22/f w pneumonia after a really bad cough

Three weeks ago I had a really really bad cough. So bad in fact that a few days after it started I noticed a soreness in my left rib. It's just over that spot really and it hurts when I yawn or take a deep breath. Prior to that I had a bit of a cold but it did not concern me enough to visit my GP. My mum who's a nurse describes it as the worst cough she has ever seen. The cough was so bad that I ended up vomiting. My GP had put me on Amoxycillin/Clavalunate but my symptoms were not improving much after a week. He also prescribed me some Paracetamol/Codeine (1g/30mg QID) for pain that I have been taking regularly but my pain was still not very well under control. I got chills/rigors just as my course of antibiotics was finishing. The cough had settled slightly by then but the pain was unbearable especially when lying down and taking deep breaths/coughing. I literally couldnt lie down and sleep sitting up on a chair.  Yesterday I started to get a little short of breath so I came to emergency. I was started on roxithromycin and given a shot of ceftriaxone. I've been feeling much better since. This was a two days ago, and im coming in today for my daily shot of ceftriaxone.

*for sake of brevity, abx names have been included in the quote.

Hx: Otherwise well nil issues not on meds.

Ix: CRP 5.1 WCC17.5(14.2) w mature neutrophilia. GGT328 ALT 207 AST 128 ALP 147. CXR n. CT Chest small localized posterior R-LL pneumonia. Sputum culture from ED nad.

O/E: Chest clear. Nil SOB. localized pain in chest when coughing/yawning. stable afebrile.

What was the likely missed diagnosis?

Corticosteroids, 5-20-750

5mg of Prednisolone = 20mg Hydrocortisone = 750mg Dexamethasone

Axioms: The body produces around 20mg cortisone daily. More than 20mg hydrocortisone causes adrenal suppression. The synthetic ones produce less suppression. Above the physiologic level (bolded above), side effects rise dramatically.

Signs: In all patients consider that signs of infection may be suppressed. Cushingoid appearance: moon face, hirsutism, buffalo hump, flushing, increased bruising, striae, acne.

Why Corticosteroids Are Bad For You:

• Osteoporosis
• Muscle wasting
• Skin thinning
• Hyperglycaemia
• Adrenal atrophy - via negative feedback on the hypothalamic-pituitary-adrenal axis.
• Masked infections - anti-inflammatory, analgesic and antipyretic
• Menstrual irregularities
• Hypercoaguability - embolism

FAQ:

Prednisolone is not Prednisone. The latter requires hepatic metabolism to be converted into its active form.

Above the physiologic dose, many patients report feeling sick and unwell.

Updated 15/4/12

50/m w severe lower abdo pain

9/10 abdomen pain when I called the ambulance an hour ago. It's now probably 6/10. It's always there and spikes up every fifteen minutes to a point where it's unbearable. I've been getting these pains yearly in my lower abdomen for the past six years. It all started 12 years ago when I had part 4 feet of my terminal ileum and part of my caecum removed after a severe flare up of Crohn's disease. It was fine for the few years after the operation but the pain started 6 years later. Being the holidays and all, I had a really big meal two nights ago with my family. It started to really hurt past midnight, but was bearable until 12 hours later when it really got painful.

Further Hx: Last bowel motion 12/24 ago soft/brown/formed. Severe nausea and vomiting, unable to tolerate solids and only taking small sips of clear liquids. Otherwise well, not on any medications/steroids. No current medical issues.

O/E: Stable afebrile. Rebound and guarding in the lower abdomen with maximum severity in the RIF. Bowel sounds present. Nil renal angle tenderness. Nil masses. Abdomen looks distended but patient says it's normal for him.

Ix: FBE U&E n. CRP 8. AXR shows feacal loading. Otherwise nad erect and supine. No free gas below the diaphragam.

Rebound and guarding are very clinically important signs. The surgical registrar was called.

What is the next step in this patient's management?