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August to December 2015

The art of bedside presentation - two models.

Model 1: A 59-year-old Malay gentleman with no known medical illness and is a chronic smoker presented with central, crushing chest pain which radiates to the jaw and the back. On admission, he was tachycardic and tachypnoeic with blood pressure of 94/61mmHg. Apex beat was at 5th intercostal space 2cm lateral to midclavicular line. There were no additional heart sounds, murmur or bi-basal crepitations. An electrocardiogram was done immediately which shows ventricular tachycardia. Intravenous amiodarone was given. Subsequently he underwent synchronized cardioversion and the rhythm reverted to sinus rhythm. He was diagnosed with ventricular tachycardia secondary to myocardial infarction.

Model 2: A 59 year old man, a smoker, presented with sudden onset of central chest pain, tachycardia and hypotension. His pulse rate was (120 per minute?) and his BP was 94/61mm Hg. Auscultation of the heart and lungs were normal. An urgent ECG showed ventricular tachycardia. He was initially given intravenous amiodarone but he did not respond to it. He was then reverted to sinus rhythm with synchronized cardioversion (using 350 joules?). After sinus rhythm was restored, his ECG showed…….

Creating a bedside presentation from available information

The raw data: Mr MR is a 63 years old Malay gentleman with completely treated pulmonary tuberculosis 2 years ago and a known case of COPD 3 months ago, presented with shortness of breath 2 days. He also
presented with paroxysmal nocturnal dyspnoea and orthopnea. He denied cough and fever. He had
no chest pain , palpitation and leg swelling. He was an ex smoker for 40 years and 2 packs per day.
Prior 2 days to admission, he was discharged from hospital and the diagnosis was AECOAD due to
CAP. He was given Co-amoxiclav for 3 days. On admission, he was tachypnoeic and only able to
spoke in words . Auscultation of the heart showed no abnormal findings and there was no raised
JVP . Upon auscultation of the lungs , there was generalized rhonchi and bilateral equal air entry .
The examinations of other systems were not significant . Chest X ray showed widened intercostals
space , flat diaphragm, tear drop shaped heart and opacities around the perihilar region. Full blood
count showed raised white blood cell predominantly neutrophils. The provisional diagnosis was
AECOAD due to partially treated CAP . At the emergency department , he was given IV
Hydrocortisone 200mg STAT, S/C Terbutaline 0.5mg STAT, IV Aminophylline 250mg, and IV
Ceftriaxone 2g STAT. In the ward, he was treated with nebulisation 4 hourly, IV Ceftriaxone 2g twice
a day and Tablet Prednisolone 40mg once daily.

What is this case about?
It is about a 63 year old man with AECOPD and CAP.

Next: Having decided that what you are going to present is a man with AECOPD and CAP, ask yourself how significant the following pieces of information are to this presentation? Depending on your answers, you will have to include it or exclude it from your presentation.

  1. Treated for PTB 2 years ago
  2. PND and othopnoea
  3. The absence of cough and fever
  4. The absence of chest pain, palpitations and leg swelling
  5. The past history of smoking
  6. The history of admission to the hospital 2 days prior to the current admission
  7. The history of treatment with Co-Amoxiclav
  8. The clinical finding of tachypnoea
  9. The ability to speak only in words (that is, inability to speak in full sentences)
  10. The normal cardiac findings and the absence of raised JVP
  11. The auscultatory findings in the lungs
  12. The chest x-ray findings
  13. The full blood count findings
  14. The treatment details in the A&E

A 59 year old woman presented to the hospital with these investigations. Your task is to analyse these results and discuss the various things that might be wrong with her.

Item Patient's value unit of measurement normal value/range
Blood urea 26.8 mmol/L 2.8 - 7.8
Serum creatinine 773 umol/L 61 -124
Serum sodium 138 mmol/L 135 -148
Serum potassium 4.9 mmol/L 3.5 - 5.1
Serum chloride 107 mmol/L 93 - 108
Total serum protein 62 Gram/L 60 -83
Serum Albumin 36 Gram/L 35 - 48
Serum Globulin 27 Gram/L 28 - 36
Total Bilirubin 5.8 umol/L 0 -25
Alk. Phosphatase 120 U/L 36 -92
Alanine transaminase (ALT) 15 U/L < 40
Total Cholesterol 3.8 mmol/L < 5.7
Triglycerides 2.1 mmol/L 0.4 -1.8
HDL C 1.0 mmol/L > 1.7
LDL C 1.9 mmol/L < 3.3
Serum Calcium 1.95 mmol/L 2.2 - 2.65
Serum Phosphate 1.82 mmol/L 0.81 - 1.45
Fasting plasma glucose 4.2 mmol/L 3.9 - 6.6
HbA1c 6.9 % <7
24 hours urine protein 7.6 Grams Less than 150mg
Urine examination SG 1.010 protein 5G/L glucose + nitrite nil

Urine WBC: 5 to 10 / HPF (500/uL; normal less than 10/uL)
Urine RBC: 1 to 3 / HPF ; (50/uL; normal less than 5/uL)

For discussion:

  1. The discharge diagnosis is: "Chronic liver disease with thrombocytopenia". How are these two things linked?
  2. From clinical notes: "The patient has fluid overload. His x-ray chest shows congestive pattern and cardiomegaly." What exactly are we dealing with here?
  3. A woman has hypertension and a serum creatinine of 171umol/L. What do you think may be the cause of the hypertension?
  4. An 85 year old man has CKD. His fasting plasma glucose is 5.3mmol/L. Is it possible that he has diabetes?
  5. The renal profile of a patient: Blood urea 14.3mmol/L; Serum creatinine 156umol/L; Serum Na 140mmol/L; Serum K 3.2mmol/L. Question: Why is the K low when the urea and creatinine are raised?
  6. A 69 year old man has COPD and was diagnosed recently as having decompensated CCF. His ECHO showed LVEF of 60 percent. What are we dealing with here?
  7. How do you treat a patient who has chronic renal failure?
  8. What are the advantages and disadvantages of using Frusemide in chronic renal failure?
  9. Analyse this ABG: pH 7.25; PaCO2: 25; PaO2: 90; Na 135mmol/L; K 3.8mmol/L; Chloride 100mmol/L: HCO3: 12
  10. A 54 year old man with DM, HPT and CRF (Creatinine 707umol/L) and old CVA (L hemiplegia) is noted to have a BP of 236/111mm Hg on his routine clinic visit. He is on Tab Prazocin 2mg TDS, Tab Felodipine 10mg BD and Tab Metoprolol 100mg BD. What will you do next to control his BP?
  11. A 73 year old woman has DM, HPT, CRF and OA of knees. Her urea is 21mmol/L and creatinine 238umol/L. Sodium is 138mmol/L and Potassium is 5mmol/L. Serum albumin is 45gm/L and serum calcium is 2.55mmol/L (normal value of serum calcium is 2.20 to 2.65). She is currently taking Methyldopa, Amlodipine, Losartan, Metoprolol, Simvastatin, Iron, Folic acid, B complex and C vitamins as well as Mixtard insulin. Questions: a) Which of these drugs is a cause of concern for you? b) Do you think she needs to be given Calcium supplements as well?

The following questions are based on this review from NEJM.
1. A patient with diabetic ketoacidosis has these values: plasma glucose 57.7mmol/L; Na 135mmol/L; K 5.4mmol/L; Chloride 97mmol/L; Bicarbonate 10mmol/L. Questions: What are the various things that you can infer from these values?
2. Is this statement correct? "In diabetic ketoacidosis, both non-anion gap acidosis and anion gap acidosis are possible".
3. Why is the combination of Metformin and an ACEI inhibitor potentially dangerous in patients with diabetic ketoacidosis?

Dr Velayudhan Menon, MD
Clinical Associate Professor of Medicine
International Medical University, Malaysia

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