Good evening and welcome to tonight's Tuesday Night Med Ed case!

A couple of ground rules, people may be joining in from different years of their course, so please be constructive

And secondly, to make what you write easier to see tag your posts #TNMedEd

RTs appreciated!
Caveats:

- This is not medical advice

- It's medical student run - so there may be some inaccuracies, if you see any, please point them out!

#TNMedEd
How would you like to begin?

#TNMedEd
Verity says she's gone from 89kg to 80kg unintentionally over the past 6 months

She's not felt hungry, and has been feeling like she's been wanting to vomit intermittently for the past 3 months - she thinks this is why she's lost her appetite

https://twitter.com/clarissascortex/status/1361768635354796034

#TNMedEd
Afternoon doc,

Well I've been losing weight for the past six months and I've lost my appetite, I just feel like something's wrong with me

https://twitter.com/medstudentalice/status/1361768790627913728

#TNMedEd
I feel like something's quite seriously wrong, I've been losing weight for the past six months (89kg-->80kg) and I've not been trying to. I've lost my appetite too

https://twitter.com/a_c_harvey/status/1361769610157121537

#TNMedEd

@ElleLouM
I'm not sure what started it off, but for the past three months I've been feeling really sick a lot of the time, and that's just compounded me losing my appetite

https://twitter.com/somedayadoctor/status/1361769360583499779

#TNMedEd
No pain, but I have noticed I've had some vomiting with the nausea over the past month, so even when I do eat it comes up

https://twitter.com/ElleLouM/status/1361771937282818053

#TNMedEd
Mm, yeah actually :( over the past month the nausea's been associated with vomiting, so even when I do eat, it comes back up

No blood or green in it tho

Yeah, no problem with tougher food, it's just food as whole

https://twitter.com/clarissascortex/status/1361772336920354818

#TNMedEd
It's probably a bit worse in the mornings, but I can't think of any triggers

https://twitter.com/medstudentalice/status/1361772405249749000

#TNMedEd
Mm, so I've had this nausea for three months, and over the past month I've had quite a lot of vomiting with it

No blood or bile obvious in it

https://twitter.com/somedayadoctor/status/1361772852601630721

#TNMedEd
I've had nausea for about three months, and there's been a fair amount of vomiting over the past month

No abdo/waterworks issues, but I've probably been BOing less because I've just not been eating as much

https://twitter.com/a_c_harvey/status/1361772942665916421

#TNMedEd
Thanks doc, it isn't :(

I don't feel it's triggered by the eating, it's probably worse in the morning, but it does mean of what little I do eat, quite a lot of it comes back up

No blood or bile obvious

https://twitter.com/ElleLouM/status/1361773669068988416

#TNMedEd
↓ bowels, but I've not been eating much. (PUing fine)

No cough or waking hot + sweaty

I do have depression that I take St John's Wort for, and I have felt pretty sickly for the past 6 months

https://twitter.com/clarissascortex/status/1361775149784137728

#tnmeded

(Sorry for the wait, just finishing my tea!)
Well, my husband left me about a year ago, and adjusting to living alone has been quite difficult, I can't think of anything otherwise

https://twitter.com/medstudentalice/status/1361775763230498817

#TNMedEd
No, it doesn't feel like the vomiting is related to actually eating - I have no symptoms related to mealtimes

https://twitter.com/a_c_harvey/status/1361776561087774720

#TNMedEd
I have been feeling a bit lightheaded over the past few weeks now you mention it

I had my last period about 5 years ago, and since my husband left me I've had no sexual partners

https://twitter.com/a_c_harvey/status/1361779768174247936

#TNMedEd
No, no heartburn

Hmmmmm, I drink half a bottle of wine probably three times a week, and I've smoked 10 cigarettes a day since I was a teenager

https://twitter.com/clarissascortex/status/1361779841973047299

#TNMedEd
No, I haven't, I think the food gets down to my stomach

https://twitter.com/somedayadoctor/status/1361780121686917122

#TNMedEd
It feels like it mostly happens in the mornings

https://twitter.com/medstudentalice/status/1361780383063412737

#TNMedEd
No, nothing like that, I do just feel a bit unsteady on my feet when I stand up too quickly

No bleeding down below

https://twitter.com/a_c_harvey/status/1361780814745337865

#TNMedEd
I've been a wine drinker for years, but to tell the truth, I probably am drinking more now that I'm by myself and with lockdown as well

https://twitter.com/medstudentalice/status/1361781072397291520

#TNMedEd
No, I don't see my GP for anything - tried going for my depression years ago then I didn't hear anything, so I just take St John's Wort now.

C section 30 years ago only hosp stay

Yeah, my dad died of colon cancer :(

https://twitter.com/a_c_harvey/status/1361782522888265728

#TNMedEd
She looks slightly unkempt, and you think you see some angular cheilitis, her abdomen is distended

CVS and RS exams are normal

When you say assessment of fluid status, what do you want me to do?

HR 95
BP 149/80
RR 18
Temp 36.1

https://twitter.com/somedayadoctor/status/1361786035198455813

#TNMedEd
I've been taking the St John's Wort for about 15 years and it's better than it was, but I have been a bit low over the past year - then again I think everyone has been

My dad was 87 when he was diagnosed

https://twitter.com/a_c_harvey/status/1361786223002542083

https://twitter.com/a_c_harvey/status/1361786777141395461

#TNMedEd
Sure, JVP is normal, mucous membranes are moist, central and peripheral CRTs are <2

https://twitter.com/somedayadoctor/status/1361788283307622400

#TNMedEd
Well, actually...our GP practice is trialling POCT FBC machines, so we could have that back preetty quickly :P

https://twitter.com/somedayadoctor/status/1361789427945717764

#TNMedEd
Glucose is 7.3

https://twitter.com/a_c_harvey/status/1361789614965596170

#TNMedEd
Sure, have some electrolytes too from our magic machine

Hb 108
MCV 109
WCC 9.5
Platelets 125
Na 132
K 3.8
Urea 2.1
Creat 94

https://twitter.com/somedayadoctor/status/1361789865369739266

#TNMedEd
(BM is 7.1)

#TNMedEd
+ve leukocytes, otherwise NAD

https://twitter.com/a_c_harvey/status/1361792047368318979

#TNMedEd
Lol, fair @a_c_harvey

Hb 115-160
MCV 80-100
WCC 4-10
Platelets 150-400
Urea 2.5-7
Creatinine 70-120

https://twitter.com/Dominic_G_M/status/1361792360133369856

#TNMedEd
The lab'll process them as a priority

https://twitter.com/StudentDoctorB2/status/1361793307127537665

#TNMedEd
Why do we think she's got a microcytic anaemia?

https://twitter.com/a_c_harvey/status/1361794748378398740

@anidioticfool @somedayadoctor

#TNMedEd
*MACROCYTIC
Sure we can

@somedayadoctor @a_c_harvey

Thoughts on differentials atm?

https://twitter.com/somedayadoctor/status/1361794549501280256

#TNMedEd
:( Soz, I meant

She has a macrocytic anaemia, what could be causing that?

@somedayadoctor

https://twitter.com/a_c_harvey/status/1361796001737170954
#TNMedEd
So do we think she ticks the 2WW box?

https://twitter.com/somedayadoctor/status/1361795730785058817

#TNMedEd
Exactly! There was a slightly hidden clue in the social history...

https://twitter.com/StudentDoctorB2/status/1361796319216566276

#TNMedEd
Good call, will try and finish this up shortly...you're going in the right direction

https://twitter.com/clarissascortex/status/1361796448384409608

#TNMedEd
It's 10 o'clock, and we have a winner...

https://twitter.com/StudentDoctorB2/status/1361796648251379722 and @anidioticfool both got it within about a minute of each other!

The LFTs have also incidentally turned up

ALP 360 (30-350)
GGT 885 (10-50)
ALT 270 (5-35)
Albumin 22 (35-50)
Bili 28 (3-19)

#TNMedEd
I think you could defo justify endoscopy, but before you got far enough down that path you'd find a massive liver on USS...and see the above LFTs ;)

https://twitter.com/somedayadoctor/status/1361797003399766020

#TNMedEd
She's on that path, but she's not quite got those signs just yet

#TNMedEd https://twitter.com/a_c_harvey/status/1361797880793731078
Our patient was being a little coy and underestimating her alcohol consumption

Sorry, that was really mean ;) She was probably closer to a bottle most days more recently, hence the worsening nausea and vomiting

https://twitter.com/Dominic_G_M/status/1361783886670426116

#TNMedEd
@a_c_harvey
You can follow @Dominic_G_M.
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