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Sdiver
05-10-2013, 11:51
Okay, this one might be just a bit too easy, but let's see how it unfolds. I'll set this up to be as dynamic as possible and answer all questions as they come up.

I initially set this up as the patient being deaf and can only communicate through American Sign Language (ASL), but obviously, we can't do that here, but do kind of keep it in the back of your mind that the patient is deaf and you do have a language "barrier" to work through.

You respond on an unknown medical to a upper middle class neighborhood in an affluent suburb. Your patient is a 38 y/o female c/o abdominal pain. U/A find Pt. sitting in chair in living room, holding her stomach, rocking back and forth in obvious pain/discomfort.

Initial exam reveals Pt/ c/o pain in RLQ.
Pain scale 10 out of 10. Pain radiates to other three quadrants only upon palp.
RLQ is hot to the touch, with rigidity and guarding. Describes it as a “Sharp, Stabbing Pain.” Pain is more severe towards midline than lateral.

Pt. states, she didn't feel well last night. Had some slight discomfort before going to bed, but awoke this morning and felt okay. States that this pain started a few hours ago, dull at first then came on “Like a lightning bolt”.

Vitals:
B/P 102/64
HR 126 (weak)
RR 28, non-labored
SPO2 97 RA
BGL 112
Slight Nausea but has not vomited.

Had breakfast this morning; Coffee, toast and 1/2 grapefruit.

Past med Hx: Right femur Fx when she was 19 y/o

Allergies: Morphine, Codeine, Bees, Peanuts

Meds: multi-vitamins, currently on Clomid, was recently on Follistim (but discontinued due to adverse side effects).


What is your initial Dx?
What is your treatment?
What special considerations will you have?

*Ask questions and I'll answer as best I can. SD

PedOncoDoc
05-10-2013, 12:04
Okay, this one might be just a bit too easy, but let's see how it unfolds. I'll set this up to be as dynamic as possible and answer all questions as they come up.

I initially set this up as the patient being deaf and can only communicate through American Sign Language (ASL), but obviously, we can't do that here, but do kind of keep it in the back of your mind that the patient is deaf and you do have a language "barrier" to work through.

You respond on an unknown medical to a upper middle class neighborhood in an affluent suburb. Your patient is a 38 y/o female c/o abdominal pain. U/A find Pt. sitting in chair in living room, holding her stomach, rocking back and forth in obvious pain/discomfort.

Initial exam reveals Pt/ c/o pain in RLQ.
Pain scale 10 out of 10. Pain radiates to other three quadrants only upon palp.
RLQ is hot to the touch, with rigidity and guarding. Describes it as a “Sharp, Stabbing Pain.” Pain is more severe towards midline than lateral.

Pt. states, she didn't feel well last night. Had some slight discomfort before going to bed, but awoke this morning and felt okay. States that this pain started a few hours ago, dull at first then came on “Like a lightning bolt”.

Vitals:
B/P 102/64
HR 126 (weak)
RR 28, non-labored
SPO2 97 RA
BGL 112
Slight Nausea but has not vomited.

Had breakfast this morning; Coffee, toast and 1/2 grapefruit.

Past med Hx: Right femur Fx when she was 19 y/o

Allergies: Morphine, Codeine, Bees, Peanuts

Meds: multi-vitamins, currently on Clomid, was recently on Follistim (but discontinued due to adverse side effects).


What is your initial Dx?
What is your treatment?
What special considerations will you have?

*Ask questions and I'll answer as best I can. SD

I'm worried about ovarian torsion first and foremost, also consider ruptured ovarian cyst or ectopic/tubal pregnancy. I also cannot rule out appendicitis or other intestinal issue (undiagnosed malrotation with volvulus, etc), although an obstruction is less likely given the lack of vomiting, especially after having breakfast.

Given she is on reproductive assistance medications, one must presume she is pregnant and should select medications and work up (imaging) appropriately.

Trapper John
05-10-2013, 13:16
I'll get the ball rolling with the obvious.....

Dx - appendicitis, aggravated by the high acid coffee and grapefruit.

Start supplemental O2 and an IV. Palpate for signs of mass or trauma.

Special considerations? Keep them laying on their back during transport to save your ears from the screaming. Retake vitals upon arrival to the hospital.

Let the critique begin.:D:munchin

My first impression too. RO the ectopic pregnancy, ruptured ovarian cyst, other intestinal issues per PedOncDoc. All the above require immediate surgical intervention except for Ovarian cyst. Needs to be R/O but no time for DDx. Exploratory lap would be my recommendation. Don't really have time to fart around with Dx testing. Start IV NS drip, O2, transport to hospital, with alert for probable incoming ruptured appendix and prep for surgery.

Sdiver
05-10-2013, 14:36
I'll get the ball rolling with the obvious.....

Dx - appendicitis, aggravated by the high acid coffee and grapefruit.

Start supplemental O2 and an IV. Palpate for signs of mass or trauma.

Special considerations? Keep them laying on their back during transport to save your ears from the screaming. Retake vitals upon arrival to the hospital.

Let the critique begin.:D:munchin

My first impression too. RO the ectopic pregnancy, ruptured ovarian cyst, other intestinal issues per PedOncDoc. All the above require immediate surgical intervention except for Ovarian cyst. Needs to be R/O but no time for DDx. Exploratory lap would be my recommendation. Don't really have time to fart around with Dx testing. Start IV NS drip, O2, transport to hospital, with alert for probable incoming ruptured appendix and prep for surgery.

Gents,
Any questions you'd like to ask the Pt. ?

:munchin

Trapper John
05-10-2013, 15:17
Ok to RO drug side effects: (1) What side effects were there from the follistim? (2) Has she experienced any abnormal vaginal bleeding, blurred vision, heart palpitations, shortness of breath, soreness in her breasts?

I'm still thinking appendicitis (ruptured). Is their rebound splinting after palpation of the RLQ?

Could be Clomid side effect. Best case. No way to know for sure at this point. Still handle a possible ruptured appendix until proven otherwise. Need WBC w/ Differential. Maybe abdominal ultrasound to take a peak at the belly in route if possible.

Sdiver
05-10-2013, 16:54
Pt. answers in Lime.

(1) What side effects were there from the follistim? I felt sick quite a bit and threw up a lot. I gained like, 15 pounds in a month. I had pain in my stomach, almost like cramps. Plus I had a lot of diarrhea. I told my doctor about this and he took me off them. That was a couple of years ago.

(2) Has she experienced any abnormal vaginal bleeding? Nothing more than usual.
blurred vision? No
heart palpitations? No
shortness of breath? Not since stopping that Follistim medication.
soreness in her breasts? No, not really

I'm still thinking appendicitis (ruptured). Is their rebound splinting after palpation of the RLQ? No, there isn't.

Trapper John
05-10-2013, 17:58
One more question. When was your last period? Ok two more. Is the patient febrile?

Sdiver
05-10-2013, 18:53
.

One more question. When was your last period? About three weeks ago, but it was spoty and blotchy. It wasn't like my normal flow.
Ok two more. Is the patient febrile? No.

Trapper John
05-10-2013, 19:09
Have you taken a pregnancy test? What were the results? If not can we take a home pregnancy test? I am leaning toward ectopic pregnancy. Transvaginal ultrasound? When admitted get a serum beta chorionic gonadatropin hormone level. Do we have ultrasound evidence of a uterine pregnancy? If no evidence then most certainly ectopic pregnancy. Possibly ruptured. Serum bCG will be diagnostic.

Sdiver
05-10-2013, 19:24
.

Have you taken a pregnancy test? No. What were the results? I don't know, I didn't take one. If not can we take a home pregnancy test? NOW .... YOU WANT ME TO TAKE ONE RIGHT NOW !?!?!? ...... Just take me to the f-ing hospital will ya.

I am leaning toward ectopic pregnancy. Transvaginal ultrasound? When admitted get a serum beta chorionic gonadatropin hormone level. Do we have ultrasound evidence of a uterine pregnancy? If no evidence then most certainly ectopic pregnancy. Possibly ruptured. Serum bCG will be diagnostic.
Remember, we're "Pre-hospital" we don't have that stuff available.

Trapper John
05-10-2013, 19:29
Load her up. Call in probable ectopic pregnancy, probably ruptured. Start IV NS drip, O2.

Sdiver
05-10-2013, 19:34
Okay, you load her up and start transporting to the hospital.

Second set of vitals show:
B/P .. 94/58
HR ... 138 (weak)
RR ... 30
SPO2 97 4L NC
Pain still 10 out of 10 in RLQ.

Pt. now states that there is pain radiating in her Right shoulder and neck.
Rates this pain 7 out of 10.

MR2
05-10-2013, 19:42
Sdiver, you do know how much trouble you'll be in if'n a f'n alien bursts out of her chest.

Sdiver
05-10-2013, 19:46
Sdiver, you do know how much trouble you'll be in if'n a f'n alien bursts out of her chest.

LOL :D
I promise, no chestbursters.

Trapper John
05-10-2013, 19:50
Okay, you load her up and start transporting to the hospital.

Second set of vitals show:
B/P .. 94/58
HR ... 138 (weak)
RR ... 30
SPO2 97 4L NC
Pain still 10 out of 10 in RLQ.

Pt. now states that there is pain radiating in her Right shoulder and neck.
Rates this pain 7 out of 10.

Huh Oh! Add 5 mg Epinephrine to the IV turn up the drip rate.

Sdiver
05-10-2013, 19:55
Huh Oh! Add 5 mg Epinephrine to the IV turn up the drip rate.

Okay.
Would you like to do anything else?

Trapper John
05-10-2013, 20:01
Still going with ruptured ectopic pregnancy. Go faster? Check vitals.

Sdiver
05-10-2013, 20:57
Still going with ruptured ectopic pregnancy. Go faster? Check vitals.

Okay .... Increase deisel.

Anyone have anything else they'd like to add, ... do, .... ask ????

Patriot007
05-11-2013, 01:03
Sounds like a surgical abdomen.

Kick the stretcher does that hurt?
1. ruptured ectopic
2. ruptured ectopic
3. perforated appy

2 large bore lines, draw blood for type and cross and BHCG level on arrival.
Here's a bonus round:

What two "studies" could you theoretically do en route in the back of the truck to make a diagnosis and call ahead for a prepped OR.

Sdiver
05-14-2013, 00:22
Answer to above scenario ... Ectopic Pregnancy in early stages of rupture.

Trapper .... good job in catching that.

If anyone would have asked, the Pt. was Gravida: 4, Para: 1 (she miscarried the first 2, had a full term for her 3rd, and then miscarried the 4th ). The last miscarriage was 8 months ago. She does not know if she is pregnant again. She hasn't checked.

All in all, good job in RO the appendicitis, but narrowing it down to the EP. :lifter

Ectopic Pregnancy
What is an Ectopic Pregnancy? An Ectopic Pregnancy (EP) is a condition in which a fertilized egg has attached itself to anywhere other than the Uterine wall. Most EPs happen in either one of the fallopian tubes. “ This type of ectopic pregnancy is known as a tubal pregnancy.” (1) This type of EP happens in roughly 95% of the cases seen. The other areas prone to EPs would be for the egg to attach itself to the abdomen, the cervix, or within the ovary itself. Because the fallopian tubes were not designed to sustain a growing embryo, if an embryo were to attach itself to one of the tubular walls, as the embryo grows, it will stretch the fallopian tube to where it could eventually burst. The fallopian tubes are not designed to support a growing embryo. They are merely transport vessels, transporting an egg from the ovaries to the uterus. Studies have shown that, “An ectopic pregnancy occurs in about one in 50 pregnancies.” (2) So this is a very common occurrence and as EMS providers, this is something that we must be wary of in female patients complaining of lower abdominal pain. The most common occurrence of EPs happening are with woman “35 to 44 years of age.”(3) But an EP can happen in any sexually active age group.
The only true way to determine if a woman does have an EP is in the clinical or hospital setting. Through the use of either a pelvic or transvaginal ultrasound, can an MD determine if this is an EP. “Treatment options for ectopic pregnancy include observation, laparoscopy, laparotomy, and medication. Selection of these options is individualized. Some ectopic pregnancies will resolve on their own without the need for any intervention, while others will need urgent surgery due to life-threatening bleeding. However, because of the risk of rupture and potential dire consequences, most women with a diagnosed ectopic pregnancy are treated with medications or surgery.” (2)
As EMS providers the best treatment plan for a suspected EP would be to provide comfort care, pain management and treat for shock (if present). If the pain is present on the RightLower Quadrant of any female, don’t be fooled into thinking it is an appendix issue. A detailed physical exam along with a detailed history is important. Even in the above simulation, having to deal with the “language barrier” presented, getting a detailed history can be the difference in alerting the receiving facility to have the appropriate people standing by to deal with either an appendicitis or an ectopic pregnancy.

Sdiver
05-14-2013, 00:24
Huh Oh! Add 5 mg Epinephrine to the IV turn up the drip rate.

I could be a real prick and ask .... What's your drip rate? (show your work) :D

:munchin

Trapper John
05-14-2013, 08:45
I could be a real prick and ask .... What's your drip rate? (show your work) :D

:munchin

No not all. I would have asked the same of my students at SFS back in the day. I will be more complete with my responses in the future ;)

For this one, if I recall correctly, a standard drip rate would be 60 gtt/min? This would deliver ~250 ml/h assuming a standard drip chamber and IV tubing. I was assuming a 1 L bag of NS to which I added 5 mg Epinephrine (1.25 mg/h). I would turn up the drip rate to 120 gtt/min to deliver 2.5 mg Epi/h.

You or the Docs may need to correct me on this, working from memory here. :D

Thanks for the challenge. Please post another one when you can. This is fun!