Clinical Case 120: Vomiting VBG

Gday – I am off on leave this month – so here is a quick case from the files.

It’s an unusual VBG.  I will tell you a few features on the history and you need to work out the diagnosis and tell me how you are going to manage this!

The patient is a 25 year old chap who presents with 2 main symptoms: intractable vomiting and the near obsessive need to shower – long hot showers.  He has presented today because the ondansetron wafers that his GP prescribed have not been helping with the vomiting and his hot-water system is not able to keep up his need for hot showers!

He certainly looks dry and miserable.  His palms and soles are macerated from all the hot water.  He gets an IV sited and a quick blood gas is drawn….

So here are the questions:

(1) What is the diagnosis?

(2) Which meds will you try to truncate the vomiting?

(3)  What fluid will you choose to correct his metabolic derangement ??


thanks to @davebergie for the gas image


PODCAST: Really Rural Surgery with Dr. Bret Batchelor

Dr Bret Batchelor is a Canadian GP working in rural British Columbia.  He is also a part-time surgeon practicing his “Extended Surgical Skills” in a small town.

Over the last year Bret has been podcasting at “Really Rural Surgery“.  The podcast is a heavily evidence-based look at the practice of Surgery & procedural Obstetrics with a focus on doing common procedures in the small towns.  There is a strong flavour of “medical myth busting” which we love!

Bret was kind enough to spend half an hour chatting with me about his practice, the ethos of rural procedural work and how to train in the field.

If you are interested in Rural Surgery or EBM check out the podcast and site here.

Bret is on Twitter @ReallyRuralSurg  – he is a super smart guy and keen to spread the word – so ask him some questions and send some comments to the site.  Are there any questions you want answered about everyday Surgery?

Here is the podcast:



Clinical Case 119: Trauma & the Sensitive New Age Ultrasound

OK tonight I have a trauma case for you.

Billifred is a 24 year old man whom lives with his partner.  There relationship took a turn for the worse this evening when she found her sister’s underpants in his car.

Billifred is a “lover, no a fighter…” but tonight he was forced to defend himself against a series of stabbings.  He is brought in by taxi with multiple bleeding wounds.

Editorial note:   Presentation by taxi carries a significantly increased risk of serious badness in my world.  Ambulance services are essentially free, so they often get used as a public transport service.  However, if you are sick / worried enough to fork out $20 for a cab fare – there is a good chance that you are actually pretty sick.  Auto triage is a real thing IMHO.

On arrival he is bleeding from cuts to both hands and his ulnar forearms.  He has blood on his leg from wounds on his lateral calf.  There is a small spot of blood on his left shirt pocket.  He is not really very cooperative.  When asked what happened he says he “fell whilst sharpening his hunting knife…”

Obs:  HR 120/min,   RR 28/min,  SpO2 on RA = 90% but up to 98% on 6L/min HM,  BP140/100.  He looks sweaty and anxious.

After stripping off his shirt you see a 1 cm stab wound just below the clavicle on the (L) anterior chest, midclavicular line…

So – control the bleeders – he gets a tourniquet to his arm to stem the loss from the cuts there and then needs a chest US….  bugger, the O&G doc has taken the machine to labour ward.

After securing IV access x2 and giving him some analgesia the radiographer pops in and does a quick portable CXR.  It is a rough shot with him breathing fast, not really vertical and taking shallow breaths.

Whilst you are waiting for the films to be processed ( yes, we still use actual plastic films!!) the Bedside US machine reappears.  So you do a quick chest scan looking for pneumothorax or haemothorax on the left.

You scan from the clavicle down the anterior chest and…  no sliding.  A static pleural line with no sliding.  His right chest is normal with good sliding easily seen.  The heart looks good and there is no pericardial effusion.

Being a super-sleuth sonowarrior, you scan now across the chest laterally towards the bed looking for a lung point [contact point] – and at about the posterior axillary line you see this:   CLICK TO SEE US CLIP

Now – that is golden – a good sized pneumothorax with the whole anterior chest showing no sliding and a lung point around laterally.  The evidence suggests 100% specificity for US when a clear lung point is seen.

A quick look at the left lung base shows a small effusion ~ 1cm deep, looks like partially clotted blood with mixed echo texture .

Meanwhile the friendly radiographer has returned with the plain film and the verbal report is ” ALL Clear, no pneumothorax…”  Here is the CXR…

CXR norm

Alright then – we will pause the case at this point.

This is the “le moment decisif” the point in time where you need to decide what are you going to do next.

Do you:

(A)  Crack on a put in a chest tube

(B)  Sit on the patient, admit and observe.

(C)  Fly them to the closest CT scanner (1000 km away) for a CT chest.

We covered the pneumothorax / Airplane transfer debate a while back in Clinical Case 108.

(D) Something else / smarter??


You have about 20 minutes of suturing time to think about it as you close his lesser injuries.

You even decide to repeat the chest US after sewing up his limbs – and it looks the same – pneumothorax to the posterior axillary line with a small effusion – stable in size.

OK let me know how you will play this one.


Clinical Case 118: Thinking outside the box

OK team – a Paeds case for you today.  It’s one where I am going to give you just a few clues and you have to think up the diagnosis.

Here we go…..

Jemimanisha is an 8  yo. girl who lives in an Aboriginal community about an hour away.

She has been brought to ED by her mother after being up all night complaining of a headache.  She has never had headaches before.  Her Mum is concerned that she ate too much junk food at her friend’s home the night before.

On further questioning – the headache is really quite global – she points at both parietal areas and rubs her head on both sides to show where it hurts.  She has had no recent URTI sxs, no fevers, cough or injury.  She isn’t bothered by lights or the ED noise.  Up until bedtime she was fine.  She woke around 11 PM with the headache &  slept in with her mother after that – her mum says she was restless and crying out all night long [Mum looks tired!].  This morning she vomited after eating toast.  Her belly feels OK and she reports no diarrhoea.


  • Obese with a BMI of 32 [currently seeing dietician]
  • Recurrent ear disease with grommets as a child, multiple presentations with acute OM in last 5 years. None recently.
  • Had a laceration to her ankle last month that required repair under sedation in ED – that went well and she was discharged.  Wound healing OK.

On examination

  • Afebrile, HR 90 SR, well perfused,  SpO2 = 99% RA,  RR = 15/min
  • Neuro exam is NAD – PEARL, no meningism, walking well, coordinated and fundi look ok – no papilloedema.
  • ENT – old scarred TMs bilaterally, no coryza, throat NAD
  • Chest and abdo unremarkable, soft, no signs of lung disease
  • No LN or rash, mucosa looks moist.
  • Leg wound has healed but there is a 3mm dehiscence of the edge of the scar – there is clear, serous fluid oozing out.  It is non-tender, no pus or cellulitis.

OK, that is all I am going to give you at this stage…

Here are the questions:

Q1:  What further information do you want [it is a weekend in Broome – so no labs or X-rays !]

Q2:  What is the diagnosis?

Q3:  What do you need to confirm the diagnosis?

I am sure you super sleuths can work this out!  Who is fastest?


Clinical Case 117: Cancer Fishin’

OK – this case is for all the GPs and Internal Medicine types out there.  This is a relatively common scenario…  how do you play it?

Here’s the case.

Bruce is a 53 y.o. accountant.  He is a little overweight at 89 kg (BMI 31).  He is otherwise relatively well, he cycles to the cafe each morning in lycra and drinks a cappuccino in his helmet… why do they do that?

He has hypertension which is controlled by ramipril 5 mg daily.  No other meds or relevant medical history.  He is interested in his health and even has annual “Mens’ Health checks”.  He was in last month for one – which was unremarkable other than a borderline BP and his prostate screen (post full consent and shared decision-making) revealed a normal DRE and PSA level.

Today he has come to see you with a discharge letter from the local hospital.  He was admitted for work-up of “unilateral leg swelling” which occurred spontaneously last Friday.

The letter reads:

Dear Dr Leeuwenburg,

Thanks for following up Bruce who had an unprovoked DVT diagnosed on Doppler.  US showed a 5 cm proximal DVT at the Femoral-saphenous junction (L) leg.

He also had a series of tests: FBP, UECr, LFTs, Ca, Mg, PO4, CRP, TFTs, a prothrombotic screen was unhelpful and serum rhubarb – these were all normal.  WE did a CXR to be sure and this was also reported as normal.  

Bruce was commenced on enoxaparin until his warfarin was therapeutic.  He’s on 8 mg nocte with an INR of 2.3 today .  Please chase his subsequent INRs

Oh – and – please screen for occult malignancy as we have not found anything yet.

Yours truly….

So Bruce is sitting in front of you looking a bit worried.  He says that he feels fine, and the leg swelling is improving.  He was a bit spooked when the “young-looking” hospital doctor told him that DVTs “like this” are usually due to some underlying problem “like cancer”.  He really wants to know what to do next.  Does he have cancer?

OK – so here are my questions to you:

Q1:  What is the chances that Bruce has an occult malignancy?

Q2:  what screening tests, inquiries, imaging etc would you recommend / order for Bruce?

Specifically will you get a CT of the torso?

Q3:  Does it really matter if he has an asymptomatic cancer? Will it reveal itself in time anyway?

Let me know your thoughts / practice and experience.


Clinical Case 116: FEAST or Flush Fluids

Today’s case is about the Resus of severely dry children – very typical of Broome.  But before we get to the case – here is a bit of a review of some recent learning I have had on the topic.   I have started to rethink the traditional acute fluid resuscitation management of these kids.  The FEAST trial was published 4 years ago now.  IN a nutshell it showed that giving IV fluid boluses to sick kids was harmful – lead to higher mortality.  It was one of those trials that, if nothing else, should make us rethink our practice.  Kids with severe dehydration due to diarrheal illness were NOT included in the study, so we cannot really apply it directly to the following case. However, it certainly does make me wonder…

At SMACC in Chicago recently there was an awesome panel discussion by world leaders in fluids / sepsis management.  Dr Kathryn Maitland [lead author of FEAST] was on the stage and answered some tough questions about the role of fluids in extremely sick kids.  The mechanism by which the kids in the “bolus fluid” arm died was discussed.  The children in the “bolus” group seemed to suffer an acute cardiovascular collapse more often than the “no bolus” cohort.  Why is this?  There were a few ideas postulated.  The one that made the most sense to me is that we just might be pushing the pH over the brink of life when using bolus fluids.  But there were a few other mechanisms invoked by the brains trust also.

So anyone who has ever done the APLS or other Paeds Resus course will tell you that the treatment for severe shock is a 10 – 20 ml/kg bolus of IV (or IO) 0.9% saline.  We expect our Med Students to have this number in the front of their mind – it is the “hammer” for all Paeds Resus “Nails”.  However, if you follow the blog or are a fan of the excellent Emcrit series on acid-base therapy then you will know that “normal” SALINE is in fact a nett acidotic fluid which will raise the chloride level [narrow ones’ SID] and force your body to retain H+ ions.  Now this doesn’t matter so much in kids whom are fasting for a theatre case or otherwise well.  However if you are in a scenario where your little patient is sailing very close to the edge of biochemical disaster then a big slug of unbalanced NaCl may just be the thing that pushes them over the egde.  Do we have any direct evidence for this?  No, none that I know of.

Severe dehydration with hypovolemia and malperfusion certainly needs aggressive treatment – we have to try and restore volume / flow and pull them back from multiorgan dysfunction.  So giving fluids seems like a good idea.  But how much, how fast and which fluid to use is certainly a question that I think remains unanswered. Dr John Myburgh gave a great lecture on the ICN series on the history and current state of resuscitation fluids HERE.   My favourite line from his talk was from Dr Malcolm Wilson: “I don’t care if you use dog’s piss, as long as you use it carefully.”  Very Aussie!  But the principle is important – when dealing with really sick kids and fluid Resus – you have to think it through and reassess frequently, proceed with caution.  Fluids are ‘drugs’ just like antibiotics etc.   We need to prescribe the right stuff for the patient in front of us.

So here is the case:

JJ is a 4 month old boy whom has had a diarrheal illness for 5 days.  He has been lethargic and had a few vomits today.  His parents noticed he has been “breathing fast” all afternoon and now at midnght presents with a low-grade fever, diarrhea and lethargy / somnolence.  He is refusing to feed.

Back ground history: born at 36 weeks with IUGR  LBW = 2100g.

Breastfed and has received 1 round of infant immunisations.  Was doing well and putting on weight.  He was weighed in the clinic last week at 4000 g…   but tonight he is weighing in at 3500 g [not good!]

At triage his Obs :  Temp  = 37.3  HR 200, sluggish central cap refill, RR 55/min. He has no recession / tug.  His feet are cooler than his legs

His belly feels soft with hyperactive bowel sounds.  The chest is clear [to Ultrasound!]  The bladder is empty.

This is all consistent with Gastro.  A 500 gram weight loss in this kid equates to about 12% i.e. severe end of the spectrum.

This kid is very sick – we need to know what is going on with his electrolytes / acid:base and renal function.

Luckily an IVC is able to be placed and bloods drawn.  Here is the VBG:

pH = 7.10,   pCO2 = 17    HCO3-= 6.1   BE =  -23.1   Lactate = 3.3

Na = 156  Cl = 128  K+ = 5.1    Creat = 99      The CRP is as always…. 42!

OK…  lets hit the pause button there.  A few questions.

Q1:  Does JJ require a fluid bolus?

Q2: Which fluid and what volume would you give IV in the first instance?

Q3: Assuming he need ongoing fluid replacement – what are you going to prescribe over the coming hours?