Medical scenario II
 

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.

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

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.

Pt. answers in Lime.

One more question. When was your last period? Ok two more. Is the patient febrile?

.

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.

.

Load her up. Call in probable ectopic pregnancy, probably ruptured. Start IV NS drip, O2.

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.

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.

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

Okay.
Would you like to do anything else?

Still going with ruptured ectopic pregnancy. Go faster? Check vitals.

Okay .... Increase deisel.

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

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.

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

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!