I promised a hard scenario, consider it delivered.

[8jimi8]

I can't remember who said it on this forum....

someone mentioned about 8-9 months ago, that you should never auscultate breath sounds over any type of clothing...

i think they said something to the effect any breath sound can be mimicked by material between the scope and the patient.

I quickly amended my bad habits. Everyone's top comes of for my shift assessments...
and yes...

gotta peek under the lower part of the gown too. and yup... roll over... let me check your bottom...

 

[Lifeguards For Life]

I also appreciated how you showed the proper thought sequence to arrive at the diagnosis.

The bold explanations, were especially helpful.

I feel I was able to learn a lot from this scenario

 

[Aidey]

Most probably. Do you do that regularly when you see a patient?

Nope. I was thinking if the "do you know what your children are doing" aspect of it. Basically, if the mom and dad had been more aware, this situation probably wouldn't have progressed so far.

 

[Seaglass]

Good scenario. Thanks!

It's easy to forget botched abortions as a possible cause. I live in an area where they're relatively easy to obtain without anyone knowing, and I don't know that my agency has seen any cases in the past few years. But I could easily see it happening... teenagers are stupid and scared, parents are strict, and so on.

 

[mycrofft]

With subtle change could serve for tubal pregnancy,other closed abdominal problems

Ruptured diverticulum, mesenteric embolus, tubal pregnancy, retained intrauterine foreign objects, delayed reaction to blunt trauma. Good to differentiate. Hard to change field responses except a good history while the mnother is there and (sometimes, not this time) while the pt is still lucid.
Yeah not crystalines, but do ambulances carry blood now? Any colloids nowadays? (In WWII, plasma or some plasma subsitutes were used).

 

[Seaglass]

Hard to change field responses except a good history while the mnother is there and (sometimes, not this time) while the pt is still lucid.

Often it's best to get parents out of the room with teenage patients. Even if they're not particularly lucid, sometimes they'll still be able to communicate something important. (Of course, they sometimes also give you total nonsense, but I'll check it out if it seems at all plausible.)

 

[Aidey]

^^^ That is one of the things many of our fire officers are good at. They are the ones who do the initial paperwork and they are pretty good about picking up on hints to get family members out of the room. Usually they do it by asking for insurance cards, medications, or doctor's names and then when they get the person away, they ask all the demographic info, which takes a few minutes.

 

[Veneficus]

Ruptured diverticulum, mesenteric embolus, tubal pregnancy, retained intrauterine foreign objects, delayed reaction to blunt trauma. Good to differentiate. Hard to change field responses except a good history while the mnother is there and (sometimes, not this time) while the pt is still lucid.
Yeah not crystalines, but do ambulances carry blood now? Any colloids nowadays? (In WWII, plasma or some plasma subsitutes were used).

Right on.

The reason I chose this scenario is because DIC as a primary pathology is rare. It usually results from massive trauma or more commonly like in this case, surgical intervention.

I also hope that people will be more specific on the findings when they present a scenario.


Medic417: I was once disciplined (unfairly in my opinion) for not properly exposing a patient who was later found to have a crack pipe in her vagina. (I left her underwear on) apparently the event was she managed to conceal the pipe from me and having nowhere else to put it in the hospital decided that would work. From that day on (many years ago) I don't care if the person is wearing a thong bikinni, the physical exam wll be completed on all patients.

 

[Seaglass]

^^^ That is one of the things many of our fire officers are good at. They are the ones who do the initial paperwork and they are pretty good about picking up on hints to get family members out of the room. Usually they do it by asking for insurance cards, medications, or doctor's names and then when they get the person away, they ask all the demographic info, which takes a few minutes.

As a basic on a medic truck, that's often my job. If I think my partner will need some time, I can draw it out quite a bit.

I was once disciplined (unfairly in my opinion) for not properly exposing a patient who was later found to have a crack pipe in her vagina. (I left her underwear on) apparently the event was she managed to conceal the pipe from me and having nowhere else to put it in the hospital decided that would work. From that day on (many years ago) I don't care if the person is wearing a thong bikinni, the physical exam wll be completed on all patients.

Under my protocols and local law, if a patient is competent to refuse treatment and not under police custody, they can refuse any intervention. Doing something against their will could be assault. I've never yet had a patient I couldn't talk into a physical exam, but I could see it happening.

 

[Veneficus]

As a basic on a medic truck, that's often my job. If I think my partner will need some time, I can draw it out quite a bit.



Under my protocols and local law, if a patient is competent to refuse treatment and not under police custody, they can refuse any intervention. Doing something against their will could be assault. I've never yet had a patient I couldn't talk into a physical exam, but I could see it happening.

it's all about persuasion

 

[Melclin]

To add things not done, how many that responded or even read but did not respond would have truly exposed this or any patients. It amazes me how many will not remove patients clothes and actually look at the patient to truly evaluate them.

I probably wouldn't have, or at least, not to the extent that was required to see the vaginal discharge.

Very interesting case. I've more questions but they shall have to wait until I crawl out from underneath the many thousands of words of essays I have at the moment :unsure:

 

[LucidResq]

For once I knew what was going on, but alas, missed the boat.

I'd like to reiterate the "get everyone else out of the room" point. You'd be amazed what important information patients will tell you once their partner/sister/mother/father etc isn't there. I've seen many a resident led astray on a hx by a patient's covering up infidelity, shame or fear of abuse.

I'd also like to remind everyone that this scenario can easily apply to any age of woman. Many people think that undesired pregnancies are common to teenagers exclusively, but the majority of women I've seen terminate pregnancies are actually 20-40, often married and raising children. They may not have strict parents, but many lack access to health care, have abusive relationships, etc.

Insurance coverage for abortion is about to take a radical hit due to health care reform (it's complicated, google it or something). This combined with recent violence at clinics, and the fact that few OB/GYN and family practice residents are receiving training in abortion, means we may very well see a drop in access to safe abortion over the next few years. Many of the abortion providers in the field today were around before Roe v. Wade, and therefore saw many patients such as the one posed in this scenario suffer and die, and many will tell you that is the reason why they provide the procedure today. Almost none of the doctors who will be replacing them over the next few years have this kind of emotional investment in the issue.

Almost certainly this will lead to an increase in "back alley" type abortions and more complications such as this. One only needs to look at countries that ban or greatly restrict access to legal abortion to see that the number of abortions don't really decrease when doctors aren't providing them, they just shift to other "methods" and "practitioners." Septic pregnancy wards were once common in the US and Canada, and these patients are still very common in countries were access is banned or limited today. No matter what your ethical standpoint on abortion is, this is a reality.

Thank you for posting this scenario and reminding us that this still happens today. I'll get off my soapbox.

 

[medic417]

it's all about persuasion

Exactly just wine them and dine them and off they come.

But in all seriousness if you act like this is what you do and is expected most patients have no problems showing a professional acting person the so called "private parts". Use proper terms and explain what and why even if you think they are unconscious. You would be surprised how many mention me explaining what I am doing even though they were GCS of 3.

 

[Commonsavage]

Treat ABCs and life-threats first. O2NC 4 lpm, Large bore IV w/ blood tubing NS bolus 500ml, titrate to SBP 90-100 (explanation to follow).
This kiddo appears to be suffering some kind of hemorrhagic event. The DD ranges from viral to autoimmune/genetic. I would don full PPE (Ebola?). Purpura, bleeding, hepatomegaly indicate clotting disorder/factors diminished with probable profound enemia. As such, she's unable to maintain perfusion and you want to bolus only enough fluid to maintain minimally acceptable SBP, with further dilution of H/H and clotting factors.
Rapid transport to that educational facility, to where any other facility would probably transfer this patient. Request resus room to facilitate rapid response for possible Oneg transfusion. This kid could crash at any moment.

 

[Trayos]

Congrats!

Managed to stump a 25 year experienced Commissioned corp officer, with history in both pediatrics and exhaustive diagnosis. Very well done!

 

[nomofica]

Got a friend of mine to take it on. She did real well. She managed to get a proper dx after about 15 minutes of talking on Facebook. 20 or so year veteren of 9-1-1 EMS and an instructor for NAIT as well as an examiner for the Alberta College of Paramedics (all levels of prehopsital care)

 

[ChorusD]

I was thinking retained dead fetus syndrome with the DIC but I suppose that's way off track... :wacko: that'd be why i'm a student though

 

[MrBrown]

I might try it on that chick I was with in high school and should be a dermatology registrar now

 

[8jimi8]

I was thinking retained dead fetus syndrome with the DIC but I suppose that's way off track... :wacko: that'd be why i'm a student though

not really way off track, you got the DIC part, but the creptius (crepitus lol) is what you didn't resolve.

i figured the crepitus was from a perforation, back on the very first post, but i think it was apparently from an amniotic fluid emoblus?

 

[Veneficus]

not really way off track, you got the DIC part, but the creptius (crepitus lol) is what you didn't resolve.

i figured the crepitus was from a perforation, back on the very first post, but i think it was apparently from an amniotic fluid emoblus?

air and amniotic fluid.