Live case presentation – Week 3

ID Jude Stevenson 56 F receptionist

30m hx sever upper abdominal pain, epigastric region

acute 30m (stomach pain last two months worsening 1-52)
into back
bloating
worse when breathing and moving
alleviating – antacids
acutely 10/10

PHx
Appendectomy 9
Hysterectomy 46
Knee arthroscopy  DVT

Warfarin (dosage varied max 600mg/day)

NSAIDs for knee pain

Penicillin allergy – rash

Imm – unknown
SHx lives with husband two cats. 2 daughters uni away from home
Smoking
4-5 standards after diner
dancing

FHx father stroke 10years ago – 85

Mother – Alzheimer 82
Both at nursing home

Exam:

Distressed pale, sweaty increased BMI lower limb bruising

Vitals
Tachycardia
Normotensive
Normal RR
Normothermic

Nil CVS findings

REsp – pain on inspiration

Abdo
Appendectomy scar
Sever epigastric pain
Rigid
Generalised guarding
No organomegaly
Reduced bowel sounds
No maleana
FOBT +

ST problem
Epigastric pain
Rigidity and guarding
FOBT – abnormal GI bleeding
Sweaty and distressed – ease concerns (surrounding AMI)
Tachycardic (due to stress?)

MT
Looking after cats (hospital stay)
Away from work – financial concerns
Hospital bills/payments additionally
Pain post management (surgery)
Bruising on lower limbs

LT
Drinking (2-3 glasses red wine/night)
Smoking (3-5/day numerous years)
Dancing (inability to compete)
Weight management (CVD risk)
INR levels (+ drinking habit influence)
Use of NSAIDs for knee pain
Away from work – less support at home (arrange for support?)

DDx

GIT
- Peptic/duodenal ulcer
- GORD
- IBD
- Pancreatitis
- Gallstones/cholecystitis
- Liver disease
- Gastritis
- Bowel obstruction
- IBS
- Cancer (bowel/stomach/oesophageal)
CVS
- AAA
- AMI
- Pericarditis
 - Dissection

RESP
- Pneumonia
- PE

MSk
- Trauma (dancing)

Working DDx
(AMI)
- Peptic ulcer  perforation
- GORD
- Gallstones/cholecystitis
- Pancreatitis
- (cancer)

Ix
Wanted
- ECG
- CXR (upright – bowel perforation)
- FBC (ABO typing – for surgery)
- UEC
- Blood lipase
- Liver function
Albumin
ALT
GGT
Bilirubin
- Coags
- (urease breath testing)
- ultrasound
- CT scan?

Received
Macrocytic anaemia – reticuloctosis (high blood turnover/production)
Neutrophilia – general inflammation (not necessarily infection – WCC normal)
Increased GGT – used to find source of liver damage (can be due to alcohol as well)
(not concerning level)
ALP – normal
 general inflammatory marker

coags = elevated (as expected on warfarin and NSAIDs)

INR and APTT PT elevated

ECG
Sinus tachycardia
No ST elvation (no AMI)

CXR – upright
(upright – to be able to see gas properly if suspicious of perforation)
Diaphragm
Underneath = black space
Sub diaphragmatic free gas – perforation (potentially in stomach – due to pain immediately
afterfood)

Increased GGT =

Increased ALT =

Both increased =

Mx
ST
- Morphine
- No more NSAIDs
- Laparotomy (major surgery)
- Warfarin stopped before surgery
- Prothrombin complex concentrate + fresh plasma beforehand to reduce
complications
- Prophylactic antibiotics prior to surgery
- Packed red cells, whole blood, fresh frozen plasma (prepared and waiting)

MT
- PPU + non-selective NSAID (3days post-op)
- Walking, movement (reduce risk of DVT, mm wasting, pneumonia)
- Coagulation testing, FBC
- NSAID counselling (change to paracetamol)
- Withhold warfarin until PPI starts
- Fluids and feeding (nutrition – referral)

LT
- Warfarin management – education
- Paracetamol for pain in place of NSAIDs (continue counselling if necessary)
- Manage CV risk factors
Smoking, alcohol, nutrition, physical activity
- Financial support
- Access care at home long term