The Student Room Group

Clinical Vignette thread

Thought I'd start a thread for people to share some clinical vignettes. So the idea is to pitch a short presenting complaint and other posters will ask additional questions to elaborate the history and examination findings, request investigations, form a differential and suggest a plan etc.

A few rules:
If you think you've got the case sussed, post it in a [ spoiler] [ / spoiler ] so that other posters can continue to reason the story out.

If you want to request an investigation, try to justify why you've ordered it and what you are expecting to find. Unjustified requests will be bounced back by the disgruntled lab/radiologist.

Finally, don't turn the thread into a ****storm, as they have done in the past.

Ok, here goes:

Patient VM: A 62yr old man presents with a three week history of back pain. He also complains that he is having to void his bladder more than usual and 'just doesn't feel his usual self'.

You're also given a set of basic obs:
BP: 142/85, HR: 78, o2: 98, T: 37.3, RR: 12

Anyone want to start?
(edited 10 years ago)

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Reply 1
Any other changes in the waterworks?
Pain? Blood?


Posted from TSR Mobile
Reply 2
History of the back pain please? i.e. SOCRATES.
Reply 3
Original post by fiona_135
Any other changes in the waterworks?
Pain? Blood?


Posted from TSR Mobile


Nope. No pain, no change in colour, smell. Just increased frequency.
Reply 4
Original post by Democracy
History of the back pain please? i.e. SOCRATES.


Site: When you ask he tells you "it's on the left, doc" and gestures to his lower thorax. "It feels like I broke a rib". He says that he can't quite reach it himself, but it's as though it's one specific spot.

Quality: Describes it as a gnawing pain.

Intensity: 7/10. He seems pretty upset about it.

Timing: It's pretty constant. Doesn't vary much. It's keeping him up at night recently.

Aggrivating/Relieving: Nothing particularly. NSAIDs have not helped at all.
Reply 5
Original post by shiggydiggy
Site: When you ask he tells you "it's on the left, doc" and gestures to his lower thorax. "It feels like I broke a rib". He says that he can't quite reach it himself, but it's as though it's one specific spot.

Quality: Describes it as a gnawing pain.

Intensity: 7/10. He seems pretty upset about it.

Timing: It's pretty constant. Doesn't vary much. It's keeping him up at night recently.

Aggrivating/Relieving: Nothing particularly. NSAIDs have not helped at all.


On any current medication?
Original post by shiggydiggy
Nope. No pain, no change in colour, smell. Just increased frequency.


How much is he pissing out at each time?

Posted from TSR Mobile
Things I'd like to know:

Onset - 3 week history, ok. Does he recall roughly how quickly the symptoms came on - minutes, hours or days? Did both the polyuria and the pain start together, or did one come later?

Exacerbating/Relieving - is the pain at all stimulated or changed by eating?

Existing conditions - standard questions... Diabetes, any chronic medical conditions the patient is aware of...

Medication - prescribed and over-the-counter, of course. Also any recreational drugs, as unlikely as it would seem in a 62-year old.

Risk factors- smoking, drinking? Any recent change in either? Recent unprotected sex (I really don't care that he's 62 :lol:)



Also can I get a clarification on the site of the pain - it's posterior left lower thorax as I currently understand from posts across this thread so far? Any radiation?
Reply 8
Original post by fallenangel
On any current medication?


NKDA
Ramipril 1.25mg PO OD
Amlodipine 5mg PO OD
Simvastatin 20mg PO OD
Finished a course of amoxicillin about 3/52 ago, prescribed by the GP for community acquired pneumonia.

Original post by RollerBall
How much is he pissing out at each time?

Posted from TSR Mobile


He isn't quite sure but says that it's not an especially small amount or large amount. But he does also tell you that he's never had any problems with hesitation, flow, stopping/starting. He then nervously shuffles in his chair and asks "you're not going to do THAT exam, are you, doc? you look the type".

Original post by Friar Chris
Things I'd like to know:

Onset - 3 week history, ok. Does he recall roughly how quickly the symptoms came on - minutes, hours or days? Did both the polyuria and the pain start together, or did one come later?

Exacerbating/Relieving - is the pain at all stimulated or changed by eating?

Existing conditions - standard questions... Diabetes, any chronic medical conditions the patient is aware of...

Medication - prescribed and over-the-counter, of course. Also any recreational drugs, as unlikely as it would seem in a 62-year old.

Risk factors- smoking, drinking? Any recent change in either? Recent unprotected sex (I really don't care that he's 62 :lol:)



Also can I get a clarification on the site of the pain - it's posterior left lower thorax as I currently understand from posts across this thread so far? Any radiation?



Onset: The pain came on over days, but fast enough that he could feel it getting worse. The polyuria, he says, has been coming on gradually perhaps two or so weeks before the pain started. He tells you that it's just a nuisance more than anything now. He also feels quite thirsty with it too but the GP tested his blood sugar and it was within normal ranges.

Exacerbating: Nah, doesn't seem to change with eating.

PMHx: Nil other than recently diagnosed HPT and the now-resolved chest infection (mentioned above).

Rx: See above. No recreational drugs.

Risk factors: He has smoked around 1.5 packs a day for 20 odd years. He drinks four pints of lager on saturday and again on sunday. He has unprotected sex with his long-term wife but no other risk factors.

Site: You interrupt the history to have a quick prod of his back to see what he's talking about. You trace one of the posterior ribs with your thumb with no response until suddenly he jumps out of the chair. There seems to be one particular focal spot which is very tender, around the posterior midpoint of the 10th left rib. No radiation.
(edited 10 years ago)
Reply 9
I'm only a second year, so forgive my lack of any real knowledge haha

Due of the location of the pain, posterior/around T10 and the associated polyurea, I'd like to request U&E's
(edited 10 years ago)
Reply 10
Original post by fallenangel
I'm only a second year, so forgive my lack of any real knowledge haha

Due of the location of the pain, posterior lower ribs and the associated polyurea, I'd like to request U&E's


Na: 141mmol/L
K: 4.6mmol/L
Creatinine: 212umol/L
Urea: 8.3mmol/L
Ca: 3.2mmol/L
(edited 10 years ago)
Original post by shiggydiggy
Na: 141mmol/L
K: 4.6mmol/L
Creatinine: 212umol/L
Urea: 8.3mmol/L
Ca: 3.2mmol/L


Someone else can take it from here, I'm only into week 3 of my urinary module.
Reply 12
Original post by fallenangel
Someone else can take it from here, I'm only into week 3 of my urinary module.


Don't worry. Is there anything in the history you would like to expand on?
Original post by shiggydiggy
Don't worry. Is there anything in the history you would like to expand on?


Perhaps the 'just doesn't feel his normal self?'
Reply 14
Original post by fallenangel
Perhaps the 'just doesn't feel his normal self?'


He tells you that the wife thinks he's a bit muddled and confused. He says that he's been quite low in mood and very tired recently. He just doesn't feel like eating and he's lost almost two stone in weight in the last two months.
(edited 10 years ago)
Original post by shiggydiggy
He tells you that the wife thinks he's a bit muddled and confused. He says that he's been quite low in mood and very tired recently. He just doesn't feel like eating and he's lost almost two stone in weight in the last two months.


:erm:
Reply 16
Possibly premature:

Spoiler



Does he have any signs of anaemia when you examine him? Even if he doesn't, should do a FBC.
Reply 17
Original post by Kinkerz
Possibly premature:

Spoiler



Does he have any signs of anaemia when you examine him? Even if he doesn't, should do a FBC.


Clinically, he seems a pale with near-white conjunctiva.

FBC Results:
Hb: 84g/L
MCV: 82fL
Platelets: 128x10^9/L
WCC: 3.4x10^9/L

Results to your additional requests (which may spoiler)

Spoiler

Reply 18
Original post by shiggydiggy
Clinically, he seems a pale with near-white conjunctiva.

FBC Results:
Hb: 84g/L
MCV: 82fL
Platelets: 128x10^9/L
WCC: 3.4x10^9/L

Results to your additional requests (which may spoiler)

Spoiler


Spoiler

Reply 19
Original post by Kinkerz

Spoiler



Spoiler

(edited 10 years ago)

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