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Teachingseries: A–Eassessment in EndocrineandNeur ology DeliveDr Jesvin Sunny FY2 QEHKLDisclaimer BIDA SW teaching is led by students with supervision of junior doctors and consultants across the UK. These teachings are created to support students’ learning but should not replace your local Medical School teaching material.CASE 1 • 26 year old, Female • Complaint: 1/7 abdominal pain and vomiting • PMH: T1DM, Depression, Iron deficiency anaemia • NKDA • OBS: HR 112, BP 94/58, RR 26, SpO2 98%, T 36.8History - 1/7 generalised abdominal pain, non-radiating - Vomited 4 times – clear fluids, no blood, non-projectile - Systems review: no fever, increased urinary frequency, no bowel changes (last opened this AM) - DH: Humulin M3 6 units BD - SH: Occasional alcohol binge, non-smokerAirway • Patient gave us the history – PATENTBreathing - RR 26 - SpO2 98% on room air - Equal chest expansion, normal percussion note and equal air entry bilaterallyCirculation - HR 112, BP 94/58 - ECG: Sinus tachycardia - Bloods - FBC, U&Es, CRP, VBG - Doctor, do you want a - Resuscitation: IV fluids cannula? - Any other tests? - 26F abdo pain > pregnant?Disability - GCS 15 - PEARL - Don’t ever forget GLUCOSE: 23 mmol/l - Check ketones: 4 mmol/lExposure - Abdominal exam: SNT, BS +Here’s the VBG results doc! - pH 7.29 (7.35 – 7.45) - pO2 14 (11-13 kPa) - pCO2 4.0 (4.7 -6.0 kPa) - HCO3 16 (22 – 26 mEq/L) - BE -4 mEq/L (-2 - +2) - Lactate 3.1 (0.5 -2 mmol/l) - Glucose 23Diabetic KetoAcidosis (DKA) - Ask for help / look up trust guidelines - Fluids first – Resuscitate with saline STAT and then add fluid boluses w/ K+ - Insulin next – Fixed rate of 0.1 unit/ml/kg- Continue patients long-acting insulin, STOP short-acting - Glucose – Monitor and add dextrose if <14 mmol/ L - Closely monitor K+ and treat as required - Check for infection, fluid status, ketone levels - What caused DKA? - Night out drinking, forgot to take insulin, not eaten muchCASE 2 • 89 year old, Male • Complaint: woke up with slurred speech • PMH: Hypertension, IHD, MI 2014, CABG 2014, Aortic stenosis, T2DM • NKDA • OBS: HR 78, BP 148/112, RR 16, SpO2 96%, T 36.3Airway • PatentBreathing - RR 16 - SpO2 96% on room air - Equal chest expansion, normal percussion note and equal air entry bilaterallyCirculation - HR 78, BP 148/112 - FBC, U&Es, CRP, Coagulation - Bloods - ECG - Any other tests? - CXR if history of aspirationDisability - Eyes: open spontaneously - Verbal: slurred speech - Motor: follows commands - GCS E4 V3 M6 (13) - PEARLA - Glucose: 5.6 mmol/lExposure Neurological examination - Cranial nerves normal - Peripheral (limbs): right sided weakness Any signs of head injury?Stroke - ED: establish diagnosis using a validated tool, such as ROSIER (Recognition of Stroke in the Emergency Room) > 0 likely - CT Head to r/o ICH - Aspirin 300mg STATThe CT HeadManagement - Thrombolysis window: <4.5 hours symptom onset - Aspirin 300mg for 2 weeks Secondary prevention: - After 2 weeks: Switch to clopidogrel 75mg OD or DOAC if AF - Lifestyle measures: smoking cessation, exercise, healthy balanced diet - Statin - Optimise BP (aim systolic <130) - Manage co-morbidities: DM, HF, AF, OSA, Obesity - Driving adviseQuestions? References: - JBDS 02 DKA Guideline amended v2.pdf (amazonaws.com) - Recommendations | Stroke and transient ischaemic attack in over 16s: diagnosis and initial management | Guidance | NICE - Scenario: Secondary prevention following stroke and TIA | Management | Stroke and TIA | CKS | NICE - John, K., Singhal, P. & Cook, C. Evolution of changes in the computed tomography scans of the brain of a patient with left middle cerebral artery infarction: a case report. J Med Case Reports 2, 148 (2008). https://doi.org/10.1186/1752- 1947-2-148FOR FEEDBACK AND QUERIES: Email @ info@bidasw.com
