The question I asked to better understand


Category : Medical Rants

To recount:

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 asked for questions.  As a sign of the problem 2 commenters suggested tests.  One commenter was spot on.  

The melanic stool required explanation.  Therefore asking questions that might give information towards a diagnosis is the proper course.  I picked the right first question – what medications were you taking?  He was taking 3 medications including Voltaren (diclofenac) – a strong non-steroidal.

"How long have you been taking Voltaren?", I asked.

"10 years"

"Why were you taking it?"

"For my arthritis"

"What kind of arthritis do you have?"

"I don't know, just arthritis."

A careful examination revealed PIP and MCP joint abnormalities – spongy, squishy and tender – while the DIP joints had some mild deformities but no squishiness or sponginess.

Now I knew the sequence of events and the underlying problem.  Do you?

Comments (3)

I think I get the ARF…though the BUN / Cr are not *that* high so maybe it's AKI?  I see how NSAIDs contributed to that (and to the melena).  I see how the arthritis may not actually be OA given the nature / location of the joints involved. 

But I can't make the connection from UGI bleed to AF.  Can't wait to see what I'm missing here….does it have to do with lytes from decreased po? 

I presume he has RA?  Maybe if was diagnosed many years earlier and put on a disease modifying drug he could have avoided or cut back on NSAID use and prevented his bleeding ulcer.    I hope you didn't anticoagulate him for the afib.  Maybe the pancreatitis on CT is from a "penetrating" ulcer? 

Hemochromatosis? Check ferritin

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