Asking questions to better understand


Category : Medical Rants

Recently we made a diagnosis that really mattered for a patient.  He came to us for an entirely different problem.  Here is the rough sequence of events:

Man in his 50s, no recent hospitalizations, admitted for new atrial fibrillation with rapid ventricular response.  His symptoms followed several days for nausea, vomiting and decreased oral intake.  His abdomen was minimally tender.  All routine labs were interpreted as unremarkable including liver tests and lipase.  A CT suggested pancreatitis, but he had BS present and no other symptoms.

His atrial fibrillation responded to IV diltiazem drip – and converted to sinus rhythm.  He had two more episodes of atrial fibrillation, but eventually maintained sinus rhythm.

I first saw him on day 3 of his hospitalization.  On day 4 his Hgb dropped from 13 to 10.5 and he reported a large melanic stool.

Review of his original labs provided a clue that we had missed – his initial BUN was 42 with a creatinine of 1.4.  But in the housestaff's defense, they had checked his stool for blood at that time and it was negative.

I have left out things that I did not know until I got to the bedside on day 4.  Some questioning led us to a totally different diagnosis.

Please suggest questions for the next 24-48 hours.

Comments (4)

TFTs and an echo to rule out aortic stenosis

Was Chrohn's disease tested?

The Afib is a secondary sign–eg 2/2 a previous GI bleed, 2/2 a neoplasm. I would ask about ulcer/gastritis risk factors–NSAIDs, EtOH, travel/H pylori, family history. Pt and family history of malignancy? Has he had a colonoscopy? 

Hey I know this is off topic but I was wondering if you knew of any widgets
I could add to my blog that automatically tweet my newest
twitter updates. I’ve been looking for a plug-in like this for quite some time and was hoping maybe you would have some experience with something like this. Please let me know if you run into anything. I truly enjoy reading your blog and I look forward to your new updates.

Post a comment