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j00ni
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#61
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#61
Say what you think it is, nobody will think any less of you if you are wrong - we all have to learn. Plus if you get the diagnosis before anyone else you are better than us all
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lizziegee
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#62
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Ok then, just remember I am a student nurse. I think it COULD be luekemia, cant spell it properly.Probably wrong but hey I am not training to be a doctor thankfully.
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j00ni
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(Original post by lizziegee)
Ok then, just remember I am a student nurse. I think it COULD be luekemia, cant spell it properly.Probably wrong but hey I am not training to be a doctor thankfully.
That would definately have been my thought. Don't put yourself down, you clearly know more about medicine than you let on
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Ataloss
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#64
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#64
(Original post by j00ni)
Say what you think it is, nobody will think any less of you if you are wrong - we all have to learn. Plus if you get the diagnosis before anyone else you are better than us all
Sounds ALL right to me.
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Renal
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#65
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Subtle, real subtle! :p:
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j00ni
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#66
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(Original post by Renal)
Subtle, real subtle! :p:
Yeah like a brick
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lizziegee
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#67
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#67
I see what Renal was getting at now!!!!, I have only just noticed that the word "all" in jooni"s post was in bold linking it to a website about leukemia!!!, I didnt even notice it, just read the symptoms and made a diagnosis accordingly, for me the fact that the child had excessive brusing and listlessness , plus a palpable spleen gave it away. Then I read the blood sample results. Thanx for the compliment about me knowing more about medicine than I let on!!!!, cant wait to start uni and continue my learning!!!!!!.
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Revd. Mike
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#68
Hehe, this is a really cool thread. I've pretty much decided to go for medicine now, I look forward to all of this hehe. I was quite pleased that I got the situs invertus and appendicitis in the OP .
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j00ni
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#69
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I thought I would make this a bit more interactive:-


You are called to resus of your A&E department. The ambulance crew arrive with a clearly distressed man, you quickly assess his ABCs and get a brief history from the paramedics.

Mr A, male, 27yrs old

PC: severe respiratory distress of sudden onset

PMH: L hemidiaphragm surgical repair - 2003

DHx: None. No known allergies

SHx: Non smoker, alcohol - 12 units/52

Secondary survey gets you the following basic information:

OE: BP 60/40
Pulse 140bpm
Resps 28
Temp 37.2
GCS 14 (E4:V4:M6)

RS: tracheal deviation to R
raised JVP
L sided hyperresonance & diminished breath sounds on auscultation
R side NAD

CVS: Heart sounds normal

Abdo: Tenderness in epigastrium and L hypochondrium

What examinations, tests and investigations would you order to further your diagnosis? (if you can justify the test I will give you the results )
What is the diagnosis?
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JackieS
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#70
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(Original post by j00ni)
I thought I would make this a bit more interactive:-


You are called to resus of your A&E department. The ambulance crew arrive with a clearly distressed man, you quickly assess his ABCs and get a brief history from the paramedics.

Mr A, male, 27yrs old

PC: severe respiratory distress of sudden onset

PMH: L hemidiaphragm surgical repair - 2003

DHx: None. No known allergies

SHx: Non smoker, alcohol - 12 units/52

Secondary survey gets you the following basic information:

OE: BP 60/40
Pulse 140bpm
Resps 28
Temp 37.2
GCS 14 (E4:V4:M6)

RS: tracheal deviation to R
raised JVP
L sided hyperresonance & diminished breath sounds on auscultation
R side NAD

CVS: Heart sounds normal

Abdo: Tenderness in epigastrium and L hypochondrium

What examinations, tests and investigations would you order to further your diagnosis? (if you can justify the test I will give you the results )
What is the diagnosis?
well Im not a doc, but I'm guessing that one of the first port of calls would be a chest xray? does the scenario tell you what he was doing (if anything) to bring on his SOB?
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Ataloss
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#71
(Original post by JackieS)
well Im not a doc, but I'm guessing that one of the first port of calls would be a chest xray? does the scenario tell you what he was doing (if anything) to bring on his SOB?
I think this is one occasion not to do a CXR or any other investigations at this point.

I'll have a wide bore venflon please.
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Fluffy
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#72
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#72
Tension pneumo?
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j00ni
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#73
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(Original post by JackieS)
well Im not a doc, but I'm guessing that one of the first port of calls would be a chest xray? does the scenario tell you what he was doing (if anything) to bring on his SOB?
Ordered. Unfortunately, whilst waiting for the radiogrpher to come and set up the trauma CXR, the patient goes into respiratory arrest.

(NB, i hope this doesn't come across too harsh, it comes with experience that you will need to correct the patient's most pressing concerns - a CXR is definately needed for diagnosis, but not for immediate stabilisation (i.e. BP restoration and airway security) - good work though, as there is potential for serious misdiagnosis/mismanagement without a CXR
(Original post by Ataloss)
I think this is one occasion not to do a CXR or any other investigations at this point.

I'll have a wide bore venflon please.
Luckily Ataloss has given you some venous access, and you are able to get fluids onboard and secure an airway using RSI.

The patient is now intubated, but air entry on the left is still poor, so the CXR is carried out (see below)

Apical aspirate was not obtained


The radiographer apologises for the poor quality film - she had difficulty getting adequate access to the patient, and asks if you need another?

The anaesthetist is also complaining at having to bag the patient for so long and suggests mechanical ventilation, you get a watching medical student to do the donkey work whilst you decide... What do you do??

(Original post by Fluffy)
Tension pneumo?
Are you confident enough in your diagnosis to be correcting the problem??

If so, what would you do? If not, what else do you need doc??
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Fluffy
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(Original post by j00ni)
Ordered. Unfortunately, whilst waiting for the radiogrpher to come and set up the trauma CXR, the patient goes into respiratory arrest.

(NB, i hope this doesn't come across too harsh, it comes with experience that you will need to correct the patient's most pressing concerns - a CXR is definately needed for diagnosis, but not for immediate stabilisation (i.e. BP restoration and airway security) - good work though, as there is potential for serious misdiagnosis/mismanagement without a CXR

Luckily Ataloss has given you some venous access, and you are able to get fluids onboard and secure an airway using RSI.

The patient is now intubated, but air entry on the left is still poor, so the CXR is carried out (see below)



The radiographer apologises for the poor quality film - she had difficulty getting adequate access to the patient, and asks if you need another


Are you confident enough in your diagnosis to be correcting the problem??

If so, what would you do? If not, what else do you need doc??
Hell no. All we've done on tension pneumos is to convert it to a simple, then correct the simple, so (not confident here at all), but patient on 100% oxygen and do an emergency decompression using a needle or similar, until you can do thoracotomy?

I'm guessing it's not though, as I'm not sure that it would account for the epigastric tenderness etc..
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Fluffy
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(Original post by Fluffy)
Hell no. All we've done on tension pneumos is to convert it to a simple, then correct the simple, so (not confident here at all), but patient on 100% oxygen and do an emergency decompression using a needle or similar, until you can do thoracotomy?

I'm guessing it's not though, as I'm not sure that it would account for the epigastric tenderness etc..
Tension Fecopneumothorax would account for signs and pain?
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j00ni
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(Original post by Fluffy)
Hell no. All we've done on tension pneumos is to convert it to a simple, then correct the simple, so (not confident here at all), but patient on 100% oxygen and do an emergency decompression using a needle or similar, until you can do thoracotomy?

I'm guessing it's not though, as I'm not sure that it would account for the epigastric tenderness etc..
I wouldn't go blindly into the aspiration of air from a tension pneumo without more info, unless the patint was in full arrest.

Is there anything you want to do before treating for faecopneumothorax?

PAP ventilation seems to have slightly improved the air entry on the left after a couple of minutes of mech vent.
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Fluffy
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(Original post by j00ni)
I wouldn't go blindly into the aspiration of air from a tension pneumo without more info, unless the patint was in full arrest.

Is there anything you want to do before treating for faecopneumothorax?

PAP ventilation seems to have slightly improved the air entry on the left after a couple of minutes of mech vent.
No idea. The above is my sum 'knowledge'! May be do a explorative lap so you know exactly what you're dealing with (providing ABCs etc are taken care of and patient is stable). Anything else would have to be googled. So, I'd have to bow to someone elses superior knowledge, admit my own short commings, call someone and learn from it
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j00ni
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To be fair treatment as tension pneumo would not kill the patient in this case, and in 99% of cases similar would be the right call.

There was however only mild dyspnoea (not mentioned by the paramedics, and not elicited until secondary assessment - i forgot to mention sorry), which raises doubt to tension pneumo. Plus, with the CXR findings, despite a poor film, there is clearly no tension pneumo.
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Ataloss
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#79
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#79
(Original post by j00ni)
To be fair treatment as tension pneumo would not kill the patient in this case, and in 99% of cases similar would be the right call.

There was however only mild dyspnoea (not mentioned by the paramedics, and not elicited until secondary assessment - i forgot to mention sorry), which raises doubt to tension pneumo. Plus, with the CXR findings, despite a poor film, there is clearly no tension pneumo.

I'm still happy with my large bore venflon. . In a young patient that haemodynamically compressed with those initial respiratory examination findings you have to go with balance of probability - I probably wouldn't even touch the abdomen before doing it. ATLS guidelines would support that. As long as you stick in a chest drain straightaway -which then gives you the diagnosis by draining s*** - you stand a chance.

Fluid resus and stabilization (central line, art line etc..), CT scan and then to theatre and leave it to the butchers (I mean surgeons:p: ).
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j00ni
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OK, so patient has had a large bore cannula in midclav 2nd interspace has not aspirated significant air. Careful examination of the subsequent CXR leads the consultant to send the patient down to Ct once stabilised, with the intent to send on to the thoracic surgeons.


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