Scenerio #1 - Abdominal pain

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Flight-LP

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Here are the rules..........

Anyone can play! Those who are more familiar with the level of these scenerios are welcomed, but please allow others to respond before you give the spoiler!

There are no stupid questions, only the ones not asked.

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SCENERIO #1 - Abdominal Pain

You are called to a small community hospital's emergency department to transport a patient to the big city medical center for higher level tertiary care. Upon arrival, you receive report from the sending facility's RN.

56 y/o female presented by POV with complaint of RUQ abdominal pain x 2 days, worsening today. Pt. describes pain as sharp and radiating to both her LUQ and mid-back. Pt. also reports nausea and 2 episodes of vomiting today. Pt. is lethargic and slow to respond; she exhibits slurred speech, however no visible neuro deficits are identified.

Rummaging through her chart reveals the following information:

PMHx - Hepatitis C, Laproscopic Cholecystectomy 2 months ago, ERCP 3 weeks ago for post operative pain, HTN.

Medications - Lisinopril HCT, Pt. unable to recall others and states she is not taking medications prescribed after her recent surgery.

NKDA

Last vitals - BP 138/82, P 94, R 20 non-labored, SPO2 98% on O2 NC @ 2LPM.

Labs - CBC

RBC - 4.7
MCV - 92
HgB - 11.8
Hct - 39
WBC - 17.3
Segs - 68
Bands - 14
Lymphs - 15
Monos - 2
Eos - 1
Bas - 0
PLT - 226

Chemistry

Na - 149
K - 3.2
Ca - 1.9
Cl - 102
CO2 - 27
Phos - 1.3
BUN - 4.2
Cr - 126
AST - 136
ALT - 52
Bili - 0.6
Glu - 263

Amylase - 194
Lipase - 86

Blood Alcohol - 230

The following x ray was given to you with your chart. The RN reports the pt. needs a CT scan of her abdomen with contrast, but that their scanner is down.

Scenerio1.jpg


You find your pt. on a nasal cannula @ 2lpm and has 0.9% NaCl infusing at 150cc / hr. You load your pt. up and are off to the receiving facility..................

Whats wrong with your patient??

What is the primary cause of your patients condition?

Do you identify any immediate issues that need to be addressed?

Anything else you would want to know?

What is your treatment plan?

***Bonus Question***

What was one thing the sending facility did that probably helped your patients clinical course?
 
re

First question as the film is not labeled to orientation as it should be. Is this a PA or AP Abd.
 
Corky said:
First question as the film is not labeled to orientation as it should be. Is this a PA or AP Abd.
Click to expand...

The film is a KUB taken in a supine position and is acceptable as shown.
 
re

Patient has an elevated AST/ALT along with a elevated WBC count with bands. Sick cookie here. Xray i'm going to take a guess at. Now by history we already know she has a hepatitis and the x-ray appears to be showing a downwardly displaced ascending and transverse colon so an acute/chronic hepatomegaly will be my guess. Also of note would be the appearance of a distention of the large bowel (untrained eye here) at least it looks like it to me from what i remember seeing with belly films.

Cause would be a stricture or obstruction within the liver

I would want to know when her last BM was, as i cant really tell if that appears to be an fecal impaction there in the LLQ, that would contribute to the bowel distention

And the one thing the sending facility did to to improve this patients outcome? not do the CT with contrast at there facility and sent her to higher level of care.


Thats my guess in a nut shell. hopefully im at least close and will ready up on this after i finish some reports :P

Corky
 
I gotta look up the labs later, but I want to know about

fever?
skins?
progression on lethargy?
eating and bathroom habits?
Blood in vomit, urine, or stool? (occult?)
Bowel sounds?
Does CBC show elevation of neutrophils, specifically?
Vaginal bleeding?
LS?
Drink? Smoke?
Surgeries? (n/m)
How well does she walk? Gait?
Also, pupils, please.

As for what they did that helped her? The TKO rate on fluids rather than bolus?
 
what worries me is the K level is low. the AST/ALT are pretty typical of hep.
I would get the CT and an ultrasound to rule out stuff (including what I am guessing pancreatitis)

but hey, I am not house...
 
anthonym83 said:
i gotta look up the labs later, but i want to know about

fever? 100.4
skins? Warm, slightly jaundiced
progression on lethargy? No change
eating and bathroom habits? Normal
blood in vomit, urine, or stool? (occult?) nope
bowel sounds? Present and active
does cbc show elevation of neutrophils, specifically? The answer is in the results, but yes there is an elevation of mature neutrophils (i.e. A left shift)
vaginal bleeding? None
ls? ???????
Drink? Smoke? She is a smoker and drinker
surgeries? (n/m) revealed in her pmhx
how well does she walk? Gait? Slightly unsteady gait currently
also, pupils, please. 2 of them................
Sorry, had to! Equal, round, and reactive to light and accomodation

as for what they did that helped her? The tko rate on fluids rather than bolus?
Click to expand...

the rate of fluid infusion is acceptable.
 
silver said:
what worries me is the K level is low. the AST/ALT are pretty typical of hep.
I would get the CT and an ultrasound to rule out stuff (including what I am guessing pancreatitis)

but hey, I am not house...
Click to expand...

I too would be concerned with that Potassium level. How would you treat it?
 
Corky said:
Patient has an elevated AST/ALT along with a elevated WBC count with bands. Sick cookie here. Xray i'm going to take a guess at. Now by history we already know she has a hepatitis and the x-ray appears to be showing a downwardly displaced ascending and transverse colon so an acute/chronic hepatomegaly will be my guess. Also of note would be the appearance of a distention of the large bowel (untrained eye here) at least it looks like it to me from what i remember seeing with belly films.

Cause would be a stricture or obstruction within the liver

I would want to know when her last BM was, as i cant really tell if that appears to be an fecal impaction there in the LLQ, that would contribute to the bowel distention

And the one thing the sending facility did to to improve this patients outcome? not do the CT with contrast at there facility and sent her to higher level of care.


Thats my guess in a nut shell. hopefully im at least close and will ready up on this after i finish some reports :P

Corky
Click to expand...

Yes the LFT's and WBC are elevated. While there is some bowel issue, this is not the biggest concern curently. Good eye though!
 
Flight-LP said:
I too would be concerned with that Potassium level. How would you treat it?
Click to expand...
Uhmm I dont know what is available but generically Lactated ringers IV or if you can mix stuff KCL in NS of some sorts
 
re

Just reviewed some of the labs and also of note is the low CA++ and Phosphorus levels. Seemingly consistent with a malnourished alcoholic. Still reviewing for my next crack at this

I still haven't figured out what that is running transversely near the level of T-12 though. I don't believe it to be artifact, and it may actually be the inflamed pancreas leading to a diagnosis of acute pancreatitis
 
Last edited by a moderator:
LS was Lung Sounds?

And sorry, meant to type, "progression of lethargy". Over a matter of days? hours?

The issue of recent surgery keeps coming up, but I'd have to do research on that to ask better follow-up questions on the topic
 
Umm... wow, is her Cr really 126??
 
re

oh good catch, I didn't get that far in my lab value reviews yet!
 
Cr is creatinine right? Maybe he meant 12.6? Still really high, but it would make more sense.
 
hmm i glanced over it as a mistake and thought it was 1.26 originally, but 12.6 works
 
Yeah, depending on where the decimal point is supposed to be, it's either slightly elevated, or really high.
 
Corky said:
Just reviewed some of the labs and also of note is the low CA++ and Phosphorus levels. Seemingly consistent with a malnourished alcoholic. Still reviewing for my next crack at this

I still haven't figured out what that is running transversely near the level of T-12 though. I don't believe it to be artifact, and it may actually be the inflamed pancreas leading to a diagnosis of acute pancreatitis
Click to expand...


You are correct that it is not "artifact". It is quite significant.
 
AnthonyM83 said:
LS was Lung Sounds?

And sorry, meant to type, "progression of lethargy". Over a matter of days? hours?

The issue of recent surgery keeps coming up, but I'd have to do research on that to ask better follow-up questions on the topic
Click to expand...

Lung sounds are clear and equal bilaterally.

Lethargy has been over a couple of days.

Keep researching the recent surgery, it may be of importance........... :P
 
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