- 42, M
- 1 day severe upper abdominal pain
- Vomited 5 times
- 13 cigarettes/day / 17 units alc/week
- Temp 38, PR 93bpm, BP 140/82
- Tender epigastrium, right upper quadrant
- Voluntary guarding (tensing of abd. muscles to avoid pain)
White cell count 15 × 109/L (3.8–10.0)
ALT (alanine aminotransferase) 41 IU/L (10–50)
Alkaline phosphatase 125 IU/L (25–115)
Bilirubin 14 μmol/L (<17)
Amylase 222U/L (<220)
CRP 42 mg/L (<5)
Most likely diagnosis?
Acute cholecystitis
- 55, F
- 3 weeks memory problems and confusion
- Headaches worse when coughing/sneezing
- Associated w/ vomitng
- Resected melanoma and treated w/ adjuvant immunotherapy 2 years ago
- BP 169/100 mmHg
- No focal neurological signs
Most likely diagnosis?
Cerebral metastases
- 66, M
- Advanced gastric cancer
- Morphine sulfate (modified release, 90mg twice daily) for abd. pain
- In last days of life, unable to swallow oral meds
- Not needed doses for breakthrough pain
eGFR = >60 mL/min/1.73 m2 (>60)
Continous subcut. infusion of morphine sulfate required, as direct conversion from oral morphine sulfate. Correct dose over 24 hrs?
90 mg
(Morphine sulfate SC in 24 hrs = 0.5 x Total Morphine sulfate oral dose in 24 hrs)
- 40, F
- Low back pain day after falling while playing tennis
- Usually well, no regular meds
- Lab technician
Continue usual activity - short duration acute low back pain in fit person
- 50, F
- Burning pain in right leg
- Advanced cervical cancer compressing sciatic nerve
- As part of EOL care, takes morphine sulfate modified release (20mg twice daily)
- Requests further pain medication
Most appropriate medication to add?
Oral amitryptiline
- 75, M
- Presents to ED feeling generaly unwell
- No specific symptoms
- Treated w/ neoadjuvant chemotherapy for rectal cancer
- Underwent 2nd cycle 8 days ago
- 38.4 temp, PR 97 bpm, RR 12 breaths/min, Oxygen Sat 98% breathing air
- Blood test results not available yet
Next management step?
IV broad-spectrum antibiotics
- 41, F
- 1 day painful, swollen left knee and fever
- History of rheumatoid arthritis
- Takes methotrexate and abatacept
- 38.2 temp, PR 100 bpm, BP 119/83 mmHg
- Left knee swollen and erthythematous
White cell count 15.2 × 109/L (3.8–10.0)
Urea 6.7 mmol/L (2.5–7.8)
Creatinine 98 μmol/L (60–120)
CRP 154 mg/L (<5)
Joint aspiration: no organisms on Gram stain,
white cell count 2645/μL (<200), mostly neutrophils, no crystals.
Appropriate additional management?
IV flucloxacillin
- 64, F
- White British visits GP for NHS health check
- BMI 30, BP 110/84
- Normal urinalysis
Glycated haemoglobin 44 mmol/mol (20–42)
Appropriate next step?
Diabetes Prevention Programme
- 82, F
- 5 days worsening abdominal pain
- Recent constipation
- No rectal bleed
- 38.1 temp
- PR 105 bpm, BP 140/85
- Tenderness in left iliac fossa with rebound tenderness
- Normal bowel sounds
- Rectal exam shows hard stools only
Most likely diagnosis?
Sigmoid diverticulitis (changes in bowel habit, left iliac fossa pain, features of infection such as pyrexia)
- 23, F
- Bloody diarrhoea 5x day for past 4 weeks
- Feeling unwell
- Urgency to pass stool
- Cramping abdominal pain
- Itchy right eye, not painful
- 38.5 temp, PR 100 bpm, BP 110/70
- RR 22 breaths/min
- Negative stool culture
Ulcerative colitis
- 41, M
- Nausea, fever, rigors
- Cough productive of green sputum
- Discharged 2 days ago after being treated for a PE
- Low molecular weight heparin injections 2x daily since diagnosis
- Appendicetomy 1 yr ago
- 38.3 temp
- PR 108 bpm, BP 90/45
Activated Partial Thromboplastin Time 43 seconds (22–41)
Prothrombin Time 18 seconds (10–12)
Disseminated intravascular coagulation
