Good morning and welcome to your Tuesday dose of Your Daily Meds.
Bonus Review: Ok so what is the difference between a Hormone and a Vitamin?
Answer: A few things -
A Hormone = endogenous chemical messenger which…
* Is secreted into the blood by a ductless gland
* Combines with a specific receptor on a distant cell and;
* Produces a change in the metabolism of that distant cell
While a Vitamin = an organic substance which…
* The body cannot produce
* Must come from an exogenous source (yes, usually diet)
* Is only required in small amounts
* Is usually essential for survival
* Affects specific biochemical reactions
* Is not a caloric source
Case:
You meet a 45-year-old male in the Emergency Department.
He has a long history of peptic ulcer disease.
He tells you of severe, sudden onset epigastric pain.
And on examination, there is involuntary rigidity and percussion tenderness over the upper abdomen.
His erect chest/abdominal x-ray is shown below:
Given this man’s history and examination, what is the key finding in this x-ray?
* Omental fat between liver and diaphragm
* Pneumothorax
* Enlarged gastric bubble
* Subdiaphragmatic free gas
* Subdiaphragmatic abscess
Ward Call:
A nurse calls you quite concerned from the medical ward:
Doctor, could you please come and review Mr Smith urgently. I think he has haematuria. I just looked in his indwelling catheter drainage bag and his urine is dark red. So I am quite worried.
While you ponder this, otherwise calmly watching a soap opera in the on-call room, what are some questions you could ask over the phone to decide if you should go and review this chap, or wait until the next ad break?
Have a think.
More scroll for more chat.
That X-Ray
This man has a history of peptic ulcer disease and signs of peritonitis
The main concern should be an acutely perforated ulcer.
This would allow a communication between the stomach or duodenum with the peritoneal space, irritating the peritoneum and causing peritonitis.
The x-ray shows free gas under both domes of the diaphragm.
This is Pneumoperitoneum.
Also note a nasogastric tube in situ.
On Haematuria:
Some questions you could ask include:
* When did this ‘haematuria’ start and has it happened before?
* Are there any associated symptoms?
* eg colicky flank pain suggesting a renal tract stone. Dysuria and frequency of a UTI.
* We have been told there is a urinary catheter in place, but was this recently inserted?
* Traumatic or inexperienced IDC insertions may lead to bleeding.
* Has the patient had recent surgery?
* Procedures on the bladder and kidneys are associated with transient bleeding.
* Low gastrointestinal surgeries sometimes place the bladder at risk of injury, so an IDC may be left in situ for the actual purpose of checking for haematuria as a surrogate of bladder injury. A conversation with your surgical registrar may ensue.
* Same for women post-caesarean section - ongoing haematuria may signify damage to the at-risk bladder in surgery.
* Is the patient anti-coagulated?
* Anticoagulants may require reversal in the actively bleeding patient.
* Or withholding of those anticoagulants that cannot be reversed.
* Or, combine a couple of ideas, has this patient recently had surgery and now has ‘haematuria’ after restarting their anticoagulants (that had been withheld over the preoperative period)?
* What are the vital signs?
* Hypotension and tachycardia of significant blood loss.
* Fever of urosepsis.
* What was the reason for admission?
Ok so I have written ‘haematuria’ with the squiggles (‘‘) a couple of times above. Haematuria probably gets used a bit too often to describe dark urine.
Because there is a difference between the concentrated urine of dehydration (or the anti-diuretic state), the coca-cola urine of bilirubinuria, microscopic haematuria from laboratory microscopy (the urine looks normal to the eye), macroscopic haematuria (the urine looks dark and there is blood on the dipstick and microscopy) and frank haematuria (the patient is literally bleeding fresh blood from their urethra).
Again, dark red cordial urine is still not necessarily frank haematuria - a tiny bit of bleeding will stain a bladder full of urine to a concerning colour.
Naturally, an apparent connection between the left ventricle and urethra resulting in haemodynamic instability secondary to haemorrhage of fresh blood should warrant more concern than trace blood from a recently inserted indwelling catheter.
So those simple questions of - when was IDC inserted, reason for admission, vital signs, how does patient look - will probably give you most bang for your buck.
You will probably have to go and look at that urine at some point, however, and nursing concern should not be ignored.
But maybe it can wait until the next ad break…
Bonus: Where does Vitamin K come from? Where is it absorbed? Why is it called Vitamin K?
Answer in tomorrow’s dose.
Closing:
Thank you for taking your Meds and we will see you tomorrow for your MANE dose. As always, please contact us with any questions, concerns, tips or suggestions. Have a great day!
Luke.
Remember, you are free to rip these questions and answers and use them for your own flashcards, study and question banks.
Just credit us where credit is due.
