Week 10 – Vincent is off colour
WHAT DO WE KNOW?
PBL 1
Trigger 1
 23 y.o. male
 Tired
 Has Down’s
Syndrome
 Febrile
 Loss of appetite
 Brought in by
grandma
Trigger 2
 Only child
 Parents separated
and Grandma is his
primary carer and
has been for most
of his life
 Vincent lives in
shared
accommodation
 Has epilepsy
(treated with
Phenytoin)
 8 years ago
Vincent was in an
accident which
caused abdominal
injury
 Nail fold infection
recently, which
was treated with
Flucloxacillin
 Urine darker than
usual
 Had multiple blood
transfusions due to
the accident
 Not sexually active
 Works 3 days per
week
 Symptoms began 1
week ago, but the
abdo pain started
a few days ago
 Doesn’t drink/
drugs
Trigger 3
 Clearly jaundiced
(sclera and skin)
 Enlarged, smooth,
tender liver
 No ascities
 Spleen not
palpable
Liver Function Test:
ALT: 650 U/L (0 – 35)
AST: 450 U/L (0 – 40)
Alkaline Phosphatase:
186 U/L (35 – 100)
Gamma GT: 210 U/L (0
– 50)
Total Bilirubin: 80
umol/L (0- 20)
Glucose: 6.5 mmol/L
(3.2 – 7)
PBL 2
Trigger 5
 Diagnosed as infectious Hepatitis A
 At home with grandma
 Grandma is not coping and wants to know
Trigger 4
Serology:
HBsAg Negative
Anti-HBs Positive (All
IGG)
Anti-HBc positive
HBV-DNA negative
Anti-HCV negative
HAV-IgM positive
EBV, CMV and other
viral serology negative
Trigger 6
 Vincent recovers
what alternatives are available for Vincent’s
accommodation and care
WHAT DO WE NEED TO KNOW TO UNDERSTAND THE PROBLEM?
PBL 1
Trigger 1
 Vomiting?
 Where is the abdominal pain?
 What is the onset, timing, site,
radiation, character of the pain?
 Does anything make it better or
worse?
 Are there any associated
symptoms? (eg. Acid
regurgitation, waterbrash)
 Bowel habits?
 Early satiety?
 Weight loss?
 Taking anything of the
condition?
 Could this be a DS complication?
 Vitals?
 Medications?
 Allergies?
 Family History – illness, DS
 Occupation?
 Immunisations?
 Social history (smoke, alcohol
etc)?
 Past surgical history?
 Any other medical problems
associated with DS? (Obesity,
cardiac issues, diabetes,
neurological, early onset
Alzeimer’s, Leukaemia, arthritis,
coeliac disease, hearing loss,
epilepsy
 Results of a physical
examination?
Trigger 2
 What type of abdominal injuries
did he sustain as a result of the
car accident?
 Has he had this type of pain
before?
 Is he jaundiced?
 Has he contracted anything from
his blood transfusions?
 How long has he been on
Phenytoin?
 How long has it been since he has
been off Fluclox?
 How enlarged is the liver?
 Has he got referred shoulder tip
pain?
PBL 2
Trigger 5
 What sort of trouble/difficulties is grandma having?
 Is grandma immunised to Hepatitis A?
 Have others in the share household been immunised against Hepatitis A?
Trigger 3
Trigger 4

Who have Vincent been in contact with?
WHAT IS THE MECHANISM UNDERLYING THE PROBLEM (HYPOTHESIS)?
Trigger 1
Trigger 2
 Bile/ GB obstruction (fever + abdo pain + loss of appetite)
 Dehydrated
 Hepatitis
Trigger 3
Trigger 4
Trigger 3
Trigger 4
WHAT DO WE NEED TO SOLVE THE PROBLEM?
PBL 1
Trigger 1
 Complications of DS
PBL 2
Trigger 5
 What do antiviral meds do?
Trigger 2
 Types of Hepatitis (A, B, C)
o Blood induced
o Blood borne
o Viral (blood transfusion,
faecal-oral)
 What is Phenytoin and what is its
therapeutic Index?
 What is epilepsy?
 What is Flucloxacillin?
 Cholecystitiis
 jaundice