On sit down rounds yesterday morning, the team told me about a gentleman with severe achalasia. Because of the achalasia he had a G-tube in place for 15 years. As they told the story he came in for vomiting and was found to have a left lower lobe pneumonia. They worried that the patient had an aspiration pneumonia.
At the bedside I questioned the patient:
db: "When did you first get sick this time?"
pt: "Sunday I got sick"
db: "What was bothering you first?"
pt: "I got hot and started sweating. My wife had to wipe my brow."
db: "How bad were the sweats?"
pt: "I was sweating all day. I had to change my pajamas."
db: "Did you have any chills?"
pt: "Yes, I was shaking." (note patient mimicks a rigor)
db: "When did you start vomiting?"
pt: "Monday"
On Tuesday this patient had multiple imaging studies to look for a source of his vomiting. After taking a careful history, we postulated that he patient developed community acquired pneumonia. I suspect that he had transient bacteria and that led to his vomiting.
By yesterday, he was no longer vomiting or nauseous. We reviewed his CXR and found LLL consolidation.
We restarted his feedings and plan to discharge him today.
The timeline is an absolute key to thinking through this patient’s story. We must always strive to understand the order of symptoms. I suspect we could have done less imaging studies – although having a patient with achalasia is outside the norm and perhaps that drove our imaging.
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