Archives for June 2012

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      
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.


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.