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Which haematological and clinical chemistry tests to request? watch

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    Hey Guys;

    Well, we have been given a patient case study and I have gone over a few things, I just need a second opinion from people. Here is the patient's case study (in short hand, spoiler contains whole thing):

    Gender: Male
    Age: 80
    Health Status: Generally healthy with no major health complaints/issues in the past
    Recently he has been suffering from abdominal pain periodically and has been urinating more frequently than normal.

    Other symptoms include the pain worsening and feeling nauseous.
    The GP has taken his temperature and has found he has a temperature of 38.6 degrees C.

    The GP has taken a blood sample to be sent off for analysis and a urinary dipstick test.

    I have come to the conclusion where he has pyrexia, is frequently urinating and has abdominal pains, it is a UTI, however, no pain has been confirmed by said patient when urinating?

    Second opinion guys?

    Full case study we have been given below:

    Spoiler:
    Show

    Reg Davies is an 80 year old man who is normally very well with no major health complaints. He lives alone, following the death of his wife several years ago, bus has plenty of support from his sons and daughter who live nearby. Recently Ref has not been feeling his usual self and has been suffering with abdominal pain periodically and needing to urinate more frequently than normal. Over the last couple of days this pain has worsened and Reg now also feels nauseous and a bit confused, so he goes to see his GP.

    Reg's GP has measured his temperature and has found it to be 38.6 degrees C. She also examines his and confirms he is suffering from flank pain as well as not appearing as together as he should be.

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    Not sure...obvs FBC, U+E. Would be interesting to see CRP, Amylase and you'd probs do a gas too.

    "A bit confused" - altered mental state ?urinary sepsis

    -->have a look at the lactate on that gas

    Would be interesting to see if he was tachy and/or hypotensive

    What does 'recently' mean?
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    ?consider appendicitis
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    maybe exclude aortic aneurysm
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    (Original post by Medicnohoperno.9)
    Not sure...obvs FBC, U+E. Would be interesting to see CRP, Amylase and you'd probs do a gas too.

    "A bit confused" - altered mental state ?urinary sepsis

    -->have a look at the lactate on that gas

    Would be interesting to see if he was tachy and/or hypotensive

    What does 'recently' mean?
    Really couldn't tell you, it's exactly what they said. Although, I would imagine it means in the last fortnight or so?
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    It's too ambiguous :P
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    (Original post by Scienceisgood)
    Hey Guys;

    Well, we have been given a patient case study and I have gone over a few things, I just need a second opinion from people. Here is the patient's case study (in short hand, spoiler contains whole thing):

    Gender: Male
    Age: 80
    Health Status: Generally healthy with no major health complaints/issues in the past
    Recently he has been suffering from abdominal pain periodically and has been urinating more frequently than normal.

    Other symptoms include the pain worsening and feeling nauseous.
    The GP has taken his temperature and has found he has a temperature of 38.6 degrees C.

    The GP has taken a blood sample to be sent off for analysis and a urinary dipstick test.

    I have come to the conclusion where he has pyrexia, is frequently urinating and has abdominal pains, it is a UTI, however, no pain has been confirmed by said patient when urinating?

    Second opinion guys?

    Full case study we have been given below:
    Spoiler:
    Show

    Reg Davies is an 80 year old man who is normally very well with no major health complaints. He lives alone, following the death of his wife several years ago, bus has plenty of support from his sons and daughter who live nearby. Recently Ref has not been feeling his usual self and has been suffering with abdominal pain periodically and needing to urinate more frequently than normal. Over the last couple of days this pain has worsened and Reg now also feels nauseous and a bit confused, so he goes to see his GP.

    Reg's GP has measured his temperature and has found it to be 38.6 degrees C. She also examines his and confirms he is suffering from flank pain as well as not appearing as together as he should be.

    Fairly obviously kidney infection - flank pain, increased urinary frequency, abdo pain, nausea, pyrexia, confusion (due to pyrexia), aetiology of gradual onset over a few days starting with increased frequency and abdo pain. Also age as increases likelihood of UTI due to BPH. Pain on micturition not necessary.

    Urine sample - dipstick for non-haemolysis blood, proteins, nitrates & culture
    U&Es may be useful - check altered kidney function
    Bloods - check for signs of sepsis - FBC, WBCs, culture
    Imaging to rule out appendicitis, prostate malignancy, renal stones
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    (Original post by Scienceisgood)
    Hey Guys;

    Well, we have been given a patient case study and I have gone over a few things, I just need a second opinion from people. Here is the patient's case study (in short hand, spoiler contains whole thing):

    Gender: Male
    Age: 80
    Health Status: Generally healthy with no major health complaints/issues in the past
    Recently he has been suffering from abdominal pain periodically and has been urinating more frequently than normal.

    Other symptoms include the pain worsening and feeling nauseous.
    The GP has taken his temperature and has found he has a temperature of 38.6 degrees C.

    The GP has taken a blood sample to be sent off for analysis and a urinary dipstick test.

    I have come to the conclusion where he has pyrexia, is frequently urinating and has abdominal pains, it is a UTI, however, no pain has been confirmed by said patient when urinating?

    Second opinion guys?

    Full case study we have been given below:
    Spoiler:
    Show

    Reg Davies is an 80 year old man who is normally very well with no major health complaints. He lives alone, following the death of his wife several years ago, bus has plenty of support from his sons and daughter who live nearby. Recently Ref has not been feeling his usual self and has been suffering with abdominal pain periodically and needing to urinate more frequently than normal. Over the last couple of days this pain has worsened and Reg now also feels nauseous and a bit confused, so he goes to see his GP.

    Reg's GP has measured his temperature and has found it to be 38.6 degrees C. She also examines his and confirms he is suffering from flank pain as well as not appearing as together as he should be.

    Immediate impression would be something like urosepsis/pylonephritis. Would also consider perforation (diverticulitis, malignancy). Any pelvic inflammation can cause urinary symptoms, particularly if you have inflamed bowel lying over the bladder.

    Important bloods would be:
    Gas & cultures (with lactate)
    FBC (signs of infection, inflammation, DIC)
    U+Es (?aki secondary to sepsis)
    Bone (?hypercalcaemia ?mets)
    LFTs (?failure secondary to sepsis, ?mets)
    CRP (inflammation)
    Amylase (acute abdomen ?pancreatitis)

    (Original post by Medicnohoperno.9)
    ?consider appendicitis
    Granted, but pretty rare in an 80 year old.
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    in real life in a GP you would need to decide in 10 minutes whether needs admission and if so why. it can be a simple urine infection but this sounds like more. the patient is old and delirious. renal pain. in GP land even if you think he needs hospital you have to then decide if this is 'medical' and goes to the AAU, if it is 'surgical' and goes to the urologist or if it is 'surgical' and goes to the general surgeons.the fact he is acutely confused (delerious), lives alone and his wife died, has a high fever, has signs on examination of possible pyelonephritis (renal pain) would make me think admission was required.whehter or not this is UTI or pyelonephritis, no one know. old and confused with a fever could really be anything. it could be UTI, it could be renal pathology, it could something else renal like a stone. it be bowel related - appendicitis, bowel obstruction. it could be gynae if it was a woman, it could even be referred pain from bones.

    you need to do a proper examination first, which would guide you. bloods and imaging are rarely helpful unless you know what you are looking for and have good rational for it. in this case in GP the urine test would be helpful. if it was full of blood it would go to the urologists. if negative i think medics.

    appendicitis you can diagnose on examination alone. i have never heard of imaging for appendicitis. you cant even see appendicitis on an image. the treatment is take it out before it bursts.
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    I think it's fairly safe to say that since this is in a GP setting they want for you to be thinking about UTI (dysuria is not always a presenting symptom btw) as opposed to the weird and wonderful - so the differentials pointed out above are all great. If he's septic, he needs a trip to A&E and IV antibiotics, so that would be for the GP to judge.

    That said, if this is a biomed PBL (which is the impression I'm getting) they won't want you to over complicate it.
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    (Original post by Democracy)
    I think it's fairly safe to say that since this is in a GP setting they want for you to be thinking about UTI (dysuria is not always a presenting symptom btw) as opposed to the weird and wonderful - so the differentials pointed out above are all great. If he's septic, he needs a trip to A&E and IV antibiotics, so that would be for the GP to judge.

    That said, if this is a biomed PBL (which is the impression I'm getting) they won't want you to over complicate it.
    Yep, that's it. =l
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    Consider uss to exclude aaa and appendix too
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    (Original post by Medicnohoperno.9)
    Consider uss to exclude aaa and appendix too
    Can you rule out acute appendicitis with an ultrasound?

    (Also very rare in the elderly)
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    I work in paeds a&e and it's usually used for a definite diagnosis with us, but yeah I dont know very much at all about geriatric medicine
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    (Original post by Medicnohoperno.9)
    I work in paeds a&e and it's usually used for a definite diagnosis with us, but yeah I dont know very much at all about geriatric medicine
    You can rule it in with a positive ultrasound in a skinny patient, but you can't rule it out with a negative ultrasound.
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    (Original post by Etomidate)
    You can rule it in with a positive ultrasound in a skinny patient, but you can't rule it out with a negative ultrasound.
    When it's retrocaecal?
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    (Original post by Medicnohoperno.9)
    When it's retrocaecal?
    Indeed. In addition to the appendix being quite difficult to visualize on ultrasound in anyone with a modicum of subcut fat.

    Also:

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    (Original post by Revenged)
    i have never heard of imaging for appendicitis. you cant even see appendicitis on an image. the treatment is take it out before it bursts.
    no role for X-ray certainly, but US and CT both important; 1st ideally do US as quicker (will only pick it up if v swollen, can be false negative), then CT if US inconclusive

    true though that most of the time you can confidently diagnose based on history and examination, but most surgeons are going to want to see some imaging before they start cutting; rare for an appendix to be so bad that it bursts before you can even do an US
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    (Original post by theresheglows)
    no role for X-ray certainly, but US and CT both important; 1st ideally do US as quicker (will only pick it up if v swollen, can be false negative), then CT if US inconclusive

    true though that most of the time you can confidently diagnose based on history and examination, but most surgeons are going to want to see some imaging before they start cutting; rare for an appendix to be so bad that it bursts before you can even do an US
    It's actually not often that imaging is done in acute appendicitis (beyond plain film - erect CXR ?perforation). A diagnostic laparoscopy is relatively uncontroversial in someone with a decently predictive alvarado score.

    Imaging/watch&wait tends to come into play when the diagnosis is uncertain or there are reasons to hold off on a lap (e.g. extensive co-morbidities). At which point a CT is usually preferred over an ultrasound for the reasons I mentioned earlier (it's also arguably easier to get a CT than it is to get an USS, especially out of hours).
 
 
 
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