Mr. Farmer
Mr. Farmer is your first patient on your next midnight shift. He is 82 years old living at home with his wife, retired on the farm. He drives, and is still cutting wood though he says he has “slowed down a bit lately”.
- Medications: Hydrochlorothiazide, atorvastatin, ASA, tamsulosin, metoprolol
- On examination: BP: 135/70, HR 90, T 37.6; Sat 96%
- No focal findings on any system. Hematology/chemistry/urine – all within normal limits.
- Watch the video below and answer the questions that follow.
- At your institution what “presenting complaint” would appear on this man’s chart?
You must be logged in to submit an answer and receive feedback. Please sign in or register to take part.
- So what could this man have?
You must be logged in to submit an answer and receive feedback. Please sign in or register to take part.
Discussion: Mr. Farmer
Participate in the discusssion by posting a comment below
You must be logged in to post a comment
These cases can be difficult. We must take the time.
There needs to be a more detailed HP, vague symptoms.
There needs to be a more detailed HP
lots of possibilites
It cannot be cholecystitis because the wife said he had his gallbladder out.
ok
Differential is huge. Sometimes getting labs back will help guide you to next differential
Could be anything with listening to the hx
could variety of differentials that should all be considered
Nice list of differentials, could be medication side effect, cognitive decline, delirium due to any sepsis any where in the body
agreed
good review
+
fsdf
could be anything
k
generalized weakness
vague history need a comprehensive exam
k
ok good to know
very true
General weakness
generally unwell
infection
ok
Very Good
good reaching points
A lot of possibilities
…
ok
probably
yup
HYEAH
.
Routine bloodwork
.
sounds appropriate
.
NONE
…
ok
ok
yes
It is NOT necessary to comment in every Discussion box to obtain credit.
according to your certificate it really is.
ok
–
okay
–
D
Weakness, malaise
yes
Generalized malaise
ok
it is necessary to continue with image exams
ok
.
.
ok
ok
ok
.
ok
Ok
need more details
.
.
probably the most common presentation in the elderly with ED visits. very vague history with non focal mutliple symptoms. tough to start a differential
I was going to say the same, with the current information provided I would not start a DDx without a more thorough assessment of focal S/S related to: Neuro… Infection… ACS… etc.
Patient has something going. Just not sure what. Needs thorough assessment.
k
great
ok
x
Needs a full work up
Vital signs may be very differential here like Temps!?
k
ok
ok
ok
great
generalized work up to start
will be difficult to diagnose based on the vague symptoms
Million dollar work up
TSH, CBC, UA, Infection from doing the chores
jkbhig
very common presentation, complete wu
yes
“Other”
ok
yes
need more information
vauge
vague sx
lots of things could be wrong
.
symptoms are vague for differentials.
.
I know we have not had much of a review of systems but this seems pretty unlikely to be a bowel obstruction. It certainly could be any number of things
ok
agree
agree
These cases can be difficult but are the most gratifying to solve.
.
requires good history, good exam, and luck.
Muy importante por qué el envejecimiento es un proceso que ocurre paulatinamente si aparecen cambios es que algo agudo está aconteciendo
Have to assess more
got it
agree
not feeling well
great for learning
not feeling himself
encephalitis-probably not/ The rest? fair game.
great list
cool
ok
great points
Good points
lethargic
ok
agree
I’m thinking encephalitis is a stretch…
Ok
good list
agree with above
so common to have a vague history/complaint
k
Common
agree
His presentation is very similar to many seniors we see in the ER
good case
ok
great
I have seen this issue before.
ok
Pt presents with a vague history which can lead an examiner down different paths. A thorough work up is needed to rule in and rule out.
I’m not sure we “know” that he didn’t have this a week ago. This may be much more chronic and the wife finally got worried enough to bring him in because she thought he fell. But in the ED we would probably not be able to come to the conclusion that there is nothing new going on.
It’s always challenging to assess Geriatric patients in ED.
However, its needs wide angle view on disease spectrum for accurate diagnosis.
requires further assessment
challenging to assess and diagnose
.
very common complaint
Very difficult to interpret problems with a vague history
difficult to diagnose- vague history and symptoms
difficult to diagnose- vague
All old people are weird & wonderful
every geriatric is a different kind of mystery to be solved
the ED loves the dx of feeling unwell, esp. @ midnight. Must be a full moon
Mr Farmer seems like a nice fella. They should check him out.
could be anything I guess
hay que dar mayor tiempo para que contesten estos paciente y buscar un familiar o cuidador adecuado
preguntar en forma completa
siempre hay que entrevistar en forma directa
problema frecuente en estos pacientes
careful with vague complaints
🙂
rn
xx
very common presentation
sss
my “favourite” case at midnight 🙁
In elderly population any symptom could rise from any disease,no classical presentations.
I had a case of “syncope in the shower and chest pain” last week that turned out to be cholecystitis
good case and educational points.thanks
I’ve been fooled more than once by cholecystitis as well
I agree with the above comment re “vague or difficult historian” it’s upto the history taker to tease out all the details
i agree, but without abnromal labs, cholcystitis is less likely, with encephalitis usually more confused than this pt,
I just had a case this week of a robust 82 year old from a nursing home with a “significant change in his behaviour” — I looked hard, including a CT abdomen with contrast despite his “normal labs” — including LFTs — The gall bladder wall lit up and on ultrasound he had impacted stones with significant cholecystitis. Normal WBC. Normal LFTs. No fever. No localized tenderness. The learning point was that with a clear change in behaviour it’s necessary to look far and wide for a cause.
this video doesnt seem to want to download.
not sure why, I’m at sinai on IE.
A cheeky medical student once pointed out to me that the person doing the recording is the historian. So when the term “poor historian” is used it should refer to the physician. Wise words.
SBO without a history of abdominal pain or vomiting and Cholycystitis without a gallbladder seem rather unlikely.
probably the most common presentation in the elderly with ED visits. very vague history with non focal mutliple symptoms. tough to start a differential