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Karen Ary is a 70 year old lady who has presented following numerous episodes of vomiting. This is the second such occurence in the past year.

Her medications include:

  • Tiotropium inhaler
  • Salbutamol inhalder
  • Carbocisteine oral

You are Karen Ary, a 70 year old lady who is absolutely fine, thank you very much. You are livid that you are in hospital and you have had a horrible night’s ‘sleep’. Indeed, to call it sleep would be generous, given the noise going on in your ward!

HPC: You have had vomiting over the past few days, which hasn’t really gone away. Initially this began with vomiting up food, but you haven’t been able to keep anything down, even water. You went to your local doctor and he panicked, sending you straight into hospital. You’ve never thought much of him. The vomit has never featured any blood, and is associated with a very dull abdominal pain. You reckon you might have lost about 1-2 stone in the last few months, but your scales have broken, so you haven’t really been measuring. Your old wedding ring looks a bit loose though, and you’ve had to investi new, smaller pyjamas. You have been feeling generally a bit rubbish too, but isn’t that what a 70 year old should feel like? You feel that you should just be left to get on to things, and resent the fuss that people are making around you. Yes, the doctor said that one of your salts is quite low, but surely that can be sorted at home? You always have salt on your food, anyway. You had a chest infection last month, and took your rescue pack for that. It seems to have cleared up but there was some green stuff coming up until early this week. Since then it’s just been vomiting! Your bowel habit hasn’t changed - you’re always constipated - whilst you haven’t had any pain when you urinate.

PMH: You have emphysema, which you think has been from your smoking. You’ve smoked since you were 14, 30 a day, and don’t plan to give up. What’s the point now? Otherwise, you’ve never really been in hospital for anything. The emphysema hasn’t even brought you into hospital. To be honest, you don’t know if you’d even bother going in for that if asked.

ICE: You’re aware that one of your salts is off, and just want to get that treated. This happened a few months ago - though without quite as much vomiting, and your salts were low then too. Otherwise you haven’t got the foggiest about what’s going on. Isn’t that what the doctors are supposed to tell you? you don’t know why you’ve been losing weight, and you haven’t eaten anything dodgy lately, or been abroad. You wish!

SH: You live alone - your partner died a few years ago. You do miss having him around, and don’t feel that your life has been quite the same. You spent a lot of time going to hospital with him towards the end of his life - he had cancer - and you think that maybe this is why you resent hospitals so much. You don’t really drink alcohol, and you manage alright at home.

The student should take a focused history on the vomiting, with an appreciation of the multiple red flags associated with the case. Getting the diagnosis is not necessarily key here - it is about identifying the risk of electrolyte disturbance and the possiblity of underlying malignancy.

An example differential diagnosis might sound something like: ‘My differential diagnosis would primarily be a gastrointestinal or infective problem: more specifically viral gastroenteritis. This is because of the short history of vomiting with lack of clear cause or associated symptoms. It would be important to rule out a biochemical problem in this patient, most specifically hyponatraemia or hypokalaemia. The weight loss and general malaise may point towards an underlying malignancy which should be investigated.’

Some possible questions for discussion may include:

  • What are the causes of hyponatraemia?
  • How is hyponatramia treated?
  • Why must special care be taken when treating hyponatraemia?
  • How may this patient be investigated for underlying malignancy?