Guess what it is

zzyzx said:
Interesting to think how an MD in, say, 1960, would have formed a diagnosis with these signs/symptoms and without CT or ultrasound.
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But not from a web forum description.
 
You can form a diagnosis, we all do it. How do you know what test/treatment is appropriate without forming a diagnosis? Testing allows us to confirm the differential we have formed. There is a reason we don't take out normal gallbladders and appendixes as much as we used to in, say, 1960.

Also, as Brandon said, it's hard to form a good differential from a limited description on an internet forum that may involve an improper term.
 
Right, I was thinking the jaundice wasn't actually jaundice.... He's tachy, dizzy, has abd pain, and has HTN.... that's why I treat for the aneurysm and transport without delay in this scenario.

Anyways....

No one gets a gold star or wins the internetz for guessing right on this forum, but it would be nice to know what the diagnosis was, @cointosser13 .
 
So the answer is.....aortic dissection. I just wanted to see what everybody would say about the jaundice. The doctor said patient came out of surgery ok and is in the ICU for the time being. What are all your thoughts on the heart rate being at around 140 with no chest pain or difficulty breathing? Do you think it was high because of the sugar being around the 300s?
 
cointosser13 said:
So the answer is.....aortic dissection. I just wanted to see what everybody would say about the jaundice. The doctor said patient came out of surgery ok and is in the ICU for the time being. What are all your thoughts on the heart rate being at around 140 with no chest pain or difficulty breathing? Do you think it was high because of the sugar being around the 300s?
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It was likely high because 1.) your pt was losing volume and 2.) in pain.
And 140 is not terrible; increased HR is not synonymous with chest pain.


Ps. Where is my gold star?
 
Sugar being high threw me off at first, but then I remembered that sympathetic response should cause that - your muscles and brain need lots of glucose to help you escape from bears.
 
Gurby said:
Sugar being high threw me off at first, but then I remembered that sympathetic response should cause that - your muscles and brain need lots of glucose to help you escape from bears.
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Plus plenty of people are just frequently hyperglycemic at their baseline. Likewise for hypertension. We're an unhealthy nation.
 
So a guy with shocky vitals, malaise, poor general appearance, and lower abdominal pain who went straight to the OR?

At first glance that sounds like appendicitis. Too bad a temp wasn't included.

Remember that appendicitis usually starts around the belly button, then migrates to the right lower quad, otherwise known as "macburney's point" (although this isn't concrete), so by "moving", I wonder if thats what he meant.

Gallbladder pain usually is higher, though I wouldn't doubt it, usually the field test for cholecystitis is to deeply palate the RUQ (like you're trying to rip their liver out mortal combat style) and have them inhale. A positive result is a worsening of the pain.

Good questions for appendicitis would be about anorexia (an excellent indicator), and rebound tenderness (not just rigidity), as well as tapping their heel, as both are signs of the associated peritonitis that accompanies appendicitis.

Also, a sugar that high in a non diabetic points to infection and other shock states causing catecholamine release.

EDIT: OOPS!! I didn't see that the answer was given, but I left the other stuff up there in case someone wanted to read my rant. :)
 
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cointosser13 said:
So yesterday my partner and I ran a call for a male in his 40's who was having abdominal pain. First impression of the guy was, stable. He looked healthy, other than a yellowish tint (Jaundice) on his chest and abdomen. Guy didn't appear in any distress. His words exactly "Hey guys, I started having this pain in my low belly yesterday, and not too long ago I felt a little dizzy". So we did the whole 9 yards, IV, monitor and so on.

Here are his vitals,

Sinus tach on the monitor - 144 bpm (12-lead, no ST elevation or ectopy)
SpO2- 97-100 %
Blood pressure - 150/90, repeat was 164/86
Blood sugar - 366
Skin - cool, dry, light colored
History - Hypertension

Patient was not complaining of chest pain or difficulty breathing. That surprised me with the pulse where it was. Anyway, I asked the patient, "In general, how are you feeling right now?" Patient said "fine, I'm just having some pain in my lower stomach, I feel like it's moving too". Stomach felt non-rigid. Patient stated that the last time he saw a doctor was about a year ago.

We drop the patient off to the ER and give report. We leave and 30 minutes later we get a call from the patient's ER doctor and said that our patient went into the OR. What do you guys think the patient had?
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Yes, I've read the thread and know what the answer is.... but when I first read this, my first thought was a leaking/dissecting AAA.

Since the patient's scleras weren't yellow, I wouldn't call it jaundice, so... his VS look like he's hypovolemic in a reversible shock. Cool, pale skin, tachy, hypertensive, still alert & oriented. BG 366... all that together tells me he's got a catecholamine release going on that's clamping down his periphery to maintain core perfusion and as a side-effect, bumped his BG up. Then throw in the pain location (not liver and doesn't seem to be appy) and high on my list is the AAA that's about to go boom. If he was going septic, I don't think I'd expect to see an elevated BP unless he's got a known hx of HTN and is still early on. The other thing that clued me in is that he went to OR really fast. While they may take an appy to OR fast, 30 minutes just seemed too fast for that.

In short, it just didn't look right for gallbladder issues or an appy, thus I was thinking leaking AAA or dissecting Abdominal Aorta.
 
Wonder what his pancreatic enzymes, LFTs, and Chem 7 showed.
 
Can someone tell me what treatment would be as a basic for an appendicitis patient?
 
That's kinda what I had in mind... When you say replace, what exactly do you mean? As in what this patient may have?
STXmedic said:
A ride to the hospital...

*You can replace appendicitis with just about any other condition.
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Austin carawan said:
That's kinda what I had in mind... When you say replace, what exactly do you mean? As in what this patient may have?
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As a EMT all you will be able to do to fix a condition is transport to the hospital for the doctor to fix. The BLS skill set and knowledge is too limited to fix problems, stabilize some yes but not fix
 
Austin carawan said:
That's kinda what I had in mind... When you say replace, what exactly do you mean? As in what this patient may have?
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As in take "patient has appendicitis", substitute any diagnosis with " appendicitis", and finished the sentance.

BLS is very limited in what we can treat in the field. Bonus points for nailing an assessment or even a pertinent physical finding.
 
Rebound tenderness is all I could turn up.... Definitely OPQRST should be a helpful thing right?
 
Austin carawan said:
Rebound tenderness is all I could turn up.... Definitely OPQRST should be a helpful thing right?
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You asked about "treatment" before. Keep in mind the difference between "treatment" and "assessment". OPQRST is a great tool to use during your gathering of history, but it is certainly no treatment. Perhaps it'll help you help the patient.

Is jaundice-esque discoloration ever localized, other than sclera early on? I've never actually had a patient with jaundice, but have seen it just out and about once. She was textbook and having a bad day. That, and every time I hear of it, it's always pretty systemic.

Was AAA versus dissection ever answered..?
 
In general, the prehospital management of appendicitis will depend on if you suspect sepsis or not--- then you'll be treating the sepsis in general.

A good chunk of appendicitis can be managed with antibiotics as monotherapy as it is. Maybe if EMS gets empiric antibiotic abilities one day that'll be tallied on to what we could do. Not much else though
 
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