Clinical Vignette thread
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A few more questions abut this pneumonia? Symptoms? Duration? Did the antibiotics help?
Urine dip, Chest xray?
small cell lung tumour secreting ACTH?
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Urine dip, Chest xray?
small cell lung tumour secreting ACTH?
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(edited 10 years ago)
Original post by My-My-My
Spoiler
Chest X-ray:
Your chest x-ray comes back and you notice that at the point he is complaining of pain, there is a well defined osteolytic lesion on the rib itself.
Urine Dipstick:
Nitrates -ve
Blood -ve
Protein +ve
(edited 10 years ago)
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)
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
I thought about a certain diagnosis within the first post
I would give this person lots of fluid as that will help bring the Ca down and also beneficial for his beleaguered kidney.
Pamidronate - and with my senior's permission give him pulse dexamethasone - 40mg hydrocortisone for 4 days.
Also a potential for Calcitonin.
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(edited 10 years ago)
Original post by Kinkerz
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Original post by Philosoraptor
I thought about a certain diagnosis within the first post
I would give this person lots of fluid as that will help bring the Ca down and also beneficial for his beleaguered kidney.
Pamidronate - and with my senior's permission give him pulse dexamethasone - 40mg hydrocortisone for 4 days.
Also a potential for Calcitonin.
I would give this person lots of fluid as that will help bring the Ca down and also beneficial for his beleaguered kidney.
Pamidronate - and with my senior's permission give him pulse dexamethasone - 40mg hydrocortisone for 4 days.
Also a potential for Calcitonin.
Yep - this chap is a sure candidate for fluids to bring his calcium down. He may also need diuretics to encourage ca loss (although I'm not sure about this when in the context of acute kidney injury - maybe someone could clarify) as well as pamidronate. Haemodialysis may be on the cards as a last resort.
(edited 10 years ago)
Ok, to continue the scenario:
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Original post by shiggydiggy
Ok, to continue the scenario:
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Original post by Kinkerz
Possibly premature:
Does he have any signs of anaemia when you examine him? Even if he doesn't, should do a FBC.
Spoiler
Does he have any signs of anaemia when you examine him? Even if he doesn't, should do a FBC.
Add 'I' to the mnemonic for infections
Original post by Kinkerz
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Hmm, ok. Let me think of another case but, to other posters, feel free to continue with VM.
(edited 10 years ago)
Original post by pgreg1
Add 'I' to the mnemonic for infections
Yeah, I tried to contrive it but it doesn't ring as nicely.
Spoiler
Original post by shiggydiggy
Hmm, ok. Let me think of another case but, to other posters, feel free to continue with VM.
Spoiler
Hmm, ok. Let me think of another case but, to other posters, feel free to continue with VM.
Cool case.
Next case: You're bleeped to the ward to see LA, a 33yr woman because she has been 'mewsing' and is becoming unresponsive. She had a bowel resection for her longstanding Crohns disease 4 days ago. You ask the nurse to repeat the obs as you head over to the ward.
On general inspection, she appears drowsy but is responding with vague noises to you. She doesn't appear pale or clammy but has signs of peripheral cyanosis.
Her obs chart reads:
HR: 64, BP: 121/83, o2: 91 on R/A, RR: 8, T:37.5
On general inspection, she appears drowsy but is responding with vague noises to you. She doesn't appear pale or clammy but has signs of peripheral cyanosis.
Her obs chart reads:
HR: 64, BP: 121/83, o2: 91 on R/A, RR: 8, T:37.5
(edited 10 years ago)
Original post by shiggydiggy
Next case: You're bleeped to the ward to see LA, a 33yr woman because she has been 'mewsing' and is becoming unresponsive. She had a bowel resection for her longstanding Crohns disease 4 days ago. You ask the nurse to repeat the obs as you head over to the ward.
On general inspection, she appears drowsy but is responding with vague noises to you. She doesn't appear pale or clammy but has signs of peripheral cyanosis.
Her obs chart reads:
HR: 64, BP: 121/83, o2: 91 on R/A, RR: 8, T:37.5
On general inspection, she appears drowsy but is responding with vague noises to you. She doesn't appear pale or clammy but has signs of peripheral cyanosis.
Her obs chart reads:
HR: 64, BP: 121/83, o2: 91 on R/A, RR: 8, T:37.5
First things first would do a proper ABCDE assessment.
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Original post by Mushi_master
A: Patent at the moment but could become at risk if she continues to deteriorate. She probably wouldn't be too happy with an OPA at this stage and there are no strange sounds.
B: Slow & shallow, but with a central trachea and bilateral breath sounds. Equal chest expansion. Sats now read 90.
C: Normal rate/rhythm. BP is normal.
D: Pinpoint pupils.
E: Temperature is ok. Surgical site looks fine. Ileostomy in-situ with good output. NAD.
(edited 10 years ago)
Original post by shiggydiggy
Next case: You're bleeped to the ward to see LA, a 33yr woman because she has been 'mewsing' and is becoming unresponsive. She had a bowel resection for her longstanding Crohns disease 4 days ago. You ask the nurse to repeat the obs as you head over to the ward.
On general inspection, she appears drowsy but is responding with vague noises to you. She doesn't appear pale or clammy but has signs of peripheral cyanosis.
Her obs chart reads:
HR: 64, BP: 121/83, o2: 91 on R/A, RR: 8, T:37.5
On general inspection, she appears drowsy but is responding with vague noises to you. She doesn't appear pale or clammy but has signs of peripheral cyanosis.
Her obs chart reads:
HR: 64, BP: 121/83, o2: 91 on R/A, RR: 8, T:37.5
Is she on any opiates for pain?
If so, stop and consider naloxone? As an f1 I think I'd be calling for senior support
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(edited 10 years ago)
Original post by shiggydiggy
A: Patent at the moment but could become at risk if she continues to deteriorate. She probably wouldn't be too happy with an OPA at this stage and there are no strange sounds.
B: Slow & shallow, but with a central trachea and bilateral breath sounds. Equal chest expansion. Sats now read 90.
C: Normal rate/rhythm. BP is normal.
D: Pinpoint pupils.
E: Temperature is ok. Surgical site looks fine. Ileostomy in-situ with good output. NAD.
B: Slow & shallow, but with a central trachea and bilateral breath sounds. Equal chest expansion. Sats now read 90.
C: Normal rate/rhythm. BP is normal.
D: Pinpoint pupils.
E: Temperature is ok. Surgical site looks fine. Ileostomy in-situ with good output. NAD.
Spoiler
Original post by shiggydiggy
A: Patent at the moment but could become at risk if she continues to deteriorate. She probably wouldn't be too happy with an OPA at this stage and there are no strange sounds.
B: Slow, but with a central trachea and bilateral breath sounds. Normal chest expansion.
C: Normal rate/rhythm. BP is normal.
D: Pinpoint pupils.
E: Temperature is ok. Surgical site looks fine. Ileostomy in-situ with good output. NAD.
B: Slow, but with a central trachea and bilateral breath sounds. Normal chest expansion.
C: Normal rate/rhythm. BP is normal.
D: Pinpoint pupils.
E: Temperature is ok. Surgical site looks fine. Ileostomy in-situ with good output. NAD.
She needs some oxygen, probably with a non-rebreathe mask at 15L flow, plus an ABG. 2 large bore cannulae, take some bloods (FBC, U+Es, LFTs, CRP, coag screen) and get some fluids going slowly (keep the lines open), get an ECG. Also would like a BM.
Spoiler
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(edited 10 years ago)
Original post by My-My-My
You look at her kardex and see that she's on regular codeine, MST and has recently been written up for PRN oramorph.
Original post by Helenia
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Spoiler
Original post by Mushi_master
She needs some oxygen, probably with a non-rebreathe mask at 15L flow, plus an ABG. 2 large bore cannulae, take some bloods (FBC, U+Es, LFTs, CRP, coag screen) and get some fluids going slowly (keep the lines open), get an ECG. Also would like a BM.
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Smashed it. Easy.
Original post by Helenia
Spoiler
I don't think that this counts as revision for the critical incident station/viva.
Back to it.
Original post by Mushi_master
She needs some oxygen, probably with a non-rebreathe mask at 15L flow, plus an ABG. 2 large bore cannulae, take some bloods (FBC, U+Es, LFTs, CRP, coag screen) and get some fluids going slowly (keep the lines open), get an ECG. Also would like a BM.
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Spoiler
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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.
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