# something to ponder



## Veneficus (Sep 27, 2010)

Does this patient need an Emergency Department? What are the potential medical problems? What do you think is wrong? What would you do?

You are dispatched to a 36 year old male complaining of an acute onset of fever, diarrhea, N/V, central abdominal pain, and head ache. There has been light rain all day, with a temperature in mid  50s F.

You arrive on scene to find the patient lying prone on the couch, with moderately damp clothing. The residence is in good repair, there are no signs of economic distress, drug use or alcohol abuse, or any other form of domestic distress. 

Upon examining the patient you note the following:
The patient is alert and oriented x4 GCS 4,5,6. (15)
Blood pressure 128/82 
pulse: 92 regular and strong
Respirations 14 
lungs clear bilaterally 
4 Lead EKG shows NSR on the monitor 
Spo2  100% RA
Temperature: 39.4 tympanic 

Physical exam:
Gross: Patient appears to be of average build for a 35 y/o western male. Slightly overweight, clean, and cloths are in good condition, though a bit damp. Skin is noticeably warm to the touch, with normal turger and color. 

HEENT: face and head symmetrical, no grossly abnormal physical findings, hair is clean and well kept, there is no lymph node enlargement, and the skin is noticeably warm to the touch. The scleras are white and some small vessels are visible. The ears are clear of serumen and the tympanic membrane is intact with no signs of infection. On inspection of the mouth, you notice no dental carries, multiple fillings, none of which are recent, mucous membranes show no signs of inflammation and are moist, no distinctive breath odors, normal papillae, and normal color and tone of sublingual vessels. There is no nasal discharge or congestion. The pain is describes as being global but worse near the temporal area. (rated as 2/10)

Thorax: Breath sounds are clear and equal bilateral in all fields and heart tones are normal in all respects. The shape of the chest is also normal and there are no visible axilary lymph nodes. A few liver spots are noted on the posterior as well as a scar on the left superior scapular region (described as old injury in previous decade). Respiratory effort is adequate, with no signs of distress.

Abdomen:  The abdomen is soft, with no involuntary guarding, no palpable masses, or distension. The patient is still of small enough stature to palpate the abdominal aortic pulse, which matches the brachial and carotid pulses. Early onset central obesity is noticed. A few liver spots are noted here as well. The pain in central just below the xyphoid process, is constant, described as “squeezing” and cannot be manipulated in any way. (rated as 4/10) Bowel sounds are constant. Caput medusa is not found.

Genital/Urinary: No abnormalities or significant findings are discovered in the genital/anal region. Patient denies abnormality of sexual interest/function.
Extremities: Full range of motion, distal pulses, motor and sensory intact and reported as normal. No deformities, or trauma of any kind. There are <5 well circumscribed nevi on the upper proximal extremities. Feet are clean and callused.

Recent events prior to contact:
Patient returned home from work at about 8PM after a dinner meeting with clients. (local, well respected restaurant, no alcohol today, but several cups of coffee) Just prior to getting home became nauseous with sudden onset of bowel urgency and sweating. Upon returning home, passed watery stool that was described by the patient as bright yellow in color (not visualized by providers) and vomited one time. (described as being commensurate with chicken, potato and vegetable meal, no gross blood, bile, or  other abnormality reported) After this episode patient noticed fever with head and abdominal pain and extreme fatigue/weakness. (described in physical findings) Wife said he “never looked this bad before” and called EMS. 

Social history:
Patient has a post graduate degree in sales/ marketing, works as an outside sales representative for a major pharmaceutical company headquartered in Europe. Works for the regional office and frequently travels internationally. In the last 14 days has made trips to Barcelona, Spain, and Chicago, Illinois with several flight connections in various European airports. Patient denies ever smoking, elicit or prescription drug use or abuse, drinks socially no more than 1-2 beers or equivalent per week.  Heterosexually active, monogamous. Expecting first Child in mid Oct. Reports high level of job stress, and denies relationship or other stressors at home aside from being nervous about being a father.

Past medical history:
GERD treated with 4 week PPI therapy in 2009, frequent “heartburn” reported when traveling abroad, treated with OTC Calcium carbonate, (2000mg) no more than once daily prior to bed when symptoms worsen. Denies “heartburn” at home except for 1 time after eating KFC, and reports predictive abdominal discomfort after fatty meals without N/V or diarrhea. Last year when treated for GERD blood test revealed elevated AST/ALT (results not available) scheduled for follow up in 1 year, has not yet reached follow up time. No allergies, no current prescription meds. No prior surgeries or hospitalizations.  Patient also reports normal bldder/bowel habits and noticeable darkening yellow color of urine over the past year.

Family history:
Paternal family members all deceased presumably from brain or abdominal aneurism. Maternal history of HTN, CAD, and type II diabetes mellitus. Mother still living (87y/o) Father deceased (69y/o)  2 female siblings living locally without known health problems. (37/29 y/o respectively)


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## Voodoo1 (Sep 27, 2010)

Bear with me here. I haven't even set foot into a classroom, but I would like to take a stab at this. 

Based on the information, I think that there could be a few things going on here with this pt. Hot gallbladder, undiagnosed liver disease, maybe even lupus. If it were me in the situation, he would be taking a ride with me to the hospital. 

If I'm way out there, I would sure appreciate some feedback. If it's not any trouble.

Oh, there is one thing in your question that is confusing. You said that the pt temp is 50F? I thought that normal temp is 97F, 37C?


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## Sandog (Sep 27, 2010)

> Oh, there is one thing in your question that is confusing. You said that the pt temp is 50F? I thought that normal temp is 97F, 37C?



No, I think 50F was the ambient temp outside.



> There has been light rain all day, with a temperature in mid 50s F.


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## Voodoo1 (Sep 27, 2010)

Sandog said:


> No, I think 50F was the ambient temp outside.



Obviously I didn't have enough coffee today.  Thanks for the pointer.


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## CAO (Sep 28, 2010)

Wow, that's a thorough assessment!

I don't want to venture a guess quite yet, but I'm sure going to keep an eye on this.


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## MrBrown (Sep 28, 2010)

Oh damn it to the bowels of bloody hell, with odd things coming out of both ends he needs to go to the hospital and get checked by the overworked, underpaid, stressed out and dangeriously fatigued first year House Officer at the ED


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## Aidey (Sep 28, 2010)

Has he received proper immunizations for his travels? When away from the wife, does he admit to different dietary or alcohol habits when on the trips? Has he taken anything for his current symptoms (Tylenol? Pepto? etc). How much of a tan does he have? History of significant sun exposure or sun burns? 

So here is my thing with this patient, my guesses are either benign acute (food poisoning) or semi-serious to serious acute on chronic (gallstones, cancer (melanoma, liver), exotic infection).


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## CAO (Sep 28, 2010)

Aidey said:


> So here is my thing with this patient, my guesses are either benign acute (food poisoning) or semi-serious to serious acute on chronic (gallstones, cancer (melanoma, liver), exotic infection).



I was going to go for the gallbladder too, but his abdominal pain isn't quite right.


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## 46Young (Sep 28, 2010)

Sure, he needs an ED. The MD's office is just going to punt and call for ambulance rather than run/order some tests and then send him home.

Why no 12 lead or BGL?

As far as the pre hospital portion of this pt's care, all we can really do is do vitals, O2, monitor, IV, txp, and maybe draw bloods and hang a bag KVO. I'd be hesitant to do pain management, although I'm not suspecting opiate withdrawal.

Progressive darkening of urine over the past year is a little over my head. Several differentials have already been mentioned. Regarding prehospital care in the U.S. we're taught to assume the worst when a clear provisional field diagnosis is not obvious, and treat for that, be it prophylactically or with meds if appropriate.

Thanks for the very thorough assessment. I'm wondering how much of that assessment would we have been expected to have completed in the field? Some agencies, particularly rural ones, generally give the pt a quick once over, load them in the bus, agree on a hospital, and then do the rest of their exam. Therefore, in those regions, discussing whether or not the pt needs an ED is irrelevant, since they would already be transporting before discovering one tenth of what you posted. I do it myself. I do a rapid onscene assessment with pertinent diagnostics, make/recommend an appropriate txp destination, and then get in depth with social/family hx, a detailed physical exam and such if time allows while enroute to the ED. Most physicians just want the bare essentials from field personnel, and will do a detailed exam/Hx of their own, regardless of what we tell them. I've noticed that the physician's interest in our report will wane after approx 30 secs to a minute unless you can provide something pertinent that keeps his attention. The doc isn't going to spend several minutes listening to us about the pt's social hx, a dental exam, perineal exam, sexual hx, job stress, an intact tympanic membrane, etc.


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## abckidsmom (Sep 28, 2010)

46Young said:


> Sure, he needs an ED. The MD's office is just going to punt and call for ambulance rather than run/order some tests and then send him home.
> 
> Why no 12 lead or BGL?
> 
> ...



And as a nurse, I've heard interns and medical students get praised for such a thorough report, and then the attending will say "next time, just the pertinent facts."


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## aewin90 (Sep 28, 2010)

Veneficus said:


> Social history:
> Patient has a post graduate degree in sales/ marketing, works as an outside sales representative for a major pharmaceutical company headquartered in Europe. *Works for the regional office and frequently travels internationally.* In the last 14 days has made trips to Barcelona, Spain, and Chicago, Illinois with several flight connections in various European airports. Patient denies ever smoking, elicit or prescription drug use or abuse, drinks socially no more than 1-2 beers or equivalent per week.  Heterosexually active, monogamous. *Expecting first Child in mid Oct. Reports high level of job stress, and denies relationship or other stressors at home aside from being nervous about being a father.*


Stress in addition to a large amount of travel could mean he's picked up a nasty bug somewhere in the big bad world.



Veneficus said:


> Family history:
> Paternal family members all deceased presumably from brain or *abdominal aneurism.*


Aw jeez, this is going to get bad.

At this point I can only recommend routine transport to the ED in position of comfort...


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## Veneficus (Sep 28, 2010)

Sent several PMs to let people know I am not ignoring them. 

The main purpose of my post is to gather data on the different perspectives of the forum members here. 

It is an actual call. (my first on a squad in years I am rather happy about.) I posted all the information I know already.


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## 46Young (Sep 29, 2010)

I do hope, after this thread runs it's course, that you enlighten us as to what Dx you and your instructor decided on, and the reason for your txp decision.


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## Veneficus (Sep 29, 2010)

It was decided that the patient did not require transport. He was encouraged to self treat the fever with his own liquid tylenol/cold product and see his PCP or call back if the conditions didn't improve or if they got worse.[/I]

_A few likely Dx were determined, but ultimately the decision was really because of lack of evidence to any acute pathology that was life threatening or would benefit from transport.

The differentials included chronic GI issues as well as a reaction to a microorganism. Potentially amplified by a state of high stress._

_ Because of the patient's age, history, and general state of health, a cardiac event was not the focus of the exam. The signs, symptoms, and complaints, were largely related to the GI or an acute immune reaction._

_Also note, that it was his wife who called, not him, and not at his request or direction, but if the doctor from the ambuulance (my preceptor, not me) is already there, why not get looked at? (by me)_

...find the patient *lying prone on the couch*, with moderately damp clothing. The residence is in good repair, there are no signs of economic distress, *drug use or alcohol abuse*, or any other form of domestic distress.

_No reason to suspect he was being untruthful.  You also don't find a lot of seriously ill people who find prone as the position of comfort._ 

Upon examining the patient you note the following:
The patient is alert and oriented x4 GCS 4,5,6. (15)

_No alteration at all. Not indicative of hypovolemia, or various endogenous or exogenous toxins in the blood or brain._

Blood pressure 128/82
pulse: 92 regular and strong

_If he was compensating for a relative hypovolemia, he was doing it rather well. The absence of hypovolemic findings rules out some of the major life threatening bleeds of vrious origin._

Respirations 14 
lungs clear bilaterally

_No distress in breathing. Not really likely in severe abd herniation into the thorax._

4 Lead EKG shows NSR on the monitor

_no ectopy and an not tachycardic._ 

Temperature: 39.4 tympanic 

_Rather acute onset of high fever, however, the wife did seem to have a cold, and with all going on in his life recently, it seemed resonable to think he could have a latent illness that exaserbated the GI findings, but this was not a major decision point._

Physical exam:
Gross: Patient appears to be of average build for a 35 y/o western male. Slightly overweight, clean, and cloths are in good condition, though a bit damp. Skin is noticeably warm to the touch, with normal turger and color.

_Not screaming out hypoperfusion, dehydration, jaundice, and rather a common overall state of health in modern society._

HEENT

_There is no lymph node enlargement.No appearance of lymphatic infection or pathomorphology and the skin is noticeably warm to the touch. He does have a fever, but not screaming out spinal shock._

The scleras are white and some small vessels are visible.

_No jaundice, (would demonstrate inability to clear billirubin/bile) probably some early onset vascular problems._

The ears are clear of serumen and the tympanic membrane is intact with no signs of infection.

_Self explanatory._

On inspection of the mouth, you notice no dental carries, multiple fillings, none of which are recent, mucous membranes show no signs of inflammation and are moist,

No insideous infection route, nor signs of upper respiratory infections.No distinctive breath odors, normal papillae,

_(Always something you notice when looking in somebody's mouth.) But distinctly nonketonic. Normal tongue rules out various microrganisms as well as some long term infections._

and normal color and tone of sublingual vessels.

_Another good sign of perfusion status._

There is no nasal discharge or congestion.

_No sign of URI._

The pain is describes as being global but worse near the temporal area. (rated as 2/10)

_He has a headache, not exactly a high risk for stroke, and his BP, mental status, and motor exams don't give any impression of it either._

Breath sounds are clear and equal bilateral in all fields and heart tones are normal in all respects.

_Heart and lungs in good. Without lower respiratory infection or cardiac insufficency. _

The shape of the chest is also normal and there are no visible axilary lymph nodes.

_No long term remodeling which could alter respiration, nor signs of microorganism or abnormal morphology. _

on the posterior as well as a scar on the left superior scapular region (described as old injury in previous decade). Respiratory effort is adequate, with no signs of distress.

_Self explanatory._

_I should have also wrote I found no protrusion of the liver below the costal margins.If it was abnormal I am sure I would have been more dilligent in my reporting._

The abdomen is soft, with no involuntary guarding,

_A highly specific sign of an acute surgical abdomen pathology. Not perfect, but reliable._

no palpable masses, or distension.

_Rules out large tumors, gas, large amounts of various fluids, etc._


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## Veneficus (Sep 29, 2010)

The patient is still of small enough stature to palpate the abdominal aortic pulse, which matches the brachial and carotid pulses.

_Not overlyobese. Attests to the depth of palpation.(how reliable findings may be)_

The pain in central just below the xyphoid process,

_I should have said "inferior to" but generally localizes below the diaphragm. Points to abd origin, and about the area of the common bile duct, which is going to be the main determinant of sick/not sick. In this case _

is constant, described as “squeezing” and cannot be manipulated in any way. (rated as 4/10)

_Not really severe, but considering past GI problems, potential early onset of vascular issues, and the current defacation, it does point to some kind of pathology._

Bowel sounds are constant.

_Body is try to get rid of something._

Caput medusa is not found.

_No prehapatic occlusion, rules out some parasites and portal/central shunting, etc._

Genital/Urinary: No abnormalities or significant findings are discovered in the genital/anal region. Patient denies abnormality of sexual interest/function.

_Psychological implications as well as vascular._

Extremities: Full range of motion, distal pulses, motor and sensory intact and reported as normal. No deformities, or trauma of any kind. There are <5 well circumscribed nevi on the upper proximal extremities.

_When we entered, he sat up to meet us, had no difficulty following commands, mentally or physically. Was not in severe enough pain to reduce compliance. People here are very white, so brown things on the skin stand out._

Recent events prior to contact:

Patient returned home from work at about 8PM after a dinner meeting with clients. (local, well respected restaurant, no alcohol today, but several cups of coffee)

_lots of caffeine enough to maybe exacerbate some things. The meal is also greasy, (the lard that is put out to spread on the bread is particularly good). If meals rich in fat don't agree with you, you should not indulge. If you are looking to impress around here though, it is definately a culinary attraction._

Just prior to getting home became nauseous with sudden onset of bowel urgency and sweating.

_high fat meal, with a history of problems with this. Gallbladder stimulation._

 Upon returning home, passed watery stool that was described by the patient as bright yellow in color

_Like from a stimulated gallbladder. The fact it was grossly apparent demonstrates there is not likely a total occlusion of the common bile duct which would be suspect for severe billiary and/or pancreatic pathology. From the previous history of PPI therapy and stress, current or healed fibrotic duodenal ulcer that causes partial occlusion of vater possible._

and vomited one time. (described as being commensurate with chicken, potato and vegetable meal, *no gross blood, bile, or  other abnormality reported*)

_Contents still remaining in respective upper/lower proportions. Rules out intestinal occlusions, bleeding. More high fat food. (everything at that place probably is, I am rather fond of the potatoes cooked in butter and bacon.) _ 

After this episode patient noticed fever with head and abdominal pain and extreme fatigue/weakness.

_Related later that he has had similar symptoms before. Also the possibility of acute immune reaction to microorganisms. Vomited only once is also indicative of a GI problem over a nervous system problem._

(described in physical findings) Wife said he “never looked this bad before”

_Which led us to believe it has happened before._

Social history:

Patient has a post graduate degree in sales/ marketing, works as an outside sales representative for a major pharmaceutical company headquartered in Europe.

_Not entirely accurate to protect the identity. I wanted to clearly convey that this is a person who takes decent care of himself and doesn't suffer from a lot of socioeconomic illnesses._

frequently travels internationally. In the last 14 days has made trips to Barcelona, Spain, and Chicago, Illinois with several flight connections in various European airports.

_Connections and destinations rearranged to protect identity. But still in US and Europe, So not a lot of chance for parasitic organisms. (Outside of pork tapeworm)_

Patient denies ever smoking, elicit or prescription drug use or abuse, drinks socially no more than 1-2 beers or equivalent per week.

_Toxicology potential, general state of health, and risk factors._

Heterosexually active, monogamous.

_No suspicion of STI or occult trauma._

Expecting first Child in mid Oct. Reports high level of job stress, and denies relationship or other stressors at home aside from being nervous about being a father.

_Demonstrates constant physiologic stress response state (amplify/suppress various signs and symptoms) and psych health._

Past medical history:
GERD treated with 4 week PPI therapy in 2009, frequent “heartburn” reported when traveling abroad, treated with OTC Calcium carbonate, (2000mg)
no more than once daily prior to bed

_Has occasional upper GI issues treated with OTC antacid well within dose on label._

Denies “heartburn” at home except for 1 time after eating KFC,

_another high fat meal, more evidence of billiary issues.
(not that the taste alone won't kill)_

*and reports predictive abdominal discomfort after fatty meals *without N/V or diarrhea.

_(in the past) or with the addition of a response to a microorganism._

Last year when treated for GERD blood test revealed elevated AST/ALT (results not available) scheduled for follow up in 1 year...

_Could be too many things to list here, but apparently it wasn't significant enough to cause the PCP enough concern to recheck it in less than a year._

No allergies, no current prescription meds. No prior surgeries or hospitalizations.  Patient also reports normal bladder/bowel habits and noticeable darkening yellow color of urine over the past year.

_Darkening of urine can point to excretion of conjugated bile/billirubin, which would be consistant with hepatobiliary compensation._

Family history:
Paternal family members all deceased presumably from brain or abdominal aneurism. Maternal history of HTN, CAD, and type II diabetes mellitus. Mother still living (87y/o) Father deceased (69y/o)  2 female siblings living locally without known health problems. (37/29 y/o respectively)

_While it all sounds bad, It is not a history that points to events at early ages. Which was clarified, and again my oversight on not adding it here._

_With the findings and knowledge on hand, it was decided that an ultrasound of the hepatobiliary system and pancrease would be the main diagnostic test needed/performed. In the ED, the focus would be acute blockage or inflammation which based on clinical findings was highly unlikely. A CT if the ultrasound was not diagnostic would be a second choice. The PCP or potential GI consult would also come up with a better read and long term therapy, address the prior liver findings as well as potential cardiovascular health. 

While it would be good to observe the patient, it was not likely he would be admitted, and even if he were, the observation would be no better than at home since he certainly wasn't going to an ICU or going to receive constant neuro checks. _


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## zzyzx (Oct 12, 2010)

Nice scenario! Veneficus, I hope you post more scenarios like this. We can learn much from reading such an in-depth assessment. Very impressive.


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## DrParasite (Oct 12, 2010)

This patient absolutely needs to go to the ER, in an ALS ambulance.  The patient should receive pain meds for the abdominal pain prehospitally, and should then be transferred to the ER so further tests and monitoring can be conducted to find what the cause of the illness is.


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## SoCal (Oct 18, 2010)

*Good Read.... Hope to see more*

Great job on this scenario. So in depth and intellectual. I appreciate a post like this. :beerchug:

So, that being said, I am a big believer in prehospital pain management and the pt. setting their own "pain goal" Most people would be gracious with a pain level of 1 or 2 and not being totally pain-free, after a "pain goal" is established.

So as a prehospital provider, I would have offered my services of some O2, and some IV Morph and Zofran, and a nice calm ride to the ED. 

As I say that, I was not there and base my decision solely on the post in front of me and with the thoroughness of the post I am sure that the possible complications and options for treatment/transport were discussed with this pt. 

Great job^^^


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