Clinical Vignette thread

Why does she need 2xwide-bore cannulae, full bloods, fluids, ECG? I agree that that's all pretty standard for an unwell patient, but all other obs are ok and the diagnosis is immediately obvious. The management here is oxygen and naloxone, (and review opioid requirements) nothing more.

Yeah, I tried to contrive it but it doesn't ring as nicely.



Cool case.

I completely agree, diagnosis is clear and management simple, just suggestions for 'moulage OSCE station' completeness/covering all bases.

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Ok, case three:

Patient TJ, a 73yr old male, is brought in by a nursing home worker with a 3/7 hx of vomiting. He seems confused but the worker explains that he is known to have dementia.

That's fair enough and you're never going to be criticised in your exams for that approach, and IRL it's what you need to do whenever you don't know what's going on, but in this case IRL I'm sure you'd just jump in with O2 and narcan.

Any chance of a decent collateral from the nursing home or should I just **** it and find his notes?

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I literally knew all the answers to this due to those 2 pages in the Cheese and Onion on Myeloma I read like a year ago haha.

Lmao.

TJ has recently been moved 82 miles into his current home as his family lives nearby. You can't access any previous notes on the system and the paper copy is in the bowels of the hospital. You send a porter to go and dig them out but you fear you will never see him again.

Has the nursing staff stuck around or already ****ed off? If she's still floating about I want to know more about the vomit (consistency, frequency, any associated symptoms) and what his normal mental state is like in comparison (this is assumimg she knows the patient given he's new). Any past medical history and some contact details for the relatives.

P.s. I'm having too much fun in this thread.

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Yeah, I tried to contrive it but it doesn't ring as nicely.

She's still around and tells you that the first few times he was sick it was what he had just eaten. He's still being sick and it's now mostly greeny bile looking (no fresh blood, no coffee granules). She says that he's been sick three times since her shift started (in the last 6hrs).

When you ask about associated symptoms, she responds "like what?" with a quizzical look. She tells you that he keeps clutching his belly and moaning in pain episodically.

He is normally 'pleasantly confused' but is now completely off his food and disorientated.

PMHx: She's not really sure. She says that he has to take a few pills every day but she isn't qualified to dish them out.

She gives you contact details for the son, who is currently on holiday in Blackpool.

How are his obs? Sounds like he might need some fluids.

I'd also be interested to see if his abdomen looks distended.

BP: 110/70, HR: 98bpm, o2: 97, T:37.2, RR: 14.

Clinically, he has dry mucous membranes, slow cap refill, loss of skin turgor, no visable JVP when flat.

Yes, his abdomen is distended. You also notice an appendicectomy scar as well as what is probably a hernia repair.

He sounds a little dry - cannulate him and give some IV saline.

(Almost) never, ever, ever give saline.

He sounds a little dry - cannulate him and give some IV saline.

Could take bloods whilst you're at it - routine stuff (FBC could check the WCC but it doesn't sound septic at the minute... U+Es for electrolyte disturbances and LFTs too). Check BMs, get an ECG, and try your best to find out what medications he was taking.

What's the abdominal exam like? Specifically any masses or tenderness? Bowel sounds, shifting dullness? Change in bowel habits?

So you get a line in and you start some hartmanns .

Abdo exam:
Distended but not exquisitely tender anywhere. Palpation in any quadrant causes him to groan. No discernible masses. You can't elicit any fluid thrills or shifting dullness. On auscultation you can hear tinkling in the left hypochondrium.

Would you like to examine anything else?

Your bloods come back:
Hb: 172g/L
MCV: 92fL
Platelets: 280x10^9/L
WCC: 7x10^9/L

Na: 166mmol/L
K: 2.8mmol/L
Creatinine: 161umol/L
Urea: 10.2mmol/L

Bilirubin: 14umol/L
ALP: 80iu/L
Albumin: 42g/L
ALT: 18iu/L

Blood Glucose: 4.9mmol/L

ECG:

PR exam please

Any history of bowel habit and passing flatus?

His problems are
Dehydration (AKI + hypernatraemia)
Hypokalaemia - which may be causing ileus or an abdominal problem causing hypokalaemia
ECG shows ST depression in II, III and u waves - may be dig toxicity and hypokalaemia related

Need to stop nephrotoxins
Give lots of fluids
Correct K+
NG if still vomiting
AXR may be helpful

Need to stop nephrotoxins
Give lots of fluids
Correct K+
NG if still vomiting