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Clinical Skills Challenge - case study 1

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On the following pages are details of a fictional patient, complete with context, case history and test results. Your job is to diagnose the condition and suggest treatment options. Follow the instructions at the bottom of the article to submit your entry. Winners will receive a free training course. We will also publish a detailed review of the case study with an interpretation of the results on nursingtimes.net.

Click here to download a printable PDF of this article (recommended)

This 62-year-old gentleman was admitted at 09:00 with a presenting complaint of chest pain

History of Presenting Complaint

Over the last few weeks this man has been experiencing occasional tightness across his chest. This has generally occurred while he has been exerting himself and especially when working outside in the colder weather. He also reports a similar but less intense discomfort after eating a big meal. The tightness that he has been experiencing has lasted 6 or 7 minutes and generally resolves if he stops what he is doing.

The pain that prompted this admission came on suddenly about 2 hours ago while he was getting dressed for work. It began as a tightness that was similar in nature to the episodes he ahs been experiencing lately. However on this occasion the tightness developed into a more intense pain that he rates as
8 out of 10.

The pain / tightness is mainly across the front of his chest. He is aware of it up into his jaws and his arms feel really heavy. He has never experienced anything as bad as this before. Nothing appears to worsen or relieve the pain.

The Paramedics gave him 10mgs Morphine IV and he has vomited a number of times since then. He is very pale and sweaty on admission.

He is overweight at 130 kg and measures 180 cm in height.

Past Medical History

Hypertension for many years. (takes a beta blocker for this)

Road traffic accident 10 years ago resulting in a fractured sternum and multiple rib fractures.

He says that he is allergic to Aspirin as he developed a rash when he had it before.


Social History

He lives with his wife. They have two sons both of whom live in Sydney, Australia.

He smokes 20 cigarettes a day and drinks about 20 units of alcohol each week.

He works as a freelance brick layer and has been working long hours recently as his employer has a contract to build a large number of homes.

On admission:

He is distressed and is tachypnoeic and sweating. He is sill experiencing severe chest pain although it has dulled in intensity. He has evidence of peripheral cyanosis

Table 1: Vital signs on admission

Blood Pressure

90 / 50 mmHg

Pulse rate

95 (regular)

Respiratory rate

20 per minute

Tympanic temperature

37.4 OC

SaO2

91% on 4 litres of oxygen

Random blood glucose

16.1. mmols/L

Table 2: Blood results

Test

Result

Reference range

U&E's

Sodium

136

136 - 144

Potassium

4.4

3.5 - 5.0

Chloride

102

95 - 105

Urea

8.9

3.0 - 8.3

Creatinine

122

80 - 130

Haematology

Haemoglobin

164

120 - 160

Mean Cell Volume

87

80 - 98

White Cell Count

11.6

4.0 - 11.0

See the 2-Lead ECG and AP (portable) chest x-ray on the PDF of this article.

Comment on this mans presentation and suggest a possible diagnosis and priorities in his management.

Email your diagnosis to Charlie.bloe@cb-training.com for a chance to win a FREE place on any Charles Bloe training online courses.

See www.cb-training.com for details of all courses available.

A discussion of this case study and the winner's identity will be revealed in 6 May issue of Nursing Times.

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