postural hypotension - BPs pretty much the same both lying and standing
Venflon sited (after several attempts)
FBC
Hb - 5.5
WBC - 3
Platelets - 70
MCV - 100
Hb - 5.5
No wonder she is collapsing. ECG was ok? What antibiotic is she taking? Are her obs settling with rest and O2?
Potantialy looks like some sort of nastiness to me. Lets get her admitted, preferably under haematology. She will need a blood transfusion. Then further tests to establish what put her bone marrow on strike.
iolaus
ECG showed uncomplicated tachycardia
On augmentin (co-amoxiclav)
The tachy has come down to 120 after about an hour, resps still high
Do you want to do any tests before the transfusion to try and find the cause (not necessarily get the results but at least have taken it)
On augmentin (co-amoxiclav)
The tachy has come down to 120 after about an hour, resps still high
Do you want to do any tests before the transfusion to try and find the cause (not necessarily get the results but at least have taken it)
Tests? Well the rest of bloods (results awaited) can wait.
You need to transfuse a couple of units asap - her heart is struggling with that low Hb as evidence by tachycardia and tachypnea.
I'd be interested to know the liver function, renal function and coombs test results in particular. You could send off a viral serology panel but those take ages to get back
My diagnosis is erring towards aplastic anaemia 2ndary to infection (most likely) or poss augmentin (documented but rare) with the info given.
But like i said, immediate priority is blood transfusion (packed red cells, no need for platelets) and oxygen. She is, afterall, haemodynamically unstable.
But there are certain tests which if you take after the blood is given won't give you the correct results, and will ultimately result in her being back in as blood will treat short term only. (It is being cross matched for though as she does need it)
lymph nodes examined - nothing abnormal
The haematinics were the ones I was thinking of (especially in light of the MCV)
To give the results of them (after being transferred out of A&E under care of the haematologist)
serum iron - 20mmol/L
Ferritin 8
Folic acid 1.2
B12 1.8
3 units of blood were given, drop in BP to 96/48 tachy remains at 120, resps now 20, sats 98% one episode of slightly raised temp (37.7 resolved with paracetamol).
It's 3 days later, Now you have the above results (Hb retested and now 9.8) BP still low (as above), pulse still 120 at rest. She wants to go home
Would you let her and provisional diagnosis?
lymph nodes examined - nothing abnormal
The haematinics were the ones I was thinking of (especially in light of the MCV)
To give the results of them (after being transferred out of A&E under care of the haematologist)
serum iron - 20mmol/L
Ferritin 8
Folic acid 1.2
B12 1.8
3 units of blood were given, drop in BP to 96/48 tachy remains at 120, resps now 20, sats 98% one episode of slightly raised temp (37.7 resolved with paracetamol).
It's 3 days later, Now you have the above results (Hb retested and now 9.8) BP still low (as above), pulse still 120 at rest. She wants to go home
Would you let her and provisional diagnosis?
iolaus
Occasional social drinker (maybe 8 units a week in total)
One current sexual partner (for past 10 years)
Bloods for celiacs have gone off
Anyone want to start treatment aside from the blood transfusion?
One current sexual partner (for past 10 years)
Bloods for celiacs have gone off
Anyone want to start treatment aside from the blood transfusion?
You keep changing your focus from treatment to diagnosis and back again.
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