BushyFromOz Posted July 10, 2008 Share Posted July 10, 2008 Ok, i dont normally post case studies ( in fact, im not sure i ever have before) so bare with me............. Despatched to a routine transfer for a ? bowel obstruction. O/A you find a 90ish y/o female laying R lateral with abdominal guarding. You note she is a bit jandiced and obviously uncomfortable. Pt has a Hx of fecal incontinance, CVA's in 05 and 07 with Left sided deficit, Dementia, L4 crush/fracture in january this year, type 2 non insulin dependent diabetes, renal calculi, hypertension and a urinary tract infection last month. She has had 50mg of pethidine IMI and 20 mg Maxalon IMI at five and a half hours ago and another one just as you walked in the door. You can smell vomit in the air, and notice the clean bedpan on the floor next to her bed. A relative says she has been complaining of back pain for 2 days. What would you like to know and what would you like to do? Link to comment Share on other sites More sharing options...
Kaisu Posted July 10, 2008 Share Posted July 10, 2008 so bare with me............. OK - but you have to buy me dinner first Link to comment Share on other sites More sharing options...
mobey Posted July 10, 2008 Share Posted July 10, 2008 Last bowel movement? Last meal? Urine output? Does she feel like she has to have a BM? How bad is the dementia? Can I trust her answers about her current condition? Is she always a little jaundice or is that new? Oh ya, how long has she been in the hospital? Link to comment Share on other sites More sharing options...
Christopher.Collins Posted July 10, 2008 Share Posted July 10, 2008 *How long has she been experiencing this onset (excluding the back pain x2 days)? *Provokes / what if anything makes more comfortable? 1/10 scale *Onset/provoke, location/radiation of the back pain? 1/10 scale *Any follow ups since treatment for the UTI? If so results/info? *Last vomit... how did it present? *Blood in stool, urine, vomitt? (If any output or on attempt) *(If a hospital) Why is patient being transferred? *Last visit to PCP, any known information from visit *Any known liver problems (not given in history but perhaps its something new awaiting test results)? *Monitor vitals (full work up including EKG) and (compare if taken by facility or first responders). If a nursing home (or other non-emergency facility) any info on patients normal mental status and vitals *Bring family member (in regards to mobey's comment on if patient is reliable for info) *If patient is not being transfferred to a hospital, reccomend that we do so (Ive brought people to dialysiss appts. that shouldnt have been at a simple dialysiss facility). Transport Code 3 if any signs/symptoms appear to be severe or jaundice is new (beyond simple abdominal pain as hx may be irrellivant to this case) ~~~~~ Ive flat out taken the word routine out of my dictionary. I dont blame dispatch, its not always there fault... but I feel your pain. Im sure we all do. I get a call to a nursing home; the usual fall and "lift assist only." Ummm ok they just wanted a lift assist for an obvious tib-fib break in which the foot was 90 degrees in the wrong direction. Link to comment Share on other sites More sharing options...
ERDoc Posted July 10, 2008 Share Posted July 10, 2008 I'd like to know what kind of workup was done at the transferring hospital. Jaundice is not typical of bowel obstruction, so was something missed? I'd also like to ask for an Australia to American medication translation dictionary (yeah, too lazy to Google). Link to comment Share on other sites More sharing options...
Don1977 Posted July 11, 2008 Share Posted July 11, 2008 I was told by an old experienced for 30 years supervisor "no transfer is routine" Link to comment Share on other sites More sharing options...
BushyFromOz Posted July 11, 2008 Author Share Posted July 11, 2008 OK - but you have to buy me dinner first Whoops, sorry, and i will stop using aussie medication lingo Okay, sending facility is very rural, limited medical staff (more like a nursing home with an "urgent care center") in fact, ther is not even a GP in attendence, the nursing staff are taking Dr's orders over the phone, and the only "work up" she had was a GP consultation about 2 hours ago with no available obs or vital signs. Dementia is very advanced, the patient tells you her washing machine jumped about six feet and out of the door when you introduce yourself. The family member has no idea of mothers history last bowel movement this morning with normal appearance Its unknown if pt has voided any urine at all today, though she has been "drinking plenty of water" Last time she ate was lunch time (beef soup) Uknown time of onset of "pain", nursing staff noticed her guarding this afternoon Unsure of provocation, though movement seems to illicit a facial grimace type response, though not consistently every time she is moved. Unable to localise pain and unable to rate Nil follow up since UTI that you are aware of, pt is on a cephaliosporin anti-biotic for it Vomit about half hour before your arrival, nurse says there is no fecal matter in it Unknown if malena or hematuria No known liver problems Abdo soft, nil facial grimaces on palpation. Nurse thinks that her tummy may be a little bit bigger but she is not sure A= Nil allergies M= Laxative, ACE inhibitor, Beta Blocker, Aspirin, Paracetamol P= Jaundice for 1 week, fecal incontinance, CVA's in 05 and 07 with Left sided deficit, Dementia, L4 crush/fracture in january this year, type 2 non insulin dependent diabetes, renal calculi, hypertension and a urinary tract infection last month L = Beef soup E = unknown, was just found with gurding this afternooon HR = 110 B/P = 150/90, radial pulse feel weak though RR = 18, clear, low tidal volume Temp = 37.7 tympanic BSL = 14.9 ECG = Only 3 lead available its non diagnostic Sinus Tach GCS = 13 (E4, V4, M5) Pt appears to be reasonably comfortable Link to comment Share on other sites More sharing options...
firedoc5 Posted July 11, 2008 Share Posted July 11, 2008 Last bowel movement in AM and normal, may rule out impacted bowel, but not completely. How has her BM's been over the last week? How has her fluid intake been? Any gastric reflux? Passing gas? What is her normal diet? Cause of UTI? I know, I'm reaching. Link to comment Share on other sites More sharing options...
itku2er Posted July 11, 2008 Share Posted July 11, 2008 What color is her stool? Hx of any liver problems? How much Paracetamol is she taking, has she been taking an excessive amount for her pain? ( Paracetamol is liver toxic in large quanities.) Link to comment Share on other sites More sharing options...
firedoc5 Posted July 11, 2008 Share Posted July 11, 2008 What color is her stool? Hx of any liver problems? How much Paracetamol is she taking, has she been taking an excessive amount for her pain? ( Paracetamol is liver toxic in large quanities.) Good call. Link to comment Share on other sites More sharing options...
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