Finished another set of twilight shifts in MAU. One of the SHOs was off sick so I got to cover a bay of patients for two shifts. The first one I ended up with the 3 sickest patients in the unit, all of whom became unwell simultaneously!
The first was a little old lady with sepsis who kept dropping her blood pressure and needed gentle fluid boluses (she also had heart failure so didnt want to send her into pulmonary oedema). She actually remained fairly stable provided she was kept sat upright (the nurses kept putting the bed head "down a little bit to make you more comfy dear" and I kept finding her gasping and tripodding herself on the edge of the bed).
The second was a lady who had come in with confusion and was about GCS 13 on admission. When I went to see her she had dropped her GCS to 7 and wasn't moving one side of her body *Erk*. She was maintaining her airway however. Phoned the med reg who was doing a lumbar puncture so went to find a consultant who said he'd "be there in a minute". Returned to my bay to find some nurses flapping because another patient (admitted with chest pain, probable costochondritis but maybe a PE) was having chest pain again, and she looked very short of breath. *Erk* (15L O2 via non rebreathe mask, urgent ECG(no acute changes), send med student running with an ABG, send nurse to find an SHO, little to find on examination, tachycardic (me, and the patient), attempt to obtain IV access).
Consultant appears and doesnt look particularly interested in this gasping patient, disappears and pokes his head round the curtains 5 mins later to declare that my GCS 7 lady is actually GCS 13 again. Med student reappears with ABG which shows a respiratory alkalosis and a PO2 of 40 (oxygenating rather well then). Patient looks much less short of breath so turn down the oxygen to 35%. Patient says chest pain has gone away and she looks back to normal. Refer for 12 hour troponin and investigation for PE.
My last shift I had one interesting patient who at first was a bit of a mystery. She had come in with shortness of breath on a background of known congestive cardiac failure, with a metallic heart valve, on warfarin. She also suffered with ischaemic heart disease and was rather overweight. It transpired she had been rather tired for several weeks, and suffered with recurrent urinary tract infections for which she had had several courses of various antibiotics. No current urinary symptoms and her stools had been darker but no PR bleeding. No recent fevers or cough. There was little to find on examination, she looked a little pale and a little breathless, possibly had a slight systolic heart murmur (and a metallic click), she also had a slightly firm left calf from where she had a recent haematoma.
So my list of differentials was quite long, anaemia, PE, ACS, endocarditis (suggested by the A&E clerking although she had no peripheral stigmata of this), hypothyroidism.. so I sent a vast array of blood tests FBC, U&E, CRP, LFT, TFT, INR, blood cultures and did an ABG which showed decreased PO2 and an Hb of 6.1. Hmm. Should have sent a group and save. Discussed with the SHO who said wait for the lab blood results to confirm anaemia. Turned out she was indeed anaemic and was transfused overnight. The cause was GI bleeding because the antibiotics for her UTIs had interfered with her warfarin metabolism giving her an INR of 7!
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