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 Best of Five 3.19

 

   

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BOF: 3.19

A 75-year-old male has been admitted to the emergency admitting unit. He has ischaemic heart disease with previous myocardial infarction and has been on treatment for chronic heart failure. He is on furosemide, ramipril, spironolactone and carvedilol.

He recently developed pain, redness and swelling of his right metatarsophalangeal joint which came on acutely overnight. His GP initially treated him with diclofenac but when he did not respond he started him on colchicine.

Following this he developed diarrhoea, which made him feel unwell. He stopped eating and drinking and took to his bed. The GP referred him to the hospital, as he was worried about the deterioration in his condition.

On examination he looked unwell, his mucus membranes were dry, skin turgor was diminished and he was tachycardic and had low blood pressure with a significant postural drop. There was a pan systolic murmur at the apex, which radiated to the axilla but apart from this no other abnormalities were detected.

Your house officer has arranged blood tests, the results are not available as yet but he calls you to see the patientís ECG as he thinks it is abnormal.

The ECG shows bradycardia, flattened p waves and a broad QRS complex.

Your next step would be:

a)      Urgent blood gas analysis

b)      10 % Calcium chloride 10 ml over 5 minutes

c)      50 % dextrose 50 ml with 10 units soluble insulin over 5 minutes

d)      Nebulised salbutamol 20 mg

e)      1.26 % Sodium bicarbonate 500ml over 30-60 mins

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