The Problem-Based Learning Workbook

Medicine and Surgery

Tim French, Terry Wardle

• Publisher: CRC Press
• Year: 2022
• eBook ISBN:
  9781000605228
• Topic: Medicine
• Subtopic: Family Medicine & General Practice

General practitioners need to know more and more about the complicated tests performed in hospitals. For most patients the GP is an accessible trusted and reliable source of information and advice. So when patients under hospital follow-up are confused about their treatment they often turn to their GP. In addition general practitioners have open access to an increasing array of hospital-based investigations and in the context of clinical governance they have a greater responsibility to understand and use them properly. This guide provides a compendium of all those hospital-based tests which the GP is likely to encounter organised according to specialty. It also includes the rather more specialised tests available only to the relevant consultant but which GPs might end up having to explain to perplexed patients. Each chapter is written by a specialist in the field and the book is edited by a general practitioner to be presented in a uniform digestible way. This essential resource enables GPs to order secondary care investigations confidently and rationally and to answer patients' queries with authority.

The scenarios

1	A student with a ‘hangover’

Catherine is 17 years old. She presents to the A&E department at 4 pm complaining of vomiting all night, and has associated severe abdominal pain. She says that she was out with friends from college the night before and drank too much alcohol. She felt hung over this morning and didn’t go to college, choosing instead to try and sleep it off. The vomiting and abdominal pain persisted, and now she feels acutely unwell. She has had type 1 diabetes mellitus since the age of 4 years old, and was transferred from the care of paediatric to adult diabetic services 6 months ago. She had not attended her scheduled annual appointment 3 months ago.

(a) What further questions would you want to ask?

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While in the A&E department she deteriorates rapidly and starts to show signs of a reduced conscious level.

(b) Which physical signs would support your working diagnosis?

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The results of the initial blood tests are shown in (c) below.

(c) Fill in the blank cells with ↑ ↓ or ↔ for increased, decreased or normal.

Plasma glucose	28 mmol/l
Urinary ketones	+ + +
Urea and electrolytes
Na^+
K^+	5.2 mmol/l
Urea
Creatinine	100 μmol/l
Arterial blood gases
pH	6.9
PaO2	13.2 kPa
PaCO2
${\text{HCO}}_3^{-}$
Anion gap

(d) Describe your initial management.

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(e) What complications might arise during treatment?

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She is started on treatment in A&E, and subsequently is transferred to the medical assessment unit. On reviewing the blood test results, the registrar comments that her white cell count is elevated at 36 × 10⁹/l and that her serum amylase level is 763 iu/l.

(f) Does this have any implications for management?

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Later she is transferred to a general medical ward and appears to have made a good recovery. She is eating and drinking, and has been restarted on her normal insulin regime. The consultant endocrinologist comments that teenage years can be particularly difficult for young people with diabetes, and that he needs to discuss certain issues with Catherine. Additionally he suggests that she see the diabetic specialist nurse whilst still an inpatient to discuss ‘sick day rules’.

(g) What would the consultant want to discuss?

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(h) What would the diabetic specialist nurse discuss with Catherine regarding ‘sick day rules’?

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(i) Which healthcare professionals will be involved in her future care?

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✓Answers and teaching notes

Key cases

• • Type 1 diabetes mellitus
• • Diabetic ketoacidosis

Clinical context

Vomiting and abdominal pain are common presenting symptoms in patients who are acutely ill. Such individuals may be referred to physicians, surgeons, and even gynaecologists, as there are so many causes of vomiting and abdominal pain. A pregnancy test is mandatory in all women of reproductive age, diabetic or not! This case illustrates the need for an accurate history to help discriminate between the various conditions; and how clinical examination is of paramount importance in assessing the severity of an illness and monitoring the response to treatment.

Diabetic ketoacidosis (DKA)

DKA should be considered in any unwell diabetic patient, particularly those who are short of breath but not hypoxaemic.

DKA results from either insulin deficiency or an excess of stress hormones with anti-insulin activity. Insulin deficiency results in increased gluconeogenesis in the liver, decreased peripheral glucose uptake and increased lipolysis in adipose tissue. The net result is severe dehydration from a rapid glucose-driven osmotic diuresis, and metabolic acidosis from the eventual accumulation of keto acids produced by fatty acid metabolism.

The symptoms and signs follow from the pathophysiological processes. Thus, DKA presents with nausea, vomiting and abdominal pain (a central effect of ketosis); signs of dehydration (from the vomiting and osmotic diuresis); hyperventilation (an attempt to remove CO₂ to compensate for the metabolic acidosis).

Additionally if the DKA has been caused by serious illness, the patient may present with the symptoms relating to that condition (e.g. myocardial infarction, pneumonia, sepsis). Such symptoms and the associated signs may mask ...

Table of contents

• Cover
• Title Page
• Copyright Page
• Table of Contents
• About the editors
• List of contributors
• Dedication
• Acknowledgements
• Abbreviations
• Introduction
• Key cases index
• The scenarios
• Quick symptom reference guide
• Main index