Sometimes hoofbeats mean Zebras!

Patient was a 37y/o Woman, presented with fevers and 3 days of diarrhoea and vomiting. Had been seen day before by GP and felt likely Gastro to return if worsens.

Notes report patient was not too bad, generalised abdominal pain, soft but slightly tender abdomen. Bloods sent, stool sent, urine nil. For review in morning after IV fluids and analgesia.

I arrived to medical ward for round following morning. Patient was clearly worse and not simple gastro. Febrile 39.2C, P 120 Bp 97/45 Guarded peritonitic lower abdomen.  Blood cultures taken. Started on Cefuroxime and Metronidazole. Called the surgeon who said “sounds like I should come and review, might not be for me. Please arrange a CT”

CT showed:

Report: Free fluid, uncertain cause. Prominent distal ilium and    
appendix, but non-specific. Is there any clinical
indication of inflammatory bowel disease or other small    
bowel inflammatory cause? Appendicitis remains in the      
differential.      
Ectopic pregnancy also remains in the differential. Has    
beta-hCG been performed?

Bloods: WCC 26, Neuts 24 CRP>350 Cr 150 Hcg<5

Proceeded to theatre for laparoscopy, which found: Green, purulent fluid and diffuse peritonitis with some inflammatory adhesions. Swabs/fluid sent. Unable to find a clear cause no obvious perforation. appendix normal.

Following day call from Lab, fluid growing pure Strep A. Was like Is this the right patient, shouldnt you be calling with E.coli or Klebsiella?

Then I went searching and found some case reports.

Apparently Group A Strep is a rare cause of peritonitis, mostly in healthy women. Its thought to be related to GU spread but no-ones certain. Most, like our patient end up going to theatre as its pretty much impossible for the surgeons not to operate and diagnosis often following labs.

Patient doing well, WCC, Markers falling. Nil pain, up and about and out the door.

So that was the Zebra that turned up when I heard hoofbeats at work this week.

Refs:

http://ajcc.aacnjournals.org/content/19/5/454.full

http://www.ncbi.nlm.nih.gov/pubmed/10777203

Things come in Twos

So ive been covering medical wards this week

Had a call on monday about a lovely syncopal lady who untill the last week was still doing, Scottish highland dancing, Aquarobics, and Spin classes. Apparently she had an AS murmur but such good function so had never been investigated.

So she came to me with an episode of syncope. Walking up a slight incline, stopped twice as lightheaded and the final time after attempting to continue collapsed. Firstly i sorted out her face, stiched her up and had a good look at her.

She really was an awesome 85 Y/O lady. I was really not that convinced she had a slow rising pulse but she had an awesome ESM murmur Grade 5.5. (when you believe you can hear it from the end of the bed!)

Plan was to keep her for the night as was 10pm and get USS ect organised for the morning. 

I went down for the USS and had a play (attached photo is not mine) i wish i could get the perfect view but as just learning its not that pretty.

 

I thought this was pretty impressive, peak of >100mmHg and mean >60mmHg.

Discussed with cardiology and shes off to our teritary centre for work up to a percutaneous valve replacement.

Then yesterday afternoon got a call about a nice bloke with CHF and fast AF, ESM murmur.

Arrives to me pretty wet. had 80 IV frusemide and responded well. Bumped up his digoxin which was subtheraputic week before and his rate settled nicely.

Whilst having a look at him and his old records hes on the waitlist for a TAVI…due to happen in feb 2012. AS with peak 95mmHg and mean >60…

Cool CT recon from his work up

 

So that was my Duo of tight AS with clear symptoms. Also first time I have seen Exhertional syncope secondary to AS.

So questions for anyone/everyone. What have you had come in twos or threes?

 

A bit of poetry

In memory of my first palliative patient. A local Tealady.

She used to bring the tea,

Now it comes to her, sitting on her tray.

She was the centre of conversation,

Now silence surrounds her, only broken by the beeps of machines.

She created laughter,

Now there are only tears, her visitors weep.

She brought sustenance,

Now she does not need it, nothing passes her lips.

She would comfort others,

Now slowly comfort comes, via a subcut infusion.

She was full of warmth,

Now it slowly slips away, the tea goes cold.

 

Found a good book in my ED drawer.

Came to work and found this little bound book in the drawer. Though i would share a little prayer.

“Our director (Weingart) in Sinai,

hallowed be thy name.

Your Department come,

your will be done.

Downstairs as it is up,

Give us this day our daily podcast,

and forgive us our comments,

as we also have forgiven others.

And lead us not into temptation

but deliver us from Ignorance.”

  

 I blame #Nightshift. No offense intended. 

What kept me awake last night.

Howdy,

So im having a good night shift, couple drunks to stitch up, febrile kiddies.

Then our beige phone goes, You may have a red phone, ours is beige, the colour of terror.

70 y/o female, poorly responsive, D+V, pulse 20 bpm. ETA 5 minutes, unable to get IV access. call back but no response. Crap, As im flying solo on nights and this sounds like a bit of help would be appreciated I get the switch to call the boss in. (Go ahead, shoot me)

So pt comes in, shes big, really big. GCS 13-14 more drowsy than anything. “I feel like im going to die” The night nurse bless her goes “I hope your wrong” Pt was cool to the touch, couldnt get a temp. Unable to get a BP, P 20-25 sats 91% on RA. Denies chest pain. but not exactly with the programme.

She has no veins, none. ambos had 4-5 goes nada.

So I think, going to take a while to get access and she need some rate. #ATROPINE IM, not cause ive read anything but cause makes sense to get something on board. moment of humour and as nurse draws back first before injecting, then goes “bugger no blood”

ECG comes back its a bit unclear, not a stonking inferior MI. Were now about 5 mins down the line of me trying to get access.

 So I finally manage to get a tiny canula into her wrist (read paeds 24g) and give a IV dose of atropine, some response pulse up to 40, can get a BP now on NIBP 70/35. Reception has found her on the computer. and god bless the GP they have a summary on our new Health pathways info. it reads:

Type 2 Diabetic, very poorly compliant, HTN, very poorly compliant. (at which point i wondered what “very” poorly compliant meant..) Chronic Renal Impairment. has date of last meds collected, was yesterday…So shes prob had according to computer, 190mg metoprolol(Betaloc), Diltiazem 180mg daily, Inhibace plus, Metformin 1g TDS.

 Boss arrives and continues the search for a line, brief discussion re:IO. goes, “do you think IO is an option?” “maybe but were not going to do that”

At this point delving for better access i manage to feel a good radial pulse, so bugger it. pop a cannula in and get bloods off.More atropine and really not getting any BP with it despite pulse coming up. so calls made to place a pacing wire.

Labs are back:

pH   7.07  L   7.35 – 7.45  
pCO2   32  L   34 – 45 mm Hg
pO2   139  H   80 – 100 mm Hg
Base Excess   -21  L   -3 – +3 mmol/L
Actual Bicarbonate   9  L   23 – 29 mmol/L
Oxygen Saturation   98  
Sodium   136           135 – 145 mmol/L
Potassium   6.2  H         3.5 – 5.2 mmol/L
Chloride   114  H         95 – 110 mmol/L
Total CO2   9  L         25 – 33 mmol/L
Anion gap   20           10 – 20 mmol/L
Urea   16.4  H         3.2 – 7.7 mmol/L
Creatinine   251  H         45 – 90 umol/L
Glucose   15.4  H

 Nothing too exciting, her renal function is better than when last tested, not too sure about the potassium as might be haemolysed some but not high enough to jump on it. Gas was thought to be from poor tissue perfusion rather than DKA and her sugar aint too elevated. but getting rate up and getting some perfusion is prob first task whatever the cause.

So we wander to radiology and the boss goes, “done a pacing wire?” “uh, no”(im very articulate on nights)”you will have in about 20 minutes” I do the worlds fastest reading of the procedure. and away we go. 

Gown, Glove, prep and go. Get excellent flashback and im in. wire goes in nice. Feed, curls, #Sweat feed twists, #SweatSomeMore. Wonder about how hot it is all of a sudden and that lead is bloody heavy and hot. So after a bit more work get a good position but with a pretty curl in the artium. nice response without too much voltage. Boss joins in to improve it but cant help the kink and decides he will just leave it.

Then for central line. So same but on the other side except advace introducer to maximum depth get little blood but can’t hold the bloody thing down enough to get the guidewire in. discretion being the better part of valor I give up. quick CXR to show my handiwork and no pneumo and off to HDU.

Gas-man  arrives, read wonderful scottish anestetist with a great sense of humour. “Boy if you couldnt get it in there you better learn how real men put in central lines” So Uss guided jugular goes smoothly. Hes happy she has an art line in and even gets a good trace #stoked.

patients Bp still not cutting it despite rate of 90. so we started a dopamine infusion to which she responded well. decided with the metformin on board and bad perfusion not for noradrenaline. Also started cefuroxime.

 <—- My Handiwork!

And today i come to work shes doing well still brady when pacer is dropped back but less so 40-50. weaned off the inotropes. troponins didnt rise any higher so it looks like was drug related.

So questions for anyone reading do you remember your first pacing wire, art line, or central line? how did it go? or was it so long ago that the dementia has already claimed it? What would you do different? (its ok my goal is to learn)