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A simple fall goes wrong


mobey

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You are called for a interfacility transfer from a small health centre for a 60y/o female, it is 10am.

3 days ago she fell down 2 carpeted steps onto her right side.

She has 4 fractured ribs.

She has been an inpatient since the fall, She walked in on her own.

This morning (now day 4) she began deSating and c/o SOB. She has been eating well, and had normal output till today.

Current Vitals: BP 78/42. Resps 34. Sp02 92% on simple mask at 10lt. HR70. ECG= Inverted T-waves in V2&3, otherwise normal sinus. GCS15 - pleasant, and totally oriented. Her Foley was emptied last night at 3am, and is still dry. She is pale and quite diaphoretic.

She is obeise at 5'5 and 290lbs.

Nurse states the chest x-ray shows no pneumo or hemothorax, but "bilateral consolidation"

They do not have a paper copy of blood work, but have sent it electronically to the receiving facility. Nurse sts her HGB was a little low, Creatinine a little high, but otherwise normal.

Once again I will remind you, these are family medicine doc's and long term care nurses attempting to handle emergency cases, so be weary of thier interpretations!

She has had 500ml bolus of NaCl and 10mg Morphine PO for pain.

Her only Hx is HTN and arthritis.

She takes Propranolol, Pantoloc, and Arthrotec. All of which she took today.

You have a 2hr trip to a university affiliated hospital/trauma centre. No air available.

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I wanna see the X-Ray and the labs, if they aren't on paper then I wanna see on the computer. Even just to snap a pic with me smart phone to look at once I complete my assessment.

Temp?

Which 4 ribs?

Any Sub-Q signs?

Smack the docs for letting her have beta blockers if she has S/S before she got her meds.

I think it's Pericarditis, but the X-ray would help.

Edited by Arctickat
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I'm leaning towards a case of atelectasis with inadequate gas exchange r/t pain from rib fractures...

I would like to see her complete labs from initial set to the most recent to see which way her H&H are trending, and her renal function tests.

Physical exam I would like to know lung/heart sounds, normal BP for this patient...some LOL's naturally have very low BP's so I would need to know baseline. She's pale and diaphoretic, do we suspect that is because of pain or hypotension? Without an assessment of lung/heart sounds I would not feel comfortable making a dx...

I think it's Pericarditis, but the X-ray would help.

I'm curious as to why you think it could be pericarditis? Does the patient have a c/o CP or just the low sat (which isn't all that low to be honest).

My best guess right now is the atelectasis though with a sat like that, BP is a little concerning until I know more about her baseline.

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I'm leaning towards a case of atelectasis with inadequate gas exchange r/t pain from rib fractures...

I would like to see her complete labs from initial set to the most recent to see which way her H&H are trending, and her renal function tests.

Physical exam I would like to know lung/heart sounds, normal BP for this patient...some LOL's naturally have very low BP's so I would need to know baseline. She's pale and diaphoretic, do we suspect that is because of pain or hypotension? Without an assessment of lung/heart sounds I would not feel comfortable making a dx...

I would love to share the labs, but you get what I got. Let me quote the nurse.

"All the labs & x-ray are online. The Doc is back at the clinic so I can't get them for you"

No new labs/x-ray were done today, only the first ones at admit 3 days ago. You could not assess trending.

Welcome to my world

OK, normal BP? She has been around 130/85 for the last 3 days.

Chest sounds= Loud course crackles throughout.

Heart sounds unremarkable.

Pt sts some pain on deep respiration, but overall only a 3/10. Much better than previous days.

I wanna see the X-Ray and the labs, if they aren't on paper then I wanna see on the computer. Even just to snap a pic with me smart phone to look at once I complete my assessment.

Temp? 37.3

Which 4 ribs? 3-6

Any Sub-Q signs? Nope, none felt or auscultated

I think it's Pericarditis, but the X-ray would help. No dice

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Increased Pain with cough?

Pleural Effusion secondary to pericarditis. However, since I don't have an x-ray or labs to look at myself I'm just gonna monitor her condition and transport, treating complications as they arise.

Edited by Arctickat
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Rales (Crackles) is caused by the "popping open" of the airways when collapsed due to fluid. I would lean towards Pulmonary Edema. History of CHF? How long has patient been in bed? Patient is obese so CHF (even undiagnosed) can be a possibility.

The inverted T-waves can be an indicator to Ischaemic Heart Disease (I've been studying up on my EKG's).

Rales can also be cause by atelectasis so I am going to agree with Kate on this one.

Now I have reached the limit of my education and will sit back and see what else I can learn.

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The BP is nagging at me now that I know the baseline... any orthostatic changes? Skin turgor? The BP just isn't sitting right. How is her mental status? The pain only on deep inspiration is changing my thinking of the atelectasis but I'm having a hard time thinking what else it could be. I'm really wanting new labs and a CXR but I know you don't have them. Ugh why couldn't the facility have just done a repeat CXR???

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Does she have a fever?

After everything else that has been mentioned the only thing I can come up with is a possible perforation in the diaphragm. They are hard to diagnose on the initial work-up and cause a low BP after time along with the respiration issues. I'm not sure how the low urine output fits in though... :confused:

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After everything else that has been mentioned the only thing I can come up with is a possible perforation in the diaphragm.

I thought about this, but I feel like her pain would be sharper on inhalation when the diaphragm contracts... just like a torn calf muscle gets sharp pains when you try to use it... That would also cause acute epigastric pain and tenderness I believe?

There's something we're not thinking of :/

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