Station - Instructions for candidate
You are an intern on the general medical ward of a metropolitan hospital in Perth. It is 8 pm and you are covering the ward.
Kosta Papadopoulos, 68, was admitted three days ago with right lower lobe pneumonia and has been improving on antibiotics. The nurse has called you because this evening he has vomited once, complains of headache, and is drowsy and confused. She has done a set of observations and the results of bloods and urine tests taken this afternoon are back and printed below. His wife is at the bedside.
| Admission summary | 68 M, community-acquired pneumonia right lower lobe, day 3 of benzylpenicillin IV and doxycycline oral. Background: hypertension (amlodipine 5 mg), low mood - sertraline 50 mg daily started by GP 4 weeks ago. Admission sodium 131. Maintenance sodium chloride 0.9% 1 L daily charted for days 1-2. Oral intake 1.5-2 L/day. Weight 76 kg, unchanged. Chest x-ray on admission: right lower lobe consolidation, no mass. |
|---|---|
| Observations tonight | HR 84 /min, BP 128/76 mmHg lying and 126/74 mmHg standing, RR 18 /min, SpO2 95% on 2 L, T 37.6 degrees C, GCS 14 (E4 V4 M6), glucose 6.0 mmol/L. Nurse's note: moist mouth, no oedema, JVP not raised, no seizure. |
Results provided:
Serum biochemistry (taken 3 pm today)
| Item | Value | Reference range |
|---|---|---|
| Sodium | 118 mmol/L (admission 131) | 135-145 mmol/L |
| Potassium | 4.0 mmol/L | 3.5-5.0 mmol/L |
| Chloride | 86 mmol/L | 98-108 mmol/L |
| Bicarbonate | 24 mmol/L | 22-28 mmol/L |
| Urea | 3.2 mmol/L | 3.0-8.0 mmol/L |
| Creatinine | 70 micromol/L | 60-110 micromol/L |
| Glucose | 6.0 mmol/L | 4.0-7.8 mmol/L |
| Serum osmolality | 248 mOsm/kg | 275-295 mOsm/kg |
| Albumin | 36 g/L | 35-50 g/L |
| Uric acid | 0.18 mmol/L | 0.20-0.42 mmol/L |
| CRP | 60 mg/L (admission 240) | Under 5 mg/L |
Urine biochemistry and endocrine screen (taken 3 pm today)
| Item | Value | Reference range |
|---|---|---|
| Urine osmolality | 520 mOsm/kg | Under 100 mOsm/kg expected when serum osmolality is low |
| Urine sodium | 68 mmol/L | Under 30 mmol/L in hypovolaemia |
| TSH | 1.8 mIU/L | 0.4-4.0 mIU/L |
| Cortisol (9 am) | 480 nmol/L | Over 400 nmol/L excludes adrenal insufficiency |
Your tasks are to:
- Interpret the blood and urine results printed on your sheet and state your findings to the examiner.
- State your most likely diagnosis, its causes in this patient, and the differential diagnoses to the examiner.
- Outline your immediate management plan to the examiner, including fluids with volumes and rates, monitoring, and who you will call.
- The examiner will ask you two questions at the end.
- You do NOT need to take a history or examine the patient; the nurse's findings are on the sheet and she can answer brief questions.
- The patient's wife is present; you may speak to her but no separate explanation task is marked.
- Further results are available from the examiner on request.
This is a 10-minute station, with 2 minutes of reading time.