Thanks for joining the case, where as a surgical FY1 doctor you were asked to review Mr Jones, a 75 year old man who had been admitted after a fall leading to a femur fracture. The nurses were worried that he was just ‘not right’. A tricky referral! But you did a great job of figuring out the issues for this patient. We covered a few topics:
- What were the nurses actually concerned about?
- They felt he had become a little inappropriate, being intermittently grumpy and over-familiar.
- He had been passing a lot of urine, although he wasn’t on a fluid balance chart.
- What was there to find on history and examination?
- His wife had gone home (it was 2am) but the initial admission documents did not suggest any history of confusion or dementia.
- His fall was described as being due to slipping on wet leaves. His wife was clear that he did not hit his head, have any prodromal symptoms or post-fall confusion.
- He had a PMH of angina and was on aspirin, simvastatin and bisoprolol.
- Examination: Chest examination unremarkable, abdominal examination revealed diffuse tenderness but no guarding and normal bowel sounds.
- Observations showed a mild tachycardia, but was otherwise normal.
- He was oriented in place and person but seemed unaware that it was the middle of the night. He was rather inappropriate with you – laughing for no reason, then becoming angry, particularly when asked questions to test his memory, such as the name of the prime minister.
- What interventions would be appropriate?
- You wanted to know more about his urinary frequency, and suggested his urine be dipped and sent for culture. In fact his urine was negative by dipstick.
- You felt that he needed to be on a fluid balance chart, to obtain objective evidence of the polyuria the nurses describe.
- The need to look for any source of infection was raised, given that Mr J seems to have a delirium.
- Others suggested that an ECG would be a sensible given his cardiac history.
Through the conversation we realised that the confusion, polyuria and abdominal pain could all be explained by hypercalcaemia.
Hypercalcaemia can be easily remembered by the classic phrase ‘stones, moans, bones and groans’. This refers to the fact that renal stones, abdominal pain (for various reasons), psychological alteration and bone pain are classical symptoms due to hypercalcaemia. Rather than re-invent the wheel I will give you a few links to hypercalcaemia summaries:
- NICE clinical knowledge summaries http://cks.nice.org.uk/hypercalcaemia#!topicsummary
- A great brief summary from a fellow #FOAMed colleague: http://lifeinthefastlane.com/investigations/hypercalcaemia/
We finally got his blood results back (there was a mysterious delay!) and found the following:
A Phos 562
So your challenge now is to comment on these results and decide what issues need addressing for this patient.
Please reply on twitter using the hashtag #UnofficialCSIM2. Please get involved, help us fix this patient and learn along the way. See you over in the twittersphere…