# 52yr old with appendicitis? feels wrong help



## nakor (Oct 1, 2017)

Call to: 52 year old female Emma Smith. On arrival patient is lying in bed on her side with knees pulled up. Pain described as gradual onset of generalised abdominal pain over last 24 hours increasing in severity. Patient has been vomiting intermittently, has not eaten and cannot tolerate fluids. Upon questioning patient cannot localise the pain but states it began in her right lower quadrant and was "on and off” for several days. Patient’s abdomen is rigid, tender on palpation, she also appears flushed and diaphoretic with a pain scale of 9/10. She had her bowels open yesterday and has no pain or burning on urination.

PMHx:  Migraine headaches
Left hip replacement
Chronic Bronchitis

Current medication include: Panadeine as needed, Prednisolone and Asmol Inhaler as needed.

Vital Signs: 
Pulse: 120 and thready 
Respirations: 24
Blood Pressure: 90/60
Blood Glucose: 4.0mmol
SaO2: 96% pale skin
Cap refill: <2s
Pupil: Equal and reactive
GCS: 15
Temperature: 39.5C
ECG: Sinus Tachycardia 
Pain: 9/10 and constant
Abdomen: Rigid and tender
Other: Vomiting minimal bile secretions, slightly agitated, non-smoker or drinker, poor skin turgor and dry mucous membranes


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## NomadicMedic (Oct 1, 2017)

Sepsis. IV Fluids, zofran and transport.


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## E tank (Oct 1, 2017)

Why can't someone who is 52 need their appendix out?


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## nakor (Oct 1, 2017)

haha they can just doesnt feel right


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## VFlutter (Oct 1, 2017)

nakor said:


> haha they can just doesnt feel right



What type of patient would “feel right” to you?


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## DesertMedic66 (Oct 1, 2017)

Chase said:


> What type of patient would “feel right” to you?


RLQ pain that radiates to the right leg with rebound tenderness and stable vital signs...


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## nakor (Oct 2, 2017)

ruptured appendix progressed to sepsis?


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## NomadicMedic (Oct 2, 2017)

Tachycardia, a rapid respiratory rate, 103 temp and lousy blood pressure? Smells like sepsis to me.


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## nakor (Oct 2, 2017)

From the information im given though i have no suspicion of infection, no burning on urination and lots of abdo issues? Pretty much written my whole paper on acute appendicitis and mentioned sepsis but now you guys got me worried.


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## GMCmedic (Oct 2, 2017)

nakor said:


> From the information im given though i have no suspicion of infection



Why not? We have the same information and suspect it. 

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## DesertMedic66 (Oct 2, 2017)

nakor said:


> From the information im given though i have no suspicion of infection, no burning on urination and lots of abdo issues? Pretty much written my whole paper on acute appendicitis and mentioned sepsis but now you guys got me worried.


Just with those vitals signs you should have at least a deferential Dx of infection/sepsis.


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## VFlutter (Oct 2, 2017)

It sounds like you are caught up on textbook presentations. You will learn from experience that illnesses will present in all types of ways and rarely how they are described in class.


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## VentMonkey (Oct 2, 2017)

nakor said:


> ruptured appendix progressed to sepsis?


Absolutely plausible. A secondary rule out diagnosis of peritonitis along with your obviously stated SIRS markers puts this patient into the "Severe Sepsis Criteria" category pending an accurate lactate level for confirmation. OP, do some research on "SIRS", this patient appears critically ill, and hardly anything to "lol" about.

Now, how would _you_ treat them?...


nakor said:


> From the information im given though i have no suspicion of infection, no burning on urination.


You're thinking of urosepsis, one of many root causes.


nakor said:


> Pretty much written my whole paper on acute appendicitis and mentioned sepsis but now you guys got me worried.


A good lesson learned perhaps. Also, what exactly did you mention regarding sepsis?


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## nakor (Oct 2, 2017)

VentMonkey said:


> Absolutely plausible. A secondary rule out diagnosis of peritonitis along with your obviously stated SIRS markers puts this patient into the "Severe Sepsis Criteria" category pending an accurate lactate level for confirmation. OP, do some research on "SIRS", this patient appears critically ill, and hardly anything to "lol" about.
> 
> Now, how would _you_ treat them?...
> 
> ...



Fluids, ondansetron, Fentanyl, immediate transport. Then i mentioned ceftriaxone if i had more information in relation to an infection.

Just mentioned that she had the body temperature above 38.3C, heart rate higher than 90 and respiratory rate higher then 20 so shes matches the requirements for sepsis.

Also her GCS is 15 so doesnt that rule out septic shock and SIRS for now?


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## Carlos Danger (Oct 2, 2017)

nakor said:


> Also her GCS is 15 so doesnt that rule out septic shock and SIRS for now?



No. You can be in shock and perfectly coherent.


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## VentMonkey (Oct 2, 2017)

@nakor are you a paramedic student? You don't seem to be too far off with your thinking. Perhaps do a bit more research, and as someone else mentioned, learn the value of differentials. There's hardly an "all of nothing" approach to patients and their presentations. Fix what you can, and keep the rest on the back burner.


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## hometownmedic5 (Oct 2, 2017)

nakor said:


> From the information im given though i have no suspicion of infection, no burning on urination and lots of abdo issues? Pretty much written my whole paper on acute appendicitis and mentioned sepsis but now you guys got me worried.



If you dont see the infection here, we need to talk...

Why are you focused on the unremarkable urination? Infection can occur outside of the urinary tract. As the Nomad said, this patient is septic, or at the very least rules in for the septic workup(which is going to reveal this patient is SAS and headed for the unit). 

You'd expect the pain to be right lower, but not all patients localize abd pain perfectly. Other than that, as stated she is SAS and needs to go to the hospital for immediate surgical consult. Even if it isn't her appy, shes has a hot belly and is destined for the knife. Maybe some diagnostic imaging reveals a non surgical cause, but I'd bet against it.


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## DrParasite (Oct 3, 2017)

nakor said:


> Patient’s abdomen is rigid, tender on palpation, she also appears flushed and diaphoretic with a pain scale of 9/10. She had her bowels open yesterday


call me simple if you must, but this statement alone immediately takes me to infection inside the abdomen.  the rest is all supportive.  surgery on her bowels yesterday + abdomen is rigid, tender with pain 9/10 = a surgeon needs to go inside and see what is happening in there.

could it be something else unrelated to her abdomen?  sure.  but if it walks like a duck, talks like a duck, and quacks a whole lot.....


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## GMCmedic (Oct 3, 2017)

DrParasite said:


> call me simple if you must, but this statement alone immediately takes me to infection inside the abdomen.  the rest is all supportive.  surgery on her bowels yesterday + abdomen is rigid, tender with pain 9/10 = a surgeon needs to go inside and see what is happening in there.
> 
> could it be something else unrelated to her abdomen?  sure.  but if it walks like a duck, talks like a duck, and quacks a whole lot.....


I think (assuming) by open bowel he meant bowel movement. Certainly if she did have surgery that opens a new can of worms. Paralytic ileus would be a concern. 

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## NomadicMedic (Oct 3, 2017)

Clearly the OP is not from the United States. Frequently, in other countries having a bowel movement is referred to as opening ones bowels. Please tell me you got that through context though, right?


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## DrParasite (Oct 4, 2017)

I took the statement at face value, because I had no reason to think otherwise.

and TBH, I have never asked other countries what they consider to be a bowel movement.


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