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Kiwiology

Travelling Soldier

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It's one o'clock in the morning and you're called to assess a patient at home.

The patient is a 20 year old well developed female who is found upstairs in the bathroom leaning over the loo having thrown up in it.

She tells you that she is on two weeks leave from the Army and has felt generally unwell / flu-like for the past two days and it has come on gradually without provocation. Normally lives on base and eats in the camp mess with the other soldiers; nobody else has become sick; despite being in the Special Air Service she has not done anything out of the ordinary in the immediate past that she can think of which might contribute to her being sick and, as might be expected of the military, is up to date with all her immunisations.

If you're interested, the New Zealand Defence Force does allow women in combat and in the Special Air Service.

Complains of "feeling sick" with "tummy pain"

Prior medical history of unremarkable, appendectomy at 10 years and some childhood asthma which also resolved about ten years ago. Takes no regular medicines.

No family history that is remarkable.

No remarkable social history; drinks occasionally either on-base or off-base in town but only two-three drinks and does not use recreational drugs. She sometimes spends social time with male soldiers off-base but denies being sexually active.

Upon examination there is tenderness in her lower abdo which is warm to touch

Obs; BP 120/80 PR 90 RR 14 Temp 38°C SPO2 100 RA ETCO2 27 GCS 15 BGL 5 (100mg/dl)

You have the choice of leaving her at home or taking her to the hospital

Pretty basic - what do you think is wrong, what other information do you want and does she go to hospital or stay at home?

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Normal Menstrual cycle? - Urinating okay? Pain, burning, discharge from anywhere? - Back alley van abortions? - Last BM? Frequency, color, consistency. It matters. I always ask. Any Jaundice? You say lower, but which side, left right, groiny more than belly? Around the naval? Any attempted piercings? Any noticeable foul odors, not necessarily feminine.

What has the person been eating lately? Nuts, seeds, etc? Diverticulitis? Blockage? Abscess (internal or under the skin)? Ovarian Cyst?

what do you think is wrong

How the hell should I know, that's why she's being taken to the hospital.

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Normal Menstrual cycle? - Urinating okay? Pain, burning, discharge from anywhere? - Back alley van abortions? - Last BM? Frequency, color, consistency. It matters. I always ask. Any Jaundice? You say lower, but which side, left right, groiny more than belly? Around the naval? Any attempted piercings? Any noticeable foul odors, not necessarily feminine.

LMP and BM OK

Yes, she says it hurts when she pees since she has been "feeling sick"

No jaundice or piercings or foul odours that you smell

Pain is central, lower abdo/ pubis

What has the person been eating lately? Nuts, seeds, etc? Diverticulitis? Blockage? Abscess (internal or under the skin)? Ovarian Cyst?

Normal food, no diverticulitis, no history of abscesses or ovarian cysts

What would you look for that would indicate a bowel obstruction?

How the hell should I know, that's why she's being taken to the hospital.

Um, points for recognising the limits of your knowledge or no points for not listing some pathologies you are considering? Hmm

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Get some training, then lecture me on limits of knowledge.

OK - is not an acceptable answer on last BM.. and just because someone doesn't have a history of an MI, doesn't mean they're not having one. I bet a trauma patient, just in an MVA, doesn't have a history of trauma either. Last BM may have been normal on Saturday. But if it's Sunday, and that last BM was 8 days ago, that may be a problem.

Edited by 1 C

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OK - is not an acceptable answer on last BM

Six hours ago, big, well developed and smells like shit

and just because someone doesn't have a history of an MI, doesn't mean they're not having one.

Quite correct

So we've established her shit is normal, she has lower abdo/pubis is painful and warm to the touch and that she has vomited at least once

Here are some repeat obs

BP 120/80 PR 100 RR 16 Temp 38°C SPO2 100 RA ETCO2 27 GCS 15 BGL 5 (100mg/dl)

If you want to take her to the hospital that's fine but when the House Surgeon asks "what do you think is wrong with her?" what are you going to say?

Could her combined obs and physical exam be pointing toward a significant underlying pathology?

They might not ... but they might be

What could be the source of such serious pathology? ...

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House Surgeon asks "what do you think is wrong with her?" what are you going to say?

Well.. The only time we see a surgeon in the ER, is the trauma surgeon, and I doubt this is Trauma Alert worthy.

I'm going to say:

This 20 y/o/f, with stable vitals and a low grade temp is having abdominal pain below the naval w/ vomiting. States no possibility of pregnancy, normal bowel habits, normal menstrual cycle. Sign here for transfer of care, have a lovely day.

UTI? PID? Cancer? Hell if I know, I covered all the questions. You said she wasn't sexually active, has she been assaulted? Rather when asked, does she clam up, quit talking, avoid answered? Is she currently having her menstrual cycle?

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Well.. The only time we see a surgeon in the ER, is the trauma surgeon, and I doubt this is Trauma Alert worthy.

House Officers (aka House Surgeon) are first and second year Doctors; I should have said "the Doctor" or even "the Nurse" coz you know the Nurse sometimes asks too :D

This 20 y/o/f, with stable vitals and a low grade temp is having abdominal pain below the naval w/ vomiting. States no possibility of pregnancy, normal bowel habits, normal menstrual cycle. Sign here for transfer of care, have a lovely day.

Are her obs "stable"? Which ones? All of them or only some? Have any changed? Which ones? What does that infer?

There is a bit of "not seeing the trees in the woods" (which I am guilty of myself) ... her vital signs indicate significant underlying pathology which if left untreated means she will die within one to two days. With the information presented thus far, what could some possible pathologies be? What information or clinical observations would lead you to discount one over another?

UTI? PID? Cancer? Hell if I know, I covered all the questions. You said she wasn't sexually active, has she been assaulted? Rather when asked, does she clam up, quit talking, avoid answered? Is she currently having her menstrual cycle?

She is extremely, forcefully insistent she is not pregnant

No current MP; states has not had one for some time

Edited by Kiwiology

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As a diabetic, myself.. I'd consider the BGL to be perfectly fine.. In fact, 100 would be high for me, since I should practically own stock in Dex4 - the glucose tablet people. "BP 120/80 PR 90 RR 14 " are with in normal limits. The CO2 thing there is supposed to be in the 30's or something, unless I'm mistaken. That's not something we do, none of our equipment can read it, and the only time ALS reads it is in intubated patients. One expects a certain degree of rise of pulse, blood pressure and potentially respiratory rate when an ambulance arrives, as it can be embarrassing, stressful, don't know what to expect. Then of course the pain factor, pain will reflect in vitals.

Have we palpated the abdomen yet? What does it feel like? Pain to press, pain when pressure is let off, pain go away when pressing, masses, bulges, how bad is the pain. 1 none 10 child birth - that's what I say when I ask older women about pain. How long has the patient been vomiting? What color is the urine? Are we leaning toward some type of syndrome that leaves the body with excessive amounts of alkali?

Did you get your scenario from watching a TV show?

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One expects a certain degree of rise of pulse, blood pressure and potentially respiratory rate when an ambulance arrives, as it can be embarrassing, stressful, don't know what to expect. Then of course the pain factor, pain will reflect in vitals.

Very good point. So let's say the trend is below for the three sets of obs that have been taken 10 minutes apart

BP 120/80 PR 90 RR 14 Temp 38°C SPO2 100 RA ETCO2 27

BP 120/80 PR 100 RR 16 Temp 38.2°C SPO2 100 RA ETCO2 27

BP 120/80 HR 100 RR 18 Temp 38.4°C SPO2 100 RA ETCO2 27

I'm trying really hard not to state the obvious here but what does this trend tell you and why is that important in a patient like this?

Even if you cannot perform capnography what does it tell you if this patient is exhaling less CO2 than normal? Where does CO2 come from?

Have we palpated the abdomen yet? What does it feel like? Pain to press, pain when pressure is let off, pain go away when pressing, masses, bulges, how bad is the pain

Her abdomen is unremarkable except for the lower quadrant and pubis is very red and warm to touch

The abdomen is soft except in the lower quadrants and pubis; that is firm to palpate and painful for the patient.

Percussion of the lower quadrants and pubis illicit pain

Pain about 3-4/10 and sharp

No masses or organomegaly, the kidneys are not ballotable

How long has the patient been vomiting? What color is the urine? Are we leaning toward some type of syndrome that leaves the body with excessive amounts of alkali?

She has been vomiting for today only

Urine is clear but it hurts to pee

No this is not a acid/base imbalance; nor is it a KUB infection or a vascular catastrophe

Did you get your scenario from watching a TV show?

No, ew, hell no!

Edited by Kiwiology

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