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Final clinical long case 3

Created: 7/4/2004


Clinical FRCA Viva

Long case: (10 minutes to study case then questions for 20 minutes)


A 24 year old male, who is a known drug addict, has recently been admitted to medical ward.  He was found unconscious at home with a history of ?heroin overdose.  His conscious level improved with 200 mcg naloxone and he became agitated, with a Glasgow Coma Scale of 14.  He is complaining of being  unable to feel his legs and of generalised weakness.  His blood pressure is 80/40 mmHg and his peripheries are cool.


He has a past history of depression and alcohol abuse.




Arterial blood gases post-naloxone on air:     pO2  8.0 kPa
  pCO2  6.0 kPa
  pH  7.2
  HCO3-  20 mmol/L
Urea and electrolytes Na  131 mEq/L
  K  7.8 mEq/L
  Ur  13.0 mmol/L
  Cr  331 umol/L
  CK  50,000 IU


ECG    Rate 50 bpm sinus (abnormal intermittent p waves) Broad QRS peaked T waves

CXR    CVP line in situ.  Bilateral diffuse shadowing.  R middle lobe collapse.  No pneumothorax.




- Summarise the case.

- What may have made him unconscious other than heroin?

- What other drugs may he have taken? 
- How would you determine this?

- What does the ECG show?

- Why can't he feel his legs and why is he weak?

- What may the cause of his raised K+ and his renal impairment?

- What is rhabdomyolsis and how does it cause renal failure? 
- Why may he have it?

- How would you resuscitate him?

- How would you treat the K+ acutely and subsequently?

- What is the difference between haemofiltration and dialysis? 
- How do they work, and which one would you use in this case, given the choice, and why?

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