# An easy one?



## Veneficus (Jan 18, 2011)

An easy scenario.

You are called to the local college dorm for a 18 year old “sick female.” At 0130 hours.

You arrive on scene and are escorted to the room of the victim by one of the RAs and campus EMS providers. (an EMT-B prenursing student) You find the victim in the shower soaking wet with all of her cloths on. The water was shut off by her roommate who also called 911. Campus police are also on scene and the scene is safe. The room looks like the average college dorm room where one person looks like they have OCD and the other a master’s of organized chaos.

Your patient:
18 year old female, alert and oriented to person, and event with a strong smell of ETOH on breath. States: “I drank way too much.” GCS: 3,4,6 (13) vomited an unknown amount of times, remnants still in her hair, in/on toilet, on floor. Patient occasionally wretches as she talks to you. When asked how much she drank, tells you lots of beer and “stronger stuff” starting after last class at 3pm. Also states she felt bad after throwing up with substernal chest pain and bad taste in her mouth so she decided to take a shower, but couldn’t get her cloths off.

Vital signs:
GCS 3,4,6 (13)
HR: 99
BP: 112/67
RR: 16 shallow, breath sounds slightly diminished in left base.
Sp02: 100% on 4LNC (applied by campus EMS by protocol)
Temp: 36.5C
 5’5” height
Weight: 54KG

Physical exam:

HEENT: Head is symmetrical without signs of trauma, ears are clear, hair is wet with some vomit. Airway is clear, patient can hear out of both ears, pupils are equal and reactive 4mm-2mm, pt. states her vision is a bit blurry and the lights are too bright and making her head hurt. No discharges from her ears or nose, teeth are well taken care of and mucous membranes are dry with no signs of infection. Patient has trace amounts of fresh blood in sputum when dry heaving. Central pulses are regular and strong. No JVD, no tracheal deviation upon examination.

Thorax: No signs of trauma, equal chest rise and fall, breath sounds slightly diminished in left base. Pain is described as substernal and worsened by rubbing it. (2:10) no other significant findings. Heart sounds are normal.

Abdomen: is soft with some tenderness to palpation in the mid region similar to the substernal pain but lesser. There appears to be some mild guarding in the upper ABD on palpation. Liver and spleen palpable within normal margins.

Urogenital: No abnormalities to report, pt states she is on her period with her normal discharge.

Extremities: Femoral and all distal pulses are present, patient reports a little bit of numbness in her distal extremities and coordination is difficult. Cap refill is normal at +2.
History:
No known allergies

Meds: Takes PO birth control regularly, NSAIDS as needed for menstrual pain or occasional headaches.

PMHX: Previously healthy, born at term, all immunizations current, no hospitalizations, or extended illnesses. P0 G0 M0 A0. First menstruation at 13, regular since 15 when started on birth control. Was given a clean bill of health by US consulate physician prior to receiving her student visa this August.

Social history: Drinks socially, occasionally in excess, like after major exams, does not smoke, doesn’t use street or prescription drugs other than BC. (per patient)Regularly eats healthy and exercises 5 days a week and is part of the campus rowing team.

History of present illness: Started drinking after exam ~3PM with friends, at about 9 was inebriated enough that friends helped her get home and put her in bed. Pt. Remembers waking up in dark room, still fully dressed and feeling sick. Crawled to bathroom where she vomited several times and felt like she had to vomit some more but couldn’t. Tried to take a shower, but couldn’t get her cloths off so just sat under the water. Roomate returned home and found her under comfortable temperature water and thought she looked really sick. Feared she may have alcohol poisoning and called 911.

Other: Patient tells you her parents live in another country and do not speak English. The girl consents to be treated and transported. She shows you the number in her cell phone to her parents 01137109281128 

So what’s wrong with her?
What do you suspect and why?
How do you know?
Is it life threatening?
What are you planning to do for her?
Where are you taking her?
Any other info you require?


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## juxtin1987 (Jan 18, 2011)

Can we get EKG? Her diminished lung sounds on one side have me worried. Either Pneumonia or CHF but with no fever i'm hesitantly leaning toward CHF. 
Are you sure she's 18 y/o and not 88 y/o???



Editing this post: Where's she from/was a TB test done recently?


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## jjesusfreak01 (Jan 18, 2011)

Ok, so i've read through this like 5 times, so i'm ready to take a guess.

We definitely have hangover (light sensitivity) and possible alcohol poisoning symptoms (disorientation, says she drank too much), but i'm more concerned about the diminished breath sounds on one lung, blood in sputum, and substernal pain. I'm thinking possible pneumothorax caused by wretching and dry heaving. I know she isn't the standard build for spontaneous pneumo, but she might have other risk factors.

With only minimal loss of lung sounds, i'll take her to the hospital where they can confirm with x-rays and decompress if necessary.

@juxtin1987 This is supposed to be an easy scenario. CHF in an 18yof would be an odd diagnosis, and you would want a twelve lead to confirm anyways. Pneumonia is possible, but there is no history to support it. Now, had she aspirated, I might expect pneumonia in a few days.

PS: I know pneumo is an equally unlikely diagnosis, but it is somewhat supported by the symptoms. There is also the possibility that the substernal and abdominal pain is just muscle pain from continuous wretching.

You know what, she has chest pain, I want a twelve lead anyways. Who knows what she took at the party, or what she regularly takes. I don't trust the patient.


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## reaper (Jan 18, 2011)

Look at the BC that was mentioned numerous times!


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## jrm818 (Jan 18, 2011)

Veneficus said:


> An easy scenario.
> It's not that I think you're a liar, it's just that I think you're full of kakka
> 
> 
> ...



10 characters


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## juxtin1987 (Jan 18, 2011)

jjesusfreak01 said:


> @juxtin1987 This is supposed to be an easy scenario. CHF in an 18yof would be an odd diagnosis, and you would want a twelve lead to confirm anyways. Pneumonia is possible, but there is no history to support it. Now, had she aspirated, I might expect pneumonia in a few days.
> 
> PS: I know pneumo is an equally unlikely diagnosis, but it is somewhat supported by the symptoms. There is also the possibility that the substernal and abdominal pain is just muscle pain from continuous wretching.
> 
> You know what, she has chest pain, I want a twelve lead anyways. Who knows what she took at the party, or what she regularly takes. I don't trust the patient.



Noting the author of the post and the lingering question mark following its header, either he's going for a trick scenario in which the case is remarkably rare or he's assuming we'll assume the above statement and it really is just a drunk college chick with dull abd/chest pain from repetative vomiting/dry heaving. When i hear hoovebeats on this forum i think zebras or at least rare non domestic horses.


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## abckidsmom (Jan 18, 2011)

Drunk, with a little PE thrown from the DVT she picked up on her flight from Latvia?


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## Veneficus (Jan 18, 2011)

The replies in red while real easy to read, are a real pain to reply to.

_With any OD-ish scenario I'd be thinking about other ingestants, intentional or otherwise. Not everyone has learned not to drink the jungle juice..._

Not to worry, ETOH and party food (pizza and the like) is the only thing on the menu.

_In real life with the information given probably not. Since it is a scenario, defiantly yes._

But there is a dead ringer given.

_12-lead_

If you must, it is Sinus at 99 looking textbook normal.

_BGL_

80

_Any history of GI disorders?__Any history of bleeding disorders?_

No history

_Are you sure she's 18 y/o and not 88 y/o???_

18

_Can we get EKG? Her diminished lung sounds on one side have me worried. Either Pneumonia or CHF but with no fever i'm hesitantly leaning toward CHF_

Without CHF. Pneumo or not is your call.

_Where's she from/was a TB test done recently_

country code is 371, it is not Leeds, England. TB is negative.

_Look at the BC that was mentioned numerous times_

sorry, no clue there, just my forgetting if I mentioned it originally.

_Noting the author of the post and the lingering question mark following its header, either he's going for a trick scenario in which the case is remarkably rare or he's assuming we'll assume the above statement and it really is just a drunk college chick with dull abd/chest pain from repetative vomiting/dry heaving. When i hear hoovebeats on this forum i think zebras or at least rare non domestic horses._

No trick, 15% of all cases of this are spontaneous. One major finding, already given in the OP. (pneumo is possible but way too subtle. much easier than that.)


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## Veneficus (Jan 18, 2011)

abckidsmom said:


> Drunk, with a little PE thrown from the DVT she picked up on her flight from Latvia?



Flight was months ago


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## abckidsmom (Jan 18, 2011)

Veneficus said:


> Flight was months ago



I'm always wrong on these scenarios, but they never cease to get me thinking.  Besides, it was fun to figure out where the phone number came from.


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## Veneficus (Jan 18, 2011)

abckidsmom said:


> I'm always wrong on these scenarios, but they never cease to get me thinking.  Besides, it was fun to figure out where the phone number came from.



Cmon, if this one was any easier, I wouldn't have typed it up.


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## jrm818 (Jan 18, 2011)

Back to the drawing board.  Sorry about the red, hopefully this is better.

Abnormal findings from the OP:



Veneficus said:


> 18 year old female, alert and oriented to person, and event with a strong smell of ETOH on breath. States: “I drank way too much.” GCS: 3,4,6 (13) vomited an unknown amount of times, remnants still in her hair, in/on toilet, on floor. Patient occasionally wretches as she talks to you. When asked how much she drank, tells you lots of beer and “stronger stuff” starting after last class at 3pm. Also states she felt bad after throwing up with substernal chest pain and bad taste in her mouth



Most of that is normal excess EtOH stuff, with the exception of the chest pain.  Substernal mild pain could be a lot of things, but her much abused esophagus is right there, and EtOH may be dulling the pain a bit.



Veneficus said:


> RR: 16 shallow, breath sounds slightly diminished in left base.


Shallow: guarding due to pain?  Increased pain with deeper breaths?
Diminished: possibly aspiration, possibly pneumo but you said no, but possibly blood/fluid/air from another source (esophagus?)?



Veneficus said:


> pupils are equal and reactive 4mm-2mm, pt. states her vision is a bit blurry and the lights are too bright and making her head hurt. No discharges from her ears or nose, teeth are well taken care of and mucous membranes are dry with no signs of infection. Patient has trace amounts of fresh blood in sputum when dry heaving.



Again, drunk mostly, but the blood is a bit abnormal.  Leading us down the path of a traumatic event somewhere south of her mouth.





Veneficus said:


> Pain is described as substernal and worsened by rubbing it. (2:10) no other significant findings. Heart sounds are normal.



Pain, as above.



Veneficus said:


> Abdomen: is soft with some tenderness to palpation in the mid region similar to the substernal pain but lesser. There appears to be some mild guarding in the upper ABD on palpation. Liver and spleen palpable within normal margins.



As before, the mild pain could be a lot of things, but it is suspiciously close to her stomach.  Everything else seems OK.



Veneficus said:


> patient reports a little bit of numbness in her distal extremities and coordination is difficult.



Drunk.



Veneficus said:


> NSAIDS as needed for menstrual pain or occasional headaches.



Increased risk of GI bleeding...


So, I think I'm going with esophageal rupture with my likely guess.  15% spontaneous seems reasonable, assuming most are in the population with esophageal disease.  In this case I'd say the trauma (vomiting) is about to cause a medical (septic baddness), as it were....


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## blindsideflank (Jan 18, 2011)

aspiration, spontaneous pnuemo, hypovolemia/dehydration and cramping, esophageal varices/esophagitis,?
i assume she is sexually active (birth control) but confirm this with me. any new partners? new birth control since coming to country? its oly been a month, is her period still regular?

any recent illnesses?
oral contrceptives increase possibilty of a sponatneous pneumo i think. maybe alongside any STD's.
does she smoke? pot?

in all honesty i would worry about aspiration and probably leave it at that, but im dumb so...
percuss chest
tracheal deviation?
unequal expansion etc.
jvd?
purging?
i know shes british but how are her teeth(hehe)


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## Veneficus (Jan 18, 2011)

*see, that didn't take long at all.*



jrm818 said:


> Back to the drawing board.  Sorry about the red, hopefully this is better.
> 
> Shallow: guarding due to pain?  Increased pain with deeper breaths?
> Diminished: possibly aspiration, possibly pneumo but you said no, but possibly blood/fluid/air from another source (esophagus?)?
> ...



see, that wasn't so bad, but i will post a walk through


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## Veneficus (Jan 18, 2011)

An easy scenario.



Veneficus said:


> 18 year old female, alert and oriented to person, and event with a strong smell of ETOH on breath. States: “I drank way too much.”



Patients always tell you what is wrong somehow.



Veneficus said:


> vomited an unknown amount of times, remnants still in her hair, in/on toilet, on floor. Patient occasionally wretches as she talks to you.



This starts the case for complications related to Esophageal perforation. (sometime's called Boerhaave Syndrome) This describes a lot of violent vomiting. Considering her level of intoxication, it is not really obvious, but you could stipulate that her vomiting reflex is uncoordinated. (all in all, just setting the stage.)



Veneficus said:


> When asked how much she drank, tells you lots of beer and “stronger stuff” starting after last class at 3pm.



In spontaneous esophageal rupture, the time from the event to treatment directly affects the prognosis. This short of time period from sometime after dark to ~1am will give her a chance for an excellent outcome if identified and treated appropriately.



Veneficus said:


> Also states she felt bad after throwing up with substernal chest pain



Chest pain after throwing up. This helps to substantiate traumatic injury.



Veneficus said:


> and bad taste in her mouth so she decided to take a shower, but couldn’t get her cloths off.



Because she is intoxicated.

Vital signs:


Veneficus said:


> GCS 3,4,6 (13)



Intox



Veneficus said:


> HR: 99
> BP: 112/67



Boarderline tachy with no significant rise in BP for what you would expect to see in a 18 year old. Compensating for something, no physical evidence of major bleed.



Veneficus said:


> RR: 16 shallow, breath sounds slightly diminished in left base.



A non specific finding, a pneumo is entirely possible, but so is gastric contents, or worst case, blood finding it's way to a dependant area.



Veneficus said:


> Sp02: 100% on 4LNC (applied by campus EMS by protocol)



Ventilation appears unaffected, but this is still very early in the presentation. Makes it easy to get lax.



Veneficus said:


> Temp: 36.5C



Early or late infectious process not readily identifiable.



Veneficus said:


> Physical exam:



This is what always seperates the men from the boys so to speak. (the lack of detailed physical exam is also the main reason I abstain from commenting on certain scenario threads, just too much left out to make an intelligent conclusion and guessing right demonstrates no skill at all.)




Veneficus said:


> Head is symmetrical without signs of trauma, ears are clear, hair is wet with some vomit. Airway is clear, patient can hear out of both ears, pupils are equal and reactive 4mm-2mm, pt. states her vision is a bit blurry and the lights are too bright and making her head hurt. No discharges from her ears or nose, teeth are well taken care of and mucous membranes are dry with no signs of infection.



These findings reduce the suspicion of head trauma from an occult or unknown injury. She is still intoxicated though, and probably slightly dehydrated, but not overtly hypotensive.

There is also no sign of chronic infection.




Veneficus said:


> Patient has trace amounts of fresh blood in sputum when dry heaving. Central pulses are regular and strong. No JVD, no tracheal deviation upon examination.



There is evidence of minor bleeding, most likely from the dry heaving, but also suspicious for mucosal tears not involving significant vasculature.

In order to detect early onset tracheal deviation you must draw a line from the crest of the mental protuberance to the jugular notch. Deviation greater than 3mm is considered clinical tracheal deviation. (the gross deviation and tugging seen in pneumo is a late sign. If you don't know what you are looking for how do you document if you saw it or not? How do you base your judgements off of it? Pet peeve of mine to hear instructors tell students you only seen this when it is too late. Demonstrates very well they know what the text says but not what they are talking about.) 

No JVD is a minor sign that makes it look like there is not a right heart issue.



Veneficus said:


> Thorax: No signs of trauma, equal chest rise and fall, breath sounds slightly diminished in left base. Pain is described as substernal and worsened by rubbing it. (2:10) no other significant findings. Heart sounds are normal.



Heart is accounted for, diminished breath described above. Minor pain because she is medicated with ETOH. The ability to alter the pain, while not concrete, demonstrates the potential of pleural involvement and irritation. Not a slam dunk, but something to consider. 



Veneficus said:


> Abdomen: is soft with some tenderness to palpation in the mid region similar to the substernal pain but lesser. *There appears to be some mild guarding in the upper ABD on palpation*. Liver and spleen palpable within normal margins.



This is a highly sensitive sign of a surgical abdomen. When you see involuntary guarding, think surgical abdomen.

Some method behind the madness is that visceral pain is diffuse and unable to be localized. It also seems more like an abnormal feeling than pain (almost no pain reception) When it is late stage visceral pain it agitates the peritoneum, which does have pain and stretch receptors. That stimulation causes involuntary muscle contraction.

As well, when you have anything that acutely irritates the peritoneum, you get the same result. There is no physiologic process that irritates the peritoneum. It is always pathology.

So you either have an acute peritoneal process or an acute phase of a visceral process. Either way, the solution is 440 stainless steel. "Mechanical pathology requires mechanical treatment. Treating mechanical issues with medication just delays the proper care." 



Veneficus said:


> Urogenital: No abnormalities to report, pt states she is on her period with her normal discharge.



Should all but eliminate pregnancy related causes.



Veneficus said:


> Extremities: Femoral and all distal pulses are present, patient reports a little bit of numbness in her distal extremities and coordination is difficult. Cap refill is normal at +2.



She is intoxicated without signs of massive hemorrhage.



Veneficus said:


> History:
> No known allergies
> 
> Meds: Takes PO birth control regularly, NSAIDS as needed for menstrual pain or occasional headaches.



Crazy tox issues unlikely.



Veneficus said:


> PMHX: Previously healthy, born at term, all immunizations current, no hospitalizations, or extended illnesses. P0 G0 M0 A0. First menstruation at 13, regular since 15 when started on birth control. Was given a clean bill of health by US consulate physician prior to receiving her student visa this August.



No genetic or foreign travel issues.



Veneficus said:


> Social history: Drinks socially, occasionally in excess, like after major exams, does not smoke, doesn’t use street or prescription drugs other than BC. (per patient)Regularly eats healthy and exercises 5 days a week and is part of the campus rowing team.



Lowers further tox suspicion of medication mixes. In Vino Veritas. (in wine, there is truth)



Veneficus said:


> History of present illness: Started drinking after exam ~3PM with friends, at about 9 was inebriated enough that friends helped her get home and put her in bed. Pt. Remembers waking up in dark room, still fully dressed and feeling sick. Crawled to bathroom where she vomited several times and felt like she had to vomit some more but couldn’t.



Acute onset of vomiting (likely violent) which did not self resolve. In addition to a pneumo this is a very strong candidate for a spontaneous esophageal tear or complete rupture.  



Veneficus said:


> Tried to take a shower, but couldn’t get her cloths off so just sat under the water. Roomate returned home and found her under comfortable temperature water and thought she looked really sick. Feared she may have alcohol poisoning and called 911..



Because a surgical emergency does not preclude people from being drunk and looking like s***.



Veneficus said:


> Other: Patient tells you her parents live in another country and do not speak English. The girl consents to be treated and transported. She shows you the number in her cell phone to her parents 01137109281128



I just wanted to see if anyone figured out the country code. What can I say? Sadisitic curiosity. 



Veneficus said:


> So what’s wrong with her?


Esophageal perforation. (Boerhaave Syndrome) From the most likely etiology to spontaneously cause it.



Veneficus said:


> What do you suspect and why?



A surgical abdomen because she has involuntary guarding. (see how easy this is?)



Veneficus said:


> How do you know?



Understanding of pathology with a detailed physical exam looking for specific findings that would help you decide if this patient is seriously sick or not.



Veneficus said:


> Is it life threatening?



Absolutely. With the prognosis getting worse as time goes on. By the book, at around 24 hours without surgical treatment post incident mortality is greater than 40%. 

Proper surgical treatment in <4 hours often precludes septic complications with uncomplicated and total recovery estimated at 75%.




Veneficus said:


> What are you planning to do for her?



From the EMS standpoint realize that she has a life threatening emergency. Keep her calm, provide supportive care, and go to the right place. 



Veneficus said:


> Where are you taking her?



To a place with a surgeon in house.



Veneficus said:


> Any other info you require?



Shouldn't. A ride to an OR is what she needs. Anything else is just gravy.

I posted this scenario for a few reasons.

It demonstrates how important it is not to get tunnel vision and see young drunk people and write them off as simply such or start thinking only about drugs, etc. Maintain objectivity even in the face of stupidity.

It demonstrates very well the importance of performing a good physical exam. Whether you understand the pathology or not, when you have involuntary guarding in the abd. the patient needs a knife and you know that.

The patient can be equally served by an astute Basic as well as a medic. 

It is also a condition that is life threatening and time critical despite the fact the patient probably doesn't look very sick at all. (It is not listed in any EMS text I have ever seen)


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## Aidey (Jan 18, 2011)

Veneficus said:


> I just wanted to see if anyone figured out the country code. What can I say? Sadisitic curiosity.



I did, but you replied with it before I could post. 

/old friend lives in England.


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## abckidsmom (Jan 18, 2011)

Veneficus said:


> I just wanted to see if anyone figured out the country code. What can I say? Sadisitic curiosity.



Also, I got hung up on this and spent some time googling Latvian genetic anomalies, quirky Latvian epidemiology.  

Turns out, it was a random choice (apparently).  Was it random?


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## Aidey (Jan 18, 2011)

Aidey said:


> I did, but you replied with it before I could post.
> 
> /old friend lives in England.



I should explain that better, because she lives over there I've seen international numbers, and know either digits 4,5 and sometimes 6 are the country code. +37 is out of use, so it had to be +371


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## MediMike (Jan 19, 2011)

Great scenario.  While in school the new director of our program hit GI issues pretty heavy, mentioning both Booerhave's and Mallory-Weiss tears and the mortality associated with them.  Nicely played.


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## Sassafras (Jan 22, 2011)

Interesting... so what did the bcp have to do with things since it kept coming up?  I was leaning toward side effect issues there, but I guess I have more to learn.


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## 8jimi8 (Jan 22, 2011)

Veneficus said:


> Cmon, if this one was any easier, I wouldn't have typed it up.



I was thinking hernia, or aneurism.

What was with the numbness of the extremities?


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## cmetalbend (Jan 22, 2011)

Well I'm no paramedic, but did guess eso. problems.  I would suspect it could also be caused by special ingredient in the "Jungle Juice" Thats the thing about severly intoxicated people. At that point they really don't know what they're drinking.  Trace amounts of Antifreeze, for instance. More so for college settings.


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## Veneficus (Jan 22, 2011)

8jimi8 said:


> What was with the numbness of the extremities?



Alcohol effects.


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## Seaglass (Feb 3, 2011)

Veneficus said:


> Should all but eliminate pregnancy related causes.



I've known a few women who didn't realize they were pregnant at first because they experienced false periods. They didn't notice any signs, and would've reported a normal menstrual cycle.


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## Veneficus (Feb 3, 2011)

Seaglass said:


> I've known a *few* women who didn't realize they were pregnant at first because they experienced false periods. They didn't notice any signs, and would've reported a normal menstrual cycle.



While atypical presentations should always be considered, a female relyably on birthcontrol, without any other medication that would alter its effects, is not a good candidate for false pregancy. 

If you always try to cover the "what ifs" you will never reach a diagnosis without rnning every test known to man. Which is generally considered poor medicine.

Considering my choice of words and what you chose to quote, I think it was covered


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## Seaglass (Feb 3, 2011)

Veneficus said:


> While atypical presentations should always be considered, a female relyably on birthcontrol, without any other medication that would alter its effects, is not a good candidate for false pregancy.
> 
> If you always try to cover the "what ifs" you will never reach a diagnosis without rnning every test known to man. Which is generally considered poor medicine.
> 
> Considering my choice of words and what you chose to quote, I think it was covered



Fair enough, and I intended it more as a general point than criticism of you. I've just seen a lot of providers lately who interpret "highly unlikely" as "impossible" on this particular topic.


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## zzyzx (Feb 4, 2011)

Great scenario! Thanks for posting this.


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