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59yom c/c back/abdo pain 2/24

PMH MI 2005 > CABG x 3, ischaemic heart disease, angina, HTN, NIDDM

Rx Lipitor, ASA, GTN SL, isosorbide mononitrate, propanalol, coumdain, metformin

FHx DM, CAD, HTN, CX

SHx smoker, poor diet > fat/salt +++

Tonight onset severe back pain while at rest in bed, radiates abdo and right testicle, 7/10, ++ on exertion, described as sharp pain. No recent physical activity, no hx torsion or hernia. Vomited twice tonight, normal stomach contents only; last meal 7pm last night > beef, potatoes and vegetables. One episode ? faint approx 12am > self resolving.

Ambo - hypotensive 70/40, abdo pain, 250ml fluid challenge, ECG brady (SR) Q waves, old infarct, no active ischaemia, BBB or axial deviation

O/A conscious + alert

O/E A patent and intact B tachypenic/adequate C shut down cold and clammy D GCS 15/15

No cyanosis, no JVD, b/s clear+equal no crackles/good air entry bilat, chest nonresonant, h/s s1/s2 no added, no rub, abdo painful to palp, soft/non tender, no masses, bowel sounds present (last BM mane), testicles appear normal, painful to touch, warm/good circ no sign torsion, no pain on urination, dysuric pm last urinated mane, urine clear. Distal pulses symmetrical. ECG SR brady, Q waves > old infarct, no active ischaemia, no BBB or axial deviation

Chest/abdo/KUB film/ blood CBC/trop/CRP/U+E/coag/U C+S

Plain films normal, bloods normal, hematuria+proteinuria

0045 obs BP 60/40 RR 20 PR 50 SpO2 91% BSL 8 (124) Temp 35.9° Cap refill 4s Pain 7/10

0050 IV fluid one litre NS

0050 morphine 5mg IV

0100 obs BP 85/60 RR 18 PR 60 SpO2 97% Cap refill 4s Pain 6/10

0130 obs BP 110/70 RR 18 PR 66 SpO2 98% Cap refill 3s Pain 6/10

0130 morphine 5mg IV fluid one litre NS

0200 obs BP 120/70 RR 15 PR 70 SpO2 98% Cap refill 3s Pain 8/10

0210 morphine 5mg IV

0220 obs BP 120/70 RR 16 PR 70 SpO2 98% Cap refill 3s Pain 4/10

0300 obs BP 128/80 RR 14 PR 70 SpO2 98% Cap refill 3s Pain 4/10

0400 stone cold dead

What do you think killed this bloke?

Edited by kiwimedic

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I agree,AAA. What caught my eye was that I had a pt that presented exactly the same with lower back/abd pain that radiated to the groin area, hypotensive. This too was an AAA. Pt survived however.

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Few questions just because its the first time I'm doing this. What does the "2/24" refer to in "59yom c/c back/abdo pain 2/24"

It seems from what you said, a trauma cause can be ruled out correct? (ie. patient doesnt talk about any recent trauma history when asked)

Thinking some sort of rupture of something in the abdo area. I was also thinking a ruptured AAA but found it interesting that the abdomen was not firm/rigid, so not sure if there was blood loss in that region? But it is still high on the list for now.

In regards to the blood in urine, and dyuria, not sure if it would be a common sympton for a AAA but I am now also suspicious of the GU organs. I kinda suspect some sort of internal bleeding because that pressure seems pretty darn low for someone who is normally hypertensive. Wonder where it bled off to though -- I am under the impression that if it bled out to the abdo, you would feel the firmness on palpation.. maybe in the pelvic region? Would it be palpable then?

You mentioned that last meal was last night, but we are talking about tonight now (which is ~24 hrs after).. so was he anorexic?

If you were to take away the "patient died" part and the low BP, I would be prone to thinking kidney stones.

Is this meant to be a scenario where we can ask more questions or are we to base our differentials just on the information provided?

If we can ask questions, has the patient ever felt this pain before? Specifically, what portion of the abdo/back is painful? Did he take any meds for the pain?

Sorry, more questions than answers here.. All I know so far is that I need to review a lot of my patho

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What does his stool look like? His temp is a bit low. He has blood and protein in his urine but his CBC is normal? No anemia? No leucocytosis?

Did they do a BUN?

Did they check his Serum Creatinine?

I am leaning toward pyelonephritis, Intestinal bleeding possibly. The AAA is possible or an aortic dissection but I would expect rigid abdomen, guarding and tenderness and the diagnostic images should have picked them up.

It just seems that the labs do not match the symptoms.

You are not messing with us Kiwi?

Oh, did the pain radiate around his back or run through the abdomen to the groin?

Edited by DFIB
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What do you think killed this bloke?
Too much alphabet soup! Give us non-native kiwi-speakers a chance understanding what all those abbrev. mean...

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Few questions just because its the first time I'm doing this. What does the "2/24" refer to in "59yom c/c back/abdo pain 2/24"

For the last two hours. X/24 (hours), X/7 (days), X/12 (months), X/52 (weeks)

It seems from what you said, a trauma cause can be ruled out correct? (ie. patient doesnt talk about any recent trauma history when asked)

Yeah, no trauma here ... except the trauma his lifestyle has taken on his arteries, blood and heart :D

Thinking some sort of rupture of something in the abdo area. I was also thinking a ruptured AAA but found it interesting that the abdomen was not firm/rigid, so not sure if there was blood loss in that region? But it is still high on the list for now.

I am under the impression that if it bled out to the abdo, you would feel the firmness on palpation.. maybe in the pelvic region? Would it be palpable then?

You normally do yes

You mentioned that last meal was last night, but we are talking about tonight now (which is ~24 hrs after).. so was he anorexic?

No he's quite overweight. He last ate about 7 hours previous sorry "tonight" in the note was written past midnight

If you were to take away the "patient died" part and the low BP, I would be prone to thinking kidney stones.

Is this meant to be a scenario where we can ask more questions or are we to base our differentials just on the information provided?

If we can ask questions, has the patient ever felt this pain before? Specifically, what portion of the abdo/back is painful? Did he take any meds for the pain?

Oh, did the pain radiate around his back or run through the abdomen to the groin?

I suppose you can ask question, shucks .... :D

No he has not felt the pain before

The pain is lower right extending laterally to the flank, around to the abdo and and inferior to his right testicle

What does his stool look like? His temp is a bit low. He has blood and protein in his urine but his CBC is normal? No anemia? No leucocytosis?

Did they do a BUN?

Did they check his Serum Creatinine?

No poo sample sorry mate, CBC normal yes, didn't do a BUN or creat, no leukocytosis no increased eosinophils/neutrophils/bands/segs or erythrocyte seds ...

I am leaning toward pyelonephritis, Intestinal bleeding possibly. The AAA is possible or an aortic dissection but I would expect rigid abdomen, guarding and tenderness and the diagnostic images should have picked them up.

I would too but patients are pricks for not having read the textbook

It just seems that the labs do not match the symptoms You are not messing with us Kiwi?

Aw come on man would I mess with you /sly look :P

Nope I'm not messing with you mate

Would anything be on the list of differentials besides kidney stones or a AAA?

Where is one of those Consultant Physicians we have when you need one? :D

Edited by kiwimedic

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I would too but patients are pricks for not having read the textbook

There are textbooks for patients?

Would anything be on the list of differentials besides kidney stones or a AAA?

He could have parasitic inflammation of the iliocecal valve.

Parasitic intestinal perforation.

Pancreatitis.

This is a reach. I don’t even know if this is physiologically possible but could he have a sclerotic stenosis of the renal artery or arthrosclerosis that affects the juxtaglomerular secretion of rennin. This I would expect to increase BP and cause any internal leak to be more severe.

Beats me!?!

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OK- AAA is an easy guess. Could he have been dissecting and finally ruptured?

I saw someone die from a AAA right before my eyes. Scariest thing I have ever seen. A 50 year old priest walked into the ER c/o back pain. Unequal pedal pulses, hypotensive- no mass. Quickly confirmed the AAA and a surgeon was called in- approximately 45 minute ETA. In the meantime, the ER doc wanted to apply the MAST suit, and I was the only one who knew how to put them on-even though I was actually still a paramedic student. Talk about pressure. LOL

I stuck like glue to this patient, realizing he was in big trouble. He knew it was serious, he knew his life was on the line. We made small talk, and I kept looking at the ER door, hoping the surgeon was there. About 30 minutes goes by, the man's eyes got real big, the color drained from his body top to bottom like someone pulled the plug on a drain, and he went apneic. I called for the doctor, and within 30 seconds he was gone. The surgeon showed up just as we were zipping him into a morgue bag.

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There are textbooks for patients?

Only those with Munchhausen-syndrom use them, though....

;)

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