# Rib Pain from the SNF



## truetiger (Dec 21, 2012)

You are dispatched to the local SNF for a sick case. Dispatch advises an 86 year old female complaining of right lower rib pain, hx of surgery in the last 2 weeks and a BP of 90/40. You arrive to said SNF and are met by the nurse. She tells you the patient is complaining of right rib pain and is hypotensive. She also notes the patient is breathing shallow, complaining of painful inspiration. General impression of your patient is of no distress. She's alert and oriented. States her she began having pain about 21 hours earlier. She points to a spot on the right lateral rib cage near the floating ribs. You palpate, she grimaces and groans a little. No soft tissue swelling/bruising or crepitus. Pt denies any other complaints. Vitals are as follows: HR 80, BP 130/80 20 RR 96% on 2L. Where would you like to start?


----------



## JPINFV (Dec 21, 2012)

OPQRST, history, allergies, medications, what was the surgery?


----------



## medichopeful (Dec 21, 2012)

Definitely curious about the surgery she had recently.  Also any falls.  What side does she sleep on?  When in the day did the pain occur (after waking, during an activity, after a fall, etc.).  Does she still have her gallbladder?  Any history of liver issues?  Bone issues?


----------



## truetiger (Dec 21, 2012)

Onset was at midnight (we got called at 2100) Patient woke up with rib pain, thought she slept on it wrong. Palpation/movement and inspiration provoked severe pain. She stated she could not take a deep breath, but denied being short of breath. Patient appeared asymptomatic otherwise. No radiation. She had a hard time describing the pain, I had to move on with the rest of the exam, very short ride to the ER. NKDA. Typical nursing home two page med list. Patient had a pacemaker placed 2 weeks prior. Patient had a strong radial pulse of about 80 upon arrival. Facility/ pt both denied fall/trauma.


----------



## Handsome Robb (Dec 21, 2012)

There's no way this is going to be as simple as it sounds. 

Any pertinent hx besides the recent surgery?

Maybe it's just me but whenever a SNF RN/LPN tells me vitals I generally store them in my brains circular file cabinet. 

Random question...palpable liver? Someone already asked but hx of gallbladder or liver problems? How's the surgical site look, near healed I would expect after two weeks but then again it's an 86 yo.

Physical exam show anything exciting? 

So far this would be an ILS call in my system unless we decided to narcotic analgesia. Still on the edge about that though.

Any flank/back pain? difficulty/changes in urination? color/smell/floaties? Who's to say gma didn't get down with her bad self and bump into the wall and just doesn't remember doing it?


----------



## mycrofft (Dec 21, 2012)

NVRob said:


> There's no way this is going to be as simple as it sounds.
> 
> Any pertinent hx besides the recent surgery?
> 
> ...



I was waitring for someone to think flexure of the large bowel. Good. Techs are all about being out of the viscera. Never read about bowel auscultation or abdominal palp/percussion.


----------



## Aidey (Dec 21, 2012)

NVRob said:


> So far this would be an ILS call in my system unless we decided to narcotic analgesia. Still on the edge about that though.



This isn't an ILS call until she has had an EKG/12 lead. My last little old lady to complain of R sided rib pain coded in front of me. 


Granted, her 12 lead wasn't actually all that suspicious for a cardiac event. She likely had R on T from all the ectopy she was throwing.


----------



## Handsome Robb (Dec 21, 2012)

mycrofft said:


> I was waitring for someone to think flexure of the large bowel. Good. Techs are all about being out of the viscera. Never read about bowel auscultation or abdominal palp/percussion.



Can I rephrase it and say "palpable masses" and not limit it to the liver? 

I've always been told bowel sounds in EMS is kinda pointless/impractical to do a proper assessment of them but I'm always up for a different viewpoint.


----------



## JPINFV (Dec 21, 2012)

Inhalation somatic dysfunction. Give me a second, I'll just pop that back in. 

/Osteopathic medicine FTW.
//[/sarcasm]


----------



## mycrofft (Dec 21, 2012)

NVRob said:


> Can I rephrase it and say "palpable masses" and not limit it to the liver?
> 
> I've always been told bowel sounds in EMS is kinda pointless/impractical to do a proper assessment of them but I'm always up for a different viewpoint.



"Color/smell floaties" implied bowel thinking and hx-taking. Yes, "the belly is a dark and dangerous place) and techs don't have as many protocols down there, but many's the time I was able to relieve a "heart attack" with symethicone PO once we established VS were normal and ther was tympany at the left upper quadrant. I also was late on a gallbladder once because security issues kept me from doing a good if minimalist abdominal exam.

Abdominal assessment helps determine proper tx, eliminate imporper tx, and esablish acuity.


----------



## truetiger (Dec 21, 2012)

Physical exam reveals nothing exciting, only severe pain to palpation. Abdomen is soft, non tender. Surgical site looks normal, nothing out of the ordinary. Pt history reveals no other abdominal surgeries.


----------



## DrankTheKoolaid (Dec 21, 2012)

Radiation? Rash?  fever? Huge setup for shingles with the recent stress of surgery


----------



## mycrofft (Dec 21, 2012)

YEah, rash? IS this TENDER, or PAINFUL, or both? Nature of pain? (Burning?). Looking at shingles here.


----------



## NomadicMedic (Dec 21, 2012)

Did we get a 12 lead?


----------



## truetiger (Dec 21, 2012)

No rash, radiation, or fever. Painful, very painful to palpation or when moving the patient, also kept her from taking a deep breath. No 12 lead. Asked if patient had been sick recently, was told "I don't know." Patient states she's been a little weak lately.


----------



## Anjel (Dec 22, 2012)

Costochondritis. Case solved.


----------



## truetiger (Dec 22, 2012)

Anjel said:


> Costochondritis. Case solved.



Negative.


----------



## Anjel (Dec 22, 2012)

truetiger said:


> Negative.



Ha didn't think so.


----------



## Handsome Robb (Dec 22, 2012)

Musculoskeletal pain unless you give me a reason to think otherwise


----------



## truetiger (Dec 22, 2012)

Ok so here's the conclusion..... we out any reason to think it was anything besides musculoskeletal pain we transported BLS to the local community hospital about 5 mins away. As we were goofing around with the nursing staff, the doc steps in and asks for an EKG to be faxed to the big city hospital that the community hospital is a feeder for. He said its a STEMI. Our jaw dropped when we found out if came from our patient. They paged an emergency STEMI transfer. Patient ended up going to a different hospital and being admitted to the floor with an elevated troponin, however the cardiologist stated that the EKG was normal for the patient. Haven't heard anything further.


----------



## NomadicMedic (Dec 22, 2012)

Thus the reason several of us asked for a 12 lead. Was this an ALS unit that transported? If so, why wasn't a 12 lead captured pre hospital? 

If it was a BLS call, you did what you should have, put the patient on the stretcher and drive to the hospital.


----------



## Anjel (Dec 22, 2012)

My teacher always says any complaint from the neck to the navel always gets an EKG. 

Exceptions of course, but I definitely would of obtained one.


----------



## VFlutter (Dec 22, 2012)

Rhabdomyolysis anyone? Assuming the EKG was indeed normal for the patient



I am guessing Boone -> Barnes?


----------



## mycrofft (Dec 22, 2012)

Rhabdo and pulmonary embolism. Elevated trop's supposed ot be corrleated to other signs of myocardial necrosis. But in that lady, who wants to wait around for "more sings of cardiac necrosis"?


----------



## PaddyWagon (Dec 22, 2012)

Not knowing anything more than my emt-b class work it points to a pulmonary embolism, of course basics are working from a pretty small toolkit of guesses...

1) recent surgery suggests a clot, especially in an older patient
2) shallow breathing caused by pain at inhaling
3) vitals don't suggest much else going on, as far as my limited knowledge goes
4) delayed report of pain caused by older folks not feeling as acutely as young'uns do


----------



## truetiger (Dec 23, 2012)

It was an ALS unit. The pt had no pain unless that specific area was palpated. Cardiac didn't cross our mind.


----------



## Handsome Robb (Dec 23, 2012)

truetiger said:


> It was an ALS unit. The pt had no pain unless that specific area was palpated. Cardiac didn't cross our mind.



You can't get em all. 

That's an interesting though. My one and only STEMI as a PIC was right sided pinpoint, sharp, non-radiating, reproducible right sided chest pain with N/V and very mild SOB. Guy looked like crap though, had to hold the stickers on him to get the 12-lead he was so diaphoretic.


----------



## truetiger (Dec 23, 2012)

Still not so sure it was a STEMI. The docs at the community hospital misdiagnose them often. The patient was admitted to a non icu bed. Her cardiologist stated that was her normal EKG. I wish I had a picture of it to post, but it was a paced rhythm and wasn't an obvious STEMI. Given that and her lack of other symptoms, I'm very curious as to the outcome.


----------

