Clinical Skills Challenge – case study
This 49-year-old gentleman was seen by his GP 3 days ago with shortness of breath on exertion. This was causing him to rest after walking 10 – 15 metres, having previously had no problems with exercise. He had no chest pain or cough. He had taken a flight back to Scotland from Los Angeles in late October 2007.
The man is overweight at 130kg and measures 180cm in height. His GP felt that this was a viral illness but referred him to the hospital when the symptoms were not improved 3 days later. He was admitted to Hospital mid December 2007.
On admission:
He is quite uptight and is tachypnoeic and sweating. His JVP was not seen. He had no evidence of calf tenderness or swelling. He has evidence of peripheral cyanosis.
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Table 1: Vital signs on admission
| Blood Pressure | 90 / 50 mmHg |
| Pulse rate | 105 (regular) |
| Respiratory rate | 22 per minute |
| Tympanic Temperature | 37.2C |
| SaO2 | 89% on 4 litres of oxygen |
| Random blood glucose | 12.1. mmols/L |
Table 2: Blood results
| TEST | RESULT | REFERENCE RANGE |
| U&E’s | ||
| Sodium | 138 | 136-144 |
| Potassium | 4.2 | 3.5-5.0 |
| Chloride | 100 | 95-105 |
| Urea | 8.6 | 3.0-8.3 |
| Creatinine | 124 | 80-130 |
| Haematology | ||
| Haemoglobin | 174 | 120-160 |
| Mean Cell Volume | 87 | 80-98 |
| White Cell Count | 15.6 | 4.0-11.0 |
| PT | 13 | 10-14 |
| PTT | 32 | 26-36 |
| Fibrinogen | 4.3 | 1.5-4 |
| D dimer | 2816 | <250 |
Table 3: Results from arterial blood gas sample taken from radial artery
| TEST | RESULT | REFERENCE RANGE |
| pH | 7.48 | 7.35 – 7.45 |
| PCO2 | 3.9 | 4.65 – 6.0 kilopascals |
| Standard bicarbonate | 25 | 24 – 32 |
| PO2 | 9.6 | 11.5 – 14 kilopascals |
Echocardiogram
An echocardiogram was requested and the following report was obtained:
‘The echocardiogram is poor image quality. The left ventricle is not dilated and there is no obvious left ventricular impairment. The right ventricle is moderately dilated with impaired function. There is a large amount of thrombus in the right ventricle apex. The right atrium is mildly dilated.
No obvious abnormality was noted on his chest x-ray. His admission 12-Lead ECG is shown in Fig 1.
Leading questions:
What data leads you to believe there is a problem?
Is the problem urgent/non-urgent?
What clinical data would indicate that the situation needs immediate action and why?
Do you note any complications?
What further assessment needs to be done?
While the patient is utilizing oxygen, what would you need to continue to monitor?
How would you know it is functioning properly?
What additional information would be helpful for further clarification of the situation?
The following questions and activities should be answered in order to successfully accomplish the goal of this lesson.
I- What is your diagnosis of this case? -Post to forum
II- Discussions- forum
o Do you agree with the final diagnosis, if not why?
III- Work with your group to put a care plan (Please Submit your care plan in the designated area)