# I just need some water!!!



## LACoGurneyjockey (Jul 10, 2016)

You respond to the local greyhound bus station for a 48 year old male complaining of difficulty breathing and left sided chest pain. He says the difficulty breathing started 3 hours ago while he was on the bus and progressively got worse until now. The chest pain started 3 days ago, he says it feels like he broke a rib and it hurts to breath. BP 108/78, pulse of 130 and regular, breathing 30/min, spo2 78% on room air confirmed by two separate devices. It becomes difficult to get any clear answers from the patient as he is slurring his words and keeps shouting "I NEED WATER!"
You have a very limited local hospital 7 minutes away with no specialties, and a major metropolitan area with whatever specialty center you want 35 minutes away.


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## Underoath87 (Jul 10, 2016)

12 lead?  Is the chest pain reproducible?  Lung sounds?  
How much do the sats improve with a NRB?


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## sack jears (Jul 10, 2016)

lung sounds? maybe a pulmonary embolism. probably altered because of severe hypoxia. get him to the metro hospital, he's altered and critical and probably needs some kind of specialist lord only knows


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## LACoGurneyjockey (Jul 10, 2016)

15L by NRB brings him up to 88%. Lung sounds are slight crackles on the right, diminished on the left. 12 lead shows a sinus tach at 130 with inverted T waves noted throughout all leads.


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## MonkeyArrow (Jul 10, 2016)

Tracheal deviation? JVD? Quantify diminished.


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## LACoGurneyjockey (Jul 10, 2016)

MonkeyArrow said:


> Tracheal deviation? JVD? Quantify diminished.


No and no.
I don't really know how to quantify diminished. They're present and audible, but much quieter on the left than on the right.


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## Summit (Jul 10, 2016)

temperature? skin CTM?
and findings on the chest like bruising or deformity? equal, rise/fall? obvious guarding?
could he localize the chest pain? quality? was it worse on deep inspiration?
PMH?

DDx:
1. Septic pneumonia/empyema/pleuritis
2. PE
3. Ptx

88% on the NRB is the right direction... go to the local hospital because if he goes downhill it will be fast, but they can stabilize and transport to specialty center.


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## LACoGurneyjockey (Jul 10, 2016)

98.4F, cool, moist, and pale with some slight mottling around the face, but it's 95+ degrees outside where he was found. Equal rise and fall, localized it to his entire left flank, worsened on deep inspiration but not on palpation. Sharp, "like a broken rib". 
No history, no meds, no allergies, but he "smoked some good weed" 3 days ago and the chest pain started after that. But he also says he fell on the side of his couch when he was high and thinks he broke a rib. So he can't decide which, if either, caused the chest pain. 
[/QUOTE]


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## Woodtownemt (Jul 10, 2016)

Much knowledge is limited to experience only bit ill go on a limb and say ot took a major bong rip triggering the eventual collapse of his lung especially if the rip with followed with a wicked coughing episode. This could also explain the sinus tach. The elevated RR could be due to weed and anxiety of of his soptanious broken rib. Also what was his BGL. Maybe munchies shot up his sugar too high to fast causing the need for water as well. But what do I know.  hope everyone is having a smooth Sunday.


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## ERDoc (Jul 16, 2016)

Lung cancer.  He's got a large effusion on the left and is AMS and thirsty due to his SIADH.

How long has he been riding the bus for?  Any leg pain or swelling?  Is anyone else on the bus sick?


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## SpecialK (Jul 16, 2016)

Give him some oxygen to fix his hypoxia and see if that helps
Check his BGL
FAST test
12 lead ECG

I need no further information to make the decision he requires immediate referral to ED and needs to be taken there by ambulance.  What I am not sure of is where he should be taken, e.g. catchment area hospital vs pPCI centre vs stroke centre (if they are not all in the same place, which, where I am, they are).


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## N0TOK (Jul 17, 2016)

That's a tough one I would probably go to the big hospital.
When we transport we have two options 1) Med Flight 2) 50 Mile drive to the closest hospital.


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## Alan L Serve (Jul 19, 2016)

Give him a 5000U UFH bolus and an appendix transplant.


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## Summit (Jul 19, 2016)

Is there an update?
@LACoGurneyjockey


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## LACoGurneyjockey (Jul 19, 2016)

Been on the bus for a little over a day, no leg pain/swelling, no one else on the bus sick. Transported local where they never got his sats about 91%. My money was on a spontaneous pneumo or PE, but leaning more towards the pneumo. 
Ended up being diagnosed with Valley Fever and pneumonia in the left lower lobe. Just didn't have all the answers for a while.


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## gotbeerz001 (Jul 19, 2016)

Valley Fever sucks. 


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## Tigger (Jul 19, 2016)

gotshirtz001 said:


> Valley Fever sucks.
> 
> 
> Sent from my iPhone using Tapatalk


Today I learned something.


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## gotbeerz001 (Jul 20, 2016)

Tigger said:


> Today I learned something.


It's really all you need to know about it. 


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