Clinical Scenarios
A 22-year-old man comes to see you with his mother. He spends most of his time in the house and refuses to go out alone. The patient states he made an error on his income tax statement and is convinced that the tax authorities have hired detectives to gather information about his whereabouts. He states that, since his mistake, he uncovered an essential flaw in the taxation algorithm, which may expose the underpinning of the taxation system, and is convinced they have hired assassins disguised as bikers. After moving in with his mother, he did not see the bikers, but they are trying to trace his "mental activity". Also, he hears them outside his house talking about how they will kill him. He appears suspicious, avoids eye contact, and his answers to questions are delayed, during which he appears internally preoccupied.
He has a history of type 1 diabetes and takes insulin. He won't answer any questions about his diabetes control. His mother says it has been “reasonable”. His bedside blood sugar is 12 mmol/L.
What impact would his diabetes have on the management plan?
When would you start this treatment?
What treatment would you give?
To find the answers to these and other important questions, have a look at this BMJ Best Practice treatment algorithm and add diabetes as a comorbidity.
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Other useful topics:
Type 1 diabetes
Inpatient glycaemic management
Clinical Scenarios
There were twenty 500mg tablets in each packet. She says that she doesn’t care what happens to her. She feels sick but she has not vomited. She has a past history of depression. She says she takes tablets for this but is not sure of their names. She says she drank 6 units of alcohol just before the overdose. A 20-year-old woman presents 3 hours after ingesting two packets of paracetamol tablets following an argument with her family.
What treatment would you give?
When would you start this treatment?
What impact would her depression have on the management plan?
To find the answers to these and other important questions, have a look at this BMJ Best Practice treatment algorithm and add depression as a comorbidity.
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Other useful topics:
Suicide risk mitigation
Depression in adults
Clinical Scenarios
He is anxious and pacing in the hallway. Initial vital signs show a heart rate of 120 beats per minute and blood pressure of 169/104 mmHg; other vital signs are normal. On further questioning by the nurse, he states that he is nauseous and wants something to help with 'the shakes'. During the consultation the patient admits to heavy alcohol use and that he is trying to cut down on drinking. He also says that his current symptoms started to develop about 6 hours after his last drink. A 45-year-old man presents to the emergency department with restlessness and tremors.
He has a history of hypertension for which he takes atenolol.
What treatment would you give?
When would you start this treatment?
What impact would his hypertension have on the management plan?
To find the answers to these and other important questions, have a look at this BMJ Best Practice treatment algorithm and add hypertension as a comorbidity.
Read more about this BMJ Best Practice topic
Other useful topics:
Alcohol-use disorder
Essential hypertension
A 66-year-old man presents with progressive shortness of breath and a cough productive of yellowish sputum. Clinical Scenarios
His symptoms have been going on for the past 2 years. He has a smoking history of one pack per day for the past 47 years. On examination he is very thin and in moderate respiratory distress. Lung examination reveals a barrel chest and poor air entry bilaterally, with moderate inspiratory and expiratory wheezing. Lower extremities shows some pitting oedema.
What are the differential diagnoses?
What is the most likely diagnosis?
What tests would you request and what treatment would you advise?
Access BMJ Best Practice for fast answers to these important questions wherever you are, both online and offline.
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A 19-year-old man presents with a 2-day history of headache and associated nausea. Clinical Scenarios
He says that bright lights hurt his eyes. He has no significant past medical history, is not currently taking any medicine, and reports no drug allergies. He works as a librarian and has not travelled overseas for the past year. He lives with his girlfriend. On examination, he has a fever and neck stiffness. Lumbar puncture reveals polymorphonuclear pleocytosis, raised protein and low glucose in the CSF.
And what would you do?
What do you think is going on?
What tests would you request?
Access BMJ Best Practice for fast answers to these important questions wherever you are, both online and offline.
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A 78-year-old man presents with shortness of breath after a knee replacement. Clinical Scenarios
He feels faint but has not passed out. His shortness of breath has been present for three hours. He also has left-sided chest pain that worsens on deep inspiration. He had a knee replacement ten days ago. He has been slow to mobilise due to poorly controlled pain. His current vital signs reveal a fever of 38.0°C, heart rate 120 bpm, BP 95/65 mmHg, and an O₂ saturation on room air of 91%. His ECG shows tachycardia.
What tests would you request?
What treatment would you advise?
What is the most likely diagnosis?
To find the answers to these and other important questions, click on the link to look at this topic today:
Read more about this BMJ Best Practice topic
Other useful topics:
Assessment of dyspnoea
Deep vein thrombosis
A 60-year-old man comes to the emergency department complaining of severe epigastric abdominal pain that radiates to his back. Clinical Scenarios
The pain improves when he leans forwards or assumes the fetal position. It is worse when he breathes in deeply. He also complains of nausea, vomiting, and loss of appetite. He smokes ten cigarettes and drinks 14 units of alcohol per day on average. On examination, he has tachycardia, tachypnoea, and low blood pressure. He is also confused. There are decreased breath sounds over the base of his left lung.
What tests would you request?
What management would you recommend?
What is the most likely diagnosis?
To find the answers to these and other important questions, click on the link to look at this topic today:
Read more about this BMJ Best Practice topic
Other useful topics:
Chronic pancreatitis
Overview of chronic alcohol use
A 77-year-old woman presents to the emergency department. She is breathless and finds it difficult to talk in full sentences. Clinical Scenarios
On examination, she is centrally cyanosed with cool extremities. Her pulse is 110 beats per minute and systolic blood pressure is only just recordable at 80 mmHg. Jugular venous pressure is elevated 5 cm above normal, there is a gallop rhythm, and the apex beat is displaced. Respiratory rate is increased and she has widespread crackles and wheezes on chest examination.
Would you request any tests?
What management would you recommend?
What is the most likely diagnosis?
To find the answers to these and other important questions, click on the link to look at this topic today:
Read more about this BMJ Best Practice topic
Other useful topics:
Chronic congestive heart failure
Heart failure with preserved ejection fracture
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