This is a retrospective case and it is intended to be difficult. You are not expected to "solve" it straight away and it is intended as a teaching tool more than a "look at home hard this is" type of thing.
You are called to a house for an unresponsive male. Upon arrival your assessment reveals the patient has died. There is no obvious physical signs of traumatic injury apart from one or two minor skin abrasions on his arms.
Patient Information
-Male
-25 years old
-Infrequent use of intravenous recreational drugs
Recent medical history
- A week ago the patient was playing basketball with some friends at the Y and suffered what he thought was a back strain when he tripped over and grazed his arm. He consulted with his Physiotherapist who recommended rest and prescribed Voltarn (diclofenac) and acetamyophen (Panadol) for this.
- Since then the patient stated his pain was getting progressively worse and he spent much of the week in bed and had seen his GP three days ago. His GP prescribed further painkillers and recommended he see the Physio again.
- Last night the patient went ot the emergency department about 3pm.
- The Triage Nurse recorded at 3pm that the patient was having difficulty in standing, was nauseated, in 9/10 pain and had the following vital signs: BP 150/110, RR 40, PR 110, temp 36.1 deg C.
- The nurse tracked down a third year Registrar (specalist trainee in emergency medicine) and he prescribed PO diazapem, malaxon (metaclopramide) and acetamyophen. The Registrar dis not see the patient.
- One of the ED nurses saw the patient again at 3.45pm and took another set of obs. She noted he had taken the medications that the Registrar had prescribed and was c/o left buttok pain, pain in both legs but worse in left, feeling cold and sore. Obs were BP 140/100, RR 30, temp 36 and PR 116.
- At 4.10pm a second year House Officer (Doctor with two years of post medical school training who is not a specalist trainee) examined the patient. She noted that his complaints were sore back, left buttock and posterior thigh pain and feeling cold. The Doctor found no neurological signs except that the patient had severe difficulty standing or walking and was unable to pass urine when asked for a sample.
- The House Officer found that he had unequal motor power in his legs and was unable to raise his left leg beyond 10 degrees while he could raise the right about 30 degrees. The patient had an absent left knee jerk upon examination.
- At 4.30pm the patient was given 10mg of intramuscular morphine and at 6.00m was sent home without being seen by a Consultant.
- During the night the patient stated he felt hot and cold and the sensation in his legs was decreasing. He died an hour later.
So, what was wrong with this fellow?
You are called to a house for an unresponsive male. Upon arrival your assessment reveals the patient has died. There is no obvious physical signs of traumatic injury apart from one or two minor skin abrasions on his arms.
Patient Information
-Male
-25 years old
-Infrequent use of intravenous recreational drugs
Recent medical history
- A week ago the patient was playing basketball with some friends at the Y and suffered what he thought was a back strain when he tripped over and grazed his arm. He consulted with his Physiotherapist who recommended rest and prescribed Voltarn (diclofenac) and acetamyophen (Panadol) for this.
- Since then the patient stated his pain was getting progressively worse and he spent much of the week in bed and had seen his GP three days ago. His GP prescribed further painkillers and recommended he see the Physio again.
- Last night the patient went ot the emergency department about 3pm.
- The Triage Nurse recorded at 3pm that the patient was having difficulty in standing, was nauseated, in 9/10 pain and had the following vital signs: BP 150/110, RR 40, PR 110, temp 36.1 deg C.
- The nurse tracked down a third year Registrar (specalist trainee in emergency medicine) and he prescribed PO diazapem, malaxon (metaclopramide) and acetamyophen. The Registrar dis not see the patient.
- One of the ED nurses saw the patient again at 3.45pm and took another set of obs. She noted he had taken the medications that the Registrar had prescribed and was c/o left buttok pain, pain in both legs but worse in left, feeling cold and sore. Obs were BP 140/100, RR 30, temp 36 and PR 116.
- At 4.10pm a second year House Officer (Doctor with two years of post medical school training who is not a specalist trainee) examined the patient. She noted that his complaints were sore back, left buttock and posterior thigh pain and feeling cold. The Doctor found no neurological signs except that the patient had severe difficulty standing or walking and was unable to pass urine when asked for a sample.
- The House Officer found that he had unequal motor power in his legs and was unable to raise his left leg beyond 10 degrees while he could raise the right about 30 degrees. The patient had an absent left knee jerk upon examination.
- At 4.30pm the patient was given 10mg of intramuscular morphine and at 6.00m was sent home without being seen by a Consultant.
- During the night the patient stated he felt hot and cold and the sensation in his legs was decreasing. He died an hour later.
So, what was wrong with this fellow?
