Does this patient need an Emergency Department? What are the potential medical problems? What do you think is wrong? What would you do?
You are dispatched to a 36 year old male complaining of an acute onset of fever, diarrhea, N/V, central abdominal pain, and head ache. There has been light rain all day, with a temperature in mid 50s F.
You arrive on scene to find the patient lying prone on the couch, with moderately damp clothing. The residence is in good repair, there are no signs of economic distress, drug use or alcohol abuse, or any other form of domestic distress.
Upon examining the patient you note the following:
The patient is alert and oriented x4 GCS 4,5,6. (15)
Blood pressure 128/82
pulse: 92 regular and strong
Respirations 14
lungs clear bilaterally
4 Lead EKG shows NSR on the monitor
Spo2 100% RA
Temperature: 39.4 tympanic
Physical exam:
Gross: Patient appears to be of average build for a 35 y/o western male. Slightly overweight, clean, and cloths are in good condition, though a bit damp. Skin is noticeably warm to the touch, with normal turger and color.
HEENT: face and head symmetrical, no grossly abnormal physical findings, hair is clean and well kept, there is no lymph node enlargement, and the skin is noticeably warm to the touch. The scleras are white and some small vessels are visible. The ears are clear of serumen and the tympanic membrane is intact with no signs of infection. On inspection of the mouth, you notice no dental carries, multiple fillings, none of which are recent, mucous membranes show no signs of inflammation and are moist, no distinctive breath odors, normal papillae, and normal color and tone of sublingual vessels. There is no nasal discharge or congestion. The pain is describes as being global but worse near the temporal area. (rated as 2/10)
Thorax: Breath sounds are clear and equal bilateral in all fields and heart tones are normal in all respects. The shape of the chest is also normal and there are no visible axilary lymph nodes. A few liver spots are noted on the posterior as well as a scar on the left superior scapular region (described as old injury in previous decade). Respiratory effort is adequate, with no signs of distress.
Abdomen: The abdomen is soft, with no involuntary guarding, no palpable masses, or distension. The patient is still of small enough stature to palpate the abdominal aortic pulse, which matches the brachial and carotid pulses. Early onset central obesity is noticed. A few liver spots are noted here as well. The pain in central just below the xyphoid process, is constant, described as “squeezing” and cannot be manipulated in any way. (rated as 4/10) Bowel sounds are constant. Caput medusa is not found.
Genital/Urinary: No abnormalities or significant findings are discovered in the genital/anal region. Patient denies abnormality of sexual interest/function.
Extremities: Full range of motion, distal pulses, motor and sensory intact and reported as normal. No deformities, or trauma of any kind. There are <5 well circumscribed nevi on the upper proximal extremities. Feet are clean and callused.
Recent events prior to contact:
Patient returned home from work at about 8PM after a dinner meeting with clients. (local, well respected restaurant, no alcohol today, but several cups of coffee) Just prior to getting home became nauseous with sudden onset of bowel urgency and sweating. Upon returning home, passed watery stool that was described by the patient as bright yellow in color (not visualized by providers) and vomited one time. (described as being commensurate with chicken, potato and vegetable meal, no gross blood, bile, or other abnormality reported) After this episode patient noticed fever with head and abdominal pain and extreme fatigue/weakness. (described in physical findings) Wife said he “never looked this bad before” and called EMS.
Social history:
Patient has a post graduate degree in sales/ marketing, works as an outside sales representative for a major pharmaceutical company headquartered in Europe. Works for the regional office and frequently travels internationally. In the last 14 days has made trips to Barcelona, Spain, and Chicago, Illinois with several flight connections in various European airports. Patient denies ever smoking, elicit or prescription drug use or abuse, drinks socially no more than 1-2 beers or equivalent per week. Heterosexually active, monogamous. Expecting first Child in mid Oct. Reports high level of job stress, and denies relationship or other stressors at home aside from being nervous about being a father.
Past medical history:
GERD treated with 4 week PPI therapy in 2009, frequent “heartburn” reported when traveling abroad, treated with OTC Calcium carbonate, (2000mg) no more than once daily prior to bed when symptoms worsen. Denies “heartburn” at home except for 1 time after eating KFC, and reports predictive abdominal discomfort after fatty meals without N/V or diarrhea. Last year when treated for GERD blood test revealed elevated AST/ALT (results not available) scheduled for follow up in 1 year, has not yet reached follow up time. No allergies, no current prescription meds. No prior surgeries or hospitalizations. Patient also reports normal bldder/bowel habits and noticeable darkening yellow color of urine over the past year.
Family history:
Paternal family members all deceased presumably from brain or abdominal aneurism. Maternal history of HTN, CAD, and type II diabetes mellitus. Mother still living (87y/o) Father deceased (69y/o) 2 female siblings living locally without known health problems. (37/29 y/o respectively)
You are dispatched to a 36 year old male complaining of an acute onset of fever, diarrhea, N/V, central abdominal pain, and head ache. There has been light rain all day, with a temperature in mid 50s F.
You arrive on scene to find the patient lying prone on the couch, with moderately damp clothing. The residence is in good repair, there are no signs of economic distress, drug use or alcohol abuse, or any other form of domestic distress.
Upon examining the patient you note the following:
The patient is alert and oriented x4 GCS 4,5,6. (15)
Blood pressure 128/82
pulse: 92 regular and strong
Respirations 14
lungs clear bilaterally
4 Lead EKG shows NSR on the monitor
Spo2 100% RA
Temperature: 39.4 tympanic
Physical exam:
Gross: Patient appears to be of average build for a 35 y/o western male. Slightly overweight, clean, and cloths are in good condition, though a bit damp. Skin is noticeably warm to the touch, with normal turger and color.
HEENT: face and head symmetrical, no grossly abnormal physical findings, hair is clean and well kept, there is no lymph node enlargement, and the skin is noticeably warm to the touch. The scleras are white and some small vessels are visible. The ears are clear of serumen and the tympanic membrane is intact with no signs of infection. On inspection of the mouth, you notice no dental carries, multiple fillings, none of which are recent, mucous membranes show no signs of inflammation and are moist, no distinctive breath odors, normal papillae, and normal color and tone of sublingual vessels. There is no nasal discharge or congestion. The pain is describes as being global but worse near the temporal area. (rated as 2/10)
Thorax: Breath sounds are clear and equal bilateral in all fields and heart tones are normal in all respects. The shape of the chest is also normal and there are no visible axilary lymph nodes. A few liver spots are noted on the posterior as well as a scar on the left superior scapular region (described as old injury in previous decade). Respiratory effort is adequate, with no signs of distress.
Abdomen: The abdomen is soft, with no involuntary guarding, no palpable masses, or distension. The patient is still of small enough stature to palpate the abdominal aortic pulse, which matches the brachial and carotid pulses. Early onset central obesity is noticed. A few liver spots are noted here as well. The pain in central just below the xyphoid process, is constant, described as “squeezing” and cannot be manipulated in any way. (rated as 4/10) Bowel sounds are constant. Caput medusa is not found.
Genital/Urinary: No abnormalities or significant findings are discovered in the genital/anal region. Patient denies abnormality of sexual interest/function.
Extremities: Full range of motion, distal pulses, motor and sensory intact and reported as normal. No deformities, or trauma of any kind. There are <5 well circumscribed nevi on the upper proximal extremities. Feet are clean and callused.
Recent events prior to contact:
Patient returned home from work at about 8PM after a dinner meeting with clients. (local, well respected restaurant, no alcohol today, but several cups of coffee) Just prior to getting home became nauseous with sudden onset of bowel urgency and sweating. Upon returning home, passed watery stool that was described by the patient as bright yellow in color (not visualized by providers) and vomited one time. (described as being commensurate with chicken, potato and vegetable meal, no gross blood, bile, or other abnormality reported) After this episode patient noticed fever with head and abdominal pain and extreme fatigue/weakness. (described in physical findings) Wife said he “never looked this bad before” and called EMS.
Social history:
Patient has a post graduate degree in sales/ marketing, works as an outside sales representative for a major pharmaceutical company headquartered in Europe. Works for the regional office and frequently travels internationally. In the last 14 days has made trips to Barcelona, Spain, and Chicago, Illinois with several flight connections in various European airports. Patient denies ever smoking, elicit or prescription drug use or abuse, drinks socially no more than 1-2 beers or equivalent per week. Heterosexually active, monogamous. Expecting first Child in mid Oct. Reports high level of job stress, and denies relationship or other stressors at home aside from being nervous about being a father.
Past medical history:
GERD treated with 4 week PPI therapy in 2009, frequent “heartburn” reported when traveling abroad, treated with OTC Calcium carbonate, (2000mg) no more than once daily prior to bed when symptoms worsen. Denies “heartburn” at home except for 1 time after eating KFC, and reports predictive abdominal discomfort after fatty meals without N/V or diarrhea. Last year when treated for GERD blood test revealed elevated AST/ALT (results not available) scheduled for follow up in 1 year, has not yet reached follow up time. No allergies, no current prescription meds. No prior surgeries or hospitalizations. Patient also reports normal bldder/bowel habits and noticeable darkening yellow color of urine over the past year.
Family history:
Paternal family members all deceased presumably from brain or abdominal aneurism. Maternal history of HTN, CAD, and type II diabetes mellitus. Mother still living (87y/o) Father deceased (69y/o) 2 female siblings living locally without known health problems. (37/29 y/o respectively)
Thanks for the pointer.
