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Small Town Jericho


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Well it's late and you're stuck in Small Town Jericho, a little haven for us pick up loving, contemporary country music playing, pro-gun ownership conservative Christian Republicans about a yonder from civilisation.

You're called to help out Tim, a 70 year old male who has been found by his daughter-in-law in the lounge chair very confused and lethargic. She stopped in to check on him before going to bed as he usually hurls empty beer cans at the telly while watching the late shows before going to be about midnight.

PMHx DM, HTN, AF, CABG w/ stent 2005, anaemia, alcoholism

SHx lives with wife who is away for weekend, smoker, drinks heavily, trying to cut down due to financial difficulties, rehab for etoh 2004

Meds insulin, metformin, warfrin, iron, coradone, inhibace, frusemide

Today - awoke mane, ate breakfast, quiet day at home, dinner ? 7pm, found in lounge 9pm

C/C feeling weak, abdo pain diffuse all quad, constant dull aching pain 5/10 began suddenly 1/24 ago, no back pain

O/A in lounge chair, alert to voice

Physical exam

Neruo - alert + orientated, rousable to voice, PERRL, neg FAST, CN OK, peripheral neuro OK, no neuro symps

Chest/resp - CABG scar, no trauma, respnormal, trachea mid line, good air entry, lung sounds ok, no crackle or wheeze, no tactile frementus, percussion normal

Cardio - pulse reg + strong, pedal pulses present, tachycardia, S1/S2 OK nil added, no edema, no JVD, JVP 3, ECG ST

Abdo - tender, painful to palpate all quads, percussion painful, not distended, no discolouration, +BS

Extremities - ok, no clubbing or cyanosis, sunken eyes, very dry

VS R23 P120 BP 180/130 SPO2 98% RA T 37.5 (~98 F)

There is no Doctor at the local clinic so you're it tonight and unfortunately the helicopter cannot fly nor can the ambulance transfer out to Sugarland Regional in Big City.

What are you going to do with this bloke and what do you figure might be wrong with him?

Edited by kiwimedic
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One of the big concerns that I see is possible internal bleeding, Could be possible interaction between Diabetes and Alcohol. If I'm so far off please do let me know.

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Can we get a glucose reading to rule out DKA.

Whats his breath smell like. alcohol,fruity,GI smell

Has the patient had a hx of constipation

has he been compliant with all of his medication

Edited by runswithneedles
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One of the big concerns that I see is possible internal bleeding, Could be possible interaction between Diabetes and Alcohol. If I'm so far off please do let me know.

Internal bleeding is not an unreasonable differential diagnosis

Can we get a glucose reading to rule out DKA.

Whats his breath smell like. alcohol,fruity,GI smell

Has the patient had a hx of constipation

has he been compliant with all of his medication

Fingerstick BGL is 37 (~1 mmol/l)

No DKA or consitpation

Has been complaint with his medications as far as it seems

Since y'all have access to the clinic what bloods or additional tests would you like to order?

NB I shouldn't have said he was alert + orientated; he is rousable to voice but not orientated

Edited by kiwimedic
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Saweet.how about a liver enzyme panel. allong with a complete blood coount

possible liver failure

would like to see if the anemia could be playing a role secondary to poor diet

Fingerstick BGL is 37 (~1 mmol/l)

forgot to mention. I dont know the whole mmol/l. How do you convert that to mg/dL

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Saweet.how about a liver enzyme panel. allong with a complete blood coount

LFT normal

CBC normal

ETOH neg

Lactate is 7mmol/l (normal reference range 0.5-1.0mmol/l)

would like to see if the anemia could be playing a role secondary to poor diet

Normal Fe

forgot to mention. I dont know the whole mmol/l. How do you convert that to mg/dL

You muppet, 37 is mg/dl which is approx 1mmol/l; for your interest mg/dl > mmol/l is /18 and mmol/l > mg/dl is x18

Edited by kiwimedic
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Whats a muppett.

Okay. He needs glucose.

Start iv and give D50

Does his LOC improve.

Whats his CBC after the D50 push.

Can we also get a ph.

Possible lactic acidosis

Hepatitis?The metformin might be causing the increased lactate level

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Start iv and give D50

After two amps of D50 his LOC improves a bit

Whats his CBC after the D50 push.

His fingerstick glucose is now 80 or 4mmol/l

Can we also get a ph.

His pH is 7.37

The metformin might be causing the increased lactate level

What else might cause it?

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Can we also get a cardiac panel along with a 12 Lead. The increased lactate level can be from muscle death and this pt has an extensive cardiac history

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