I know it's an old post but there are some recent posts sooooooo.
How did you assess the Chest Pain?
The fact the CP was pleuritic in nature could have been discovered with a directed verbal assessment. Sir, take a deep breath, does it get worse or better. (a RGB patient would surly say the pain got MUCH worse) pleuritic in nature right? The physical movement of the pt's trunk with each breath would have made the patient scream in pain, any movement would. Not a cardiac problem
PHYSICAL EXAM & Scene: Man down outside, awake, Scene safe, no trauma suspected on visual inspection, 21 year old "healthy" male patient AOx3?, PERLS, JVD?, no allergies, VITALS, in MOD resp distress(perceived as dyspnea), no pert medical hist, was he on any MEDS? (history or no), substernal CP with bilat arm pain, skin color?,Skin feel?, temp?, pulse ox reading? 0-70 -95%??. turger?, patients Grip strength, postural?...
The chest pain is now a sharp stabbing pain, radiating to his LUQ moving everywhere it seems. The GB sits just below the rib cage on the right of the pt's stomach. If the patient ABD was palped that area URQ would have presented VERY TENDER! With that being the case at that point your going in a new direction with your working diagnosis, aye. Thus ruling out a Cardiac event.
INTERVIEW:Was this asked? last time he went? what did it look like: dark tarry, "light chaulky"<--GB issues-->Constipation?, if so how long, pain: sudden onset? What were you doing just prior to this incident? You never said???
Was the patient unremarkable on the secondary survey?
How was the ABD? Acute, rigid, masses, pulsating? (besides what he told you) If so what did you suspect at that point? cardiac?
Acute Gall Bladder issue will sometimes present with right sided "Referred" chest pain and or back pain because of stones in the bile duct or inflammation. That would explain the refered pain in the chest and else where. We know the bilateral arm pain/numbness via hyperventilation is very common. In this case it's a non-issue.
TREATMENT IN THE FIELD: IV access yes, EKG yes, ASA why (standing orders?), Nitro why (standing orders? to lower BP?). Morphine ok maybe, BUT, without knowing what you were dealing with or having a good working diagnosis was administering it a good idea? Patient comfort is a wonderful thing, but not at the expense of making a good Dx. Masking the pain with drugs inhibits a good Dx..IMHO
What did medical control order? The EKG was normal in ST considering the severe pain he was in.
I guess my only question is what was your diagnosis before going ALS with this patient.. Angina? AMI?, "unknown" roving chest Pain and patient hysteria?<--BLS call. A Hypertensive, 21 year old male with a non traumatic Acute Abdomen? That guy goes with me.
A Cardiac event and like treatment could have been ruled out by the ALS crew on the scene.
DEPENDING on transport time: OUR TREATMENT: Assess LOC, vitals, take a good history, take into account patient presentation, conduct a strong secondary survey (enrout), cut through the patients pain with strong questioning (again). The surveys alone would have put this crew in the right directionMy "working" Dx, a non-traumatic, hypertensive patient w/an acute Adbomen, the end...
Given this, try to Calm/reassure the PT,monitor the airway and LOC, obtain IV access, hiflow O2 NRM, position of comfort, EKG, vitals again, No cardiac protocols or pain meds, Med control, continue rapid transport.
When doing the follow up on this patient, it was diagnosed as Gall Bladder rupture... he had surgury that night and did fine. Who would have ever guessed! Who??
But again, I could be wrong...:blush:
LOVE MY TYPO'S TOO!
