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Join date : 2013-12-26

PostSubject: AMC Clinical exam preparation   Sat Dec 28, 2013 1:39 pm

amc clinical exam

70 yr old man from nursing home was confused and disorientated. He is on Atorvastatin, Indapamide, Imipramine. No history of fall. CVS, Respiratory and other examinations normal.

Urea – 6.5 mmol/L ( 3.5-6.5 mmol/L)
Creatinine- 90 umol/L ( 80-120 umol/L)
Na- 120 mmol/L
K- 4 mmol/L
BSL- 6 mmol/L

Task- Talk to daughter about blood result and plan of management.

Me- Hi, I understand that you are here to know the blood results of your father, is it correct ?
RP- Yes

Me- Well, as you already know, your father is confused now. What I mean by confused is, he doesn’t know where he is , what the time is and who are the people around him.
There are a lot of reasons possible. Normal CT scan has excluded the bleeding in the brain.

Here is the blood result. His renal function is perfect. BSL and K are normal.
However, Na is quite low. The lower limit of normal is 135. It is 120 now which is the cause of his confusion.
The likely causes of low Na are
-Losses from gut ( vomiting or diarrhoea)
-Losses from kidney
- Inadequate salt intake
-Side effects of medications

With your father, the most likely cause is the side effect of the medication he is taking ( Indapamide) .

So, what I will do now is
- I will stop that tablet.
- I will insert a cannula and start slow saline infusion unless he has signs of fluid overload
- I will talk to the Emergency Department doctor and will send him to the hospital with ambulance.

Hospital will do the following things.

- Review by a Medical Registrar / Physician
- Slow recorrection of Na ( orally or Intravenously depending on his clinical situation )
- Blood tests, urine tests , CXR to exclude other causes of confusion.

Me- What else do you want to know ?
RP- No, that’s all I want to know.

I finished and the bell rang when I was ready to stand up but it was only 4 mins time and examiner says you still got 4 more minutes.
I have nothing to say .
I ask examiner , do you want me to explain the other causes of confusion too ?
Examiner says “ It is what you have to decide ‘

Me- Do you want me to explain other possible but less likely causes of confusion too?
RP- Smiled and says YES

Me- The other causes are Fall and bleeding into the brain ( SDH) , Stroke, Infection anywhere in the body ( Chest infection, Urine infection, .. ) , Low Oxygen , Fluid depletion, pre existing medical conditions, heart attack,..

So, on reaching the ED, they will run bloods, urine tests, ECG, CXR to rule out other causes.

Examiner – What test do you want to do before sending to hospital ?
Me- ECG ?
Examiner – Anything else?
Me- BSL is good . It is not spurious hyponatraemia too.

Bell rang. I stepped out of door and I suddenly remembered “Urine dipstick “ and said to him when I reached door.
Examiner didn’t say anything at all.

Feedback- I just focused on Medicaiton side effect throughout my consultation which makes me to miss the very common another cause “ UTI” .
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