# Scenerio #1 - Abdominal pain



## Flight-LP (Jun 20, 2009)

Here are the rules..........

Anyone can play! Those who are more familiar with the level of these scenerios are welcomed, but please allow others to respond before you give the spoiler!

There are no stupid questions, only the ones not asked.

There will be NO BASHING or comments about education, ALS vs. BLS, volunteers, animal love, light bars, or any other subject matter not directly pertaining to the scenerio or I'll ask a CL to lock it and refrain from publishing further scenerios in the future.

Thanks and enjoy!!!!!!!!

SCENERIO #1 - Abdominal Pain

You are called to a small community hospital's emergency department to transport a patient to the big city medical center for higher level tertiary care. Upon arrival, you receive report from the sending facility's RN.

56 y/o female presented by POV with complaint of RUQ abdominal pain x 2 days, worsening today. Pt. describes pain as sharp and radiating to both her LUQ and mid-back. Pt. also reports nausea and 2 episodes of vomiting today. Pt. is lethargic and slow to respond; she exhibits slurred speech, however no visible neuro deficits are identified.

Rummaging through her chart reveals the following information:

PMHx - Hepatitis C, Laproscopic Cholecystectomy 2 months ago, ERCP 3 weeks ago for post operative pain, HTN.

Medications - Lisinopril HCT, Pt. unable to recall others and states she is not taking medications prescribed after her recent surgery.

NKDA

Last vitals - BP 138/82, P 94, R 20 non-labored, SPO2 98% on O2 NC @ 2LPM.

Labs - CBC 

          RBC - 4.7
          MCV - 92
          HgB - 11.8
          Hct - 39
          WBC - 17.3
          Segs - 68
          Bands - 14
          Lymphs - 15
          Monos - 2
          Eos - 1
          Bas - 0 
          PLT - 226

          Chemistry

          Na - 149
          K   - 3.2
          Ca - 1.9
          Cl - 102
          CO2 - 27
          Phos - 1.3
          BUN - 4.2
          Cr  -  126
          AST - 136
          ALT - 52
          Bili - 0.6
          Glu - 263

          Amylase - 194
          Lipase - 86

          Blood Alcohol - 230

The following x ray was given to you with your chart. The RN reports the pt. needs a CT scan of her abdomen with contrast, but that their scanner is down.







You find your pt. on a nasal cannula @ 2lpm and has 0.9% NaCl infusing at 150cc / hr. You load your pt. up and are off to the receiving facility..................

Whats wrong with your patient??

What is the primary cause of your patients condition?

Do you identify any immediate issues that need to be addressed?

Anything else you would want to know?

What is your treatment plan?

***Bonus Question***

What was one thing the sending facility did that probably helped your patients clinical course?


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## DrankTheKoolaid (Jun 20, 2009)

*re*

First question as the film is not labeled to orientation as it should be.  Is this a PA or AP Abd.


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## Flight-LP (Jun 20, 2009)

Corky said:


> First question as the film is not labeled to orientation as it should be.  Is this a PA or AP Abd.



The film is a KUB taken in a supine position and is acceptable as shown.


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## DrankTheKoolaid (Jun 20, 2009)

*re*

Patient has an elevated AST/ALT along with a elevated WBC count with bands.  Sick cookie here.  Xray i'm going to take a guess at.  Now by history we already know she has a hepatitis and the x-ray appears to be showing a downwardly displaced  ascending and transverse colon so an acute/chronic hepatomegaly will be my guess.  Also of note would be the appearance of a distention of the large bowel (untrained eye here) at least it looks like it to me from what i remember seeing with belly films.

Cause would be a stricture or obstruction within the liver

I would want to know when her last BM was, as i cant really tell if that appears to be an fecal impaction there in the LLQ, that would contribute to the bowel distention

And the one thing the sending facility did to to improve this patients outcome?  not do the CT with contrast at there facility and sent her to higher level of care.


Thats my guess in a nut shell.  hopefully im at least close and will ready up on this after i finish some reports   

Corky


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## AnthonyM83 (Jun 20, 2009)

I gotta look up the labs later, but I want to know about 

fever? 
skins? 
progression on lethargy?
eating and bathroom habits?
Blood in vomit, urine, or stool? (occult?)
Bowel sounds?
Does CBC show elevation of neutrophils, specifically?
Vaginal bleeding?
LS?
Drink? Smoke? 
Surgeries? (n/m)
How well does she walk? Gait?
Also, pupils, please.

As for what they did that helped her? The TKO rate on fluids rather than bolus?


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## silver (Jun 20, 2009)

what worries me is the K level is low. the AST/ALT are pretty typical of hep.
I would get the CT and an ultrasound to rule out stuff (including what I am guessing pancreatitis)

but hey, I am not house...


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## Flight-LP (Jun 20, 2009)

anthonym83 said:


> i gotta look up the labs later, but i want to know about
> 
> fever? 100.4
> skins? Warm, slightly jaundiced
> ...



the rate of fluid infusion is acceptable.


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## Flight-LP (Jun 20, 2009)

silver said:


> what worries me is the K level is low. the AST/ALT are pretty typical of hep.
> I would get the CT and an ultrasound to rule out stuff (including what I am guessing pancreatitis)
> 
> but hey, I am not house...



I too would be concerned with that Potassium level. How would you treat it?


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## Flight-LP (Jun 20, 2009)

Corky said:


> Patient has an elevated AST/ALT along with a elevated WBC count with bands.  Sick cookie here.  Xray i'm going to take a guess at.  Now by history we already know she has a hepatitis and the x-ray appears to be showing a downwardly displaced  ascending and transverse colon so an acute/chronic hepatomegaly will be my guess.  Also of note would be the appearance of a distention of the large bowel (untrained eye here) at least it looks like it to me from what i remember seeing with belly films.
> 
> Cause would be a stricture or obstruction within the liver
> 
> ...



Yes the LFT's and WBC are elevated. While there is some bowel issue, this is not the biggest concern curently. Good eye though!


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## silver (Jun 20, 2009)

Flight-LP said:


> I too would be concerned with that Potassium level. How would you treat it?


Uhmm I dont know what is available but generically Lactated ringers IV or if you can mix stuff KCL in NS of some sorts


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## DrankTheKoolaid (Jun 21, 2009)

*re*

Just reviewed some of the labs and also of note is the low CA++ and Phosphorus levels.  Seemingly consistent with a malnourished alcoholic.   Still reviewing for my next crack at this

I still haven't figured out what that is running transversely near the level of T-12 though.  I don't believe it to be artifact, and it may actually be the inflamed pancreas leading to a diagnosis of acute pancreatitis


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## AnthonyM83 (Jun 21, 2009)

LS was Lung Sounds?

And sorry, meant to type, "progression of lethargy". Over a matter of days? hours?

The issue of recent surgery keeps coming up, but I'd have to do research on that to ask better follow-up questions on the topic


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## BruceD (Jun 21, 2009)

Umm... wow,  is her Cr really 126??


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## DrankTheKoolaid (Jun 21, 2009)

*re*

oh good catch, I didn't get that far in my lab value reviews yet!


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## Aidey (Jun 21, 2009)

Cr is creatinine right? Maybe he meant 12.6? Still really high, but it would make more sense.


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## silver (Jun 21, 2009)

hmm i glanced over it as a mistake and thought it was 1.26 originally, but 12.6 works


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## Aidey (Jun 21, 2009)

Yeah, depending on where the decimal point is supposed to be, it's either slightly elevated, or really high.


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## Flight-LP (Jun 21, 2009)

BruceD said:


> Umm... wow,  is her Cr really 126??



Sorry, Cr is 2.6


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## Flight-LP (Jun 21, 2009)

Corky said:


> Just reviewed some of the labs and also of note is the low CA++ and Phosphorus levels.  Seemingly consistent with a malnourished alcoholic.   Still reviewing for my next crack at this
> 
> I still haven't figured out what that is running transversely near the level of T-12 though.  I don't believe it to be artifact, and it may actually be the inflamed pancreas leading to a diagnosis of acute pancreatitis




You are correct that it is not "artifact". It is quite significant.


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## Flight-LP (Jun 21, 2009)

AnthonyM83 said:


> LS was Lung Sounds?
> 
> And sorry, meant to type, "progression of lethargy". Over a matter of days? hours?
> 
> The issue of recent surgery keeps coming up, but I'd have to do research on that to ask better follow-up questions on the topic



Lung sounds are clear and equal bilaterally.

Lethargy has been over a couple of days.

Keep researching the recent surgery, it may be of importance...........


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## taporsnap44 (Jun 21, 2009)

Did the ERCP reveal anything? Possible Gall stones?


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## AnthonyM83 (Jun 21, 2009)

Let's see.

I'm having a high suspicion for pancreatitis, which is a possible complication of the ERCP test. The slightly elevated (depending on source) amylase and lipase values would support this, along with the fever and onset over a few days. Did they leave something in there?


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## Flight-LP (Jun 22, 2009)

The x ray does reveal inflammation around the pancreas and the diagnosis of pancreatitis is correct. In addition, the pt. has a significant WBC count with left shift indicating acute bacterial infection. The elevated lipase should have really been the clue though as it is specific to pancreatic enzymes. General rule of thumb, if its elevated, its your pancreas.

So what is the PRIMARY cause of this lady's illness? I've heard possible complications secondary to the ERCP. Anyone else have any thoughts?

How about the current rehydration plan? Any problems that you see?

We've identified the hypokalemia and the hypocalcemia. Any other electrolyte issues?

anyone want to try the bonus question????


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## SanDiegoEmt7 (Jun 22, 2009)

I'll take my shot at this.   

Patient is an alcoholic and therefore already has chronic pancreatitis.

The fact that she had a cholysectomy, *perhaps* indicates a poor diet (high in fats) which also can cause pancreatitis.

The fact that she has not been taking "the meds" that were prescribed after the procedure, I'm assuming they were antibiotics, would have allowed the infection to grow. 

The elevated WBC would simply be from fighting the infection.  

The woman needs to taper off the alcohol, change her diet, and take meds that are prescribed to her for good reason.


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## SanDiegoEmt7 (Jun 22, 2009)

Her rehydration plan needs to account for the low potassium.  The low potassium is what is causing the neurological effects (speech lethargy)

Her sodium level is borderline high.  Maybe they should be rehydrating with KCl instead?  

The abundance of Na and the lack of K have many effects at the cellular level.


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## Flight-LP (Jun 22, 2009)

Hey Paramedics! The Basics are kicking your a$$es on this one!


Yes, the Sodium is also an issue and 0.9% NaCl is not the best choice for rehydration. 0.45% would be a better option, prefereably with a little KCl added (which is what we did for her).

The alcoholism is the primary cause of her pancreatitis. Yes an ERCP has a 5%ish chance of causing it, but will usually do so within 3-5 days. Diet can also play a part.

something else to notice is her HTN history. Believe it or not, antihypertensive agents, especially calcium channel blockers and diuretics, can cause the condition.

Bonus ?? anyone???????

Awesome responses thus far. I guess I'm making it too easy!


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## silver (Jun 22, 2009)

Flight-LP said:


> Hey Paramedics! The Basics are kicking your a$$es on this one!
> 
> 
> Yes, the Sodium is also an issue and 0.9% NaCl is not the best choice for rehydration. 0.45% would be a better option, prefereably with a little KCl added (which is what we did for her).
> ...


Cr 2.6
high risk for temporary renal failure with contrast CT...


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## Flight-LP (Jun 22, 2009)

silver said:


> Cr 2.6
> high risk for temporary renal failure with contrast CT...



**bowing down** We're not worthy.....................

Awesome!!!!

In addition to the possible renal issues, IV contrast is known to prolong and complicate acute pancreatitis (disputed heavily, but generally accepted as feasible and concerning).

Thanks for playing, job well done!

More to come....................


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## SanDiegoEmt7 (Jun 24, 2009)

silver said:


> Cr 2.6
> high risk for temporary renal failure with contrast CT...



I could not for the life of me figure this one out... I had been waiting for the answer, thanks!


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## SeeNoMore (Jul 30, 2009)

This was a great scanario to follow. A great indication of just how much I have no idea about yet, but very interesting. Thanks to all who participated.


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