hammerpcp Posted June 1, 2006 Share Posted June 1, 2006 93 y/o female pt co severe abdo pn primarily in LLQ raditating to back and legs (pt can not be any more specific). Feels like "sharp/stabbing" consatant pn, not releived or increased by mov't/palp/urination/etc. Pt states she awoke to go to the bathroom at approx. 0100 hrs, pt had normal urination then sudden onset of this pain. Pt began feeling extremely dizzy shortly thereafter. Pt contacted her family who came over to the house. (pt resides alone and is completley independent, coping adequatley). Pt's family activated 911 at approx 0600 hrs, pn had not increased but had not subsided either. Slight language barrier, pt polish speaking primarily, but able to communicate simple ideas in english. Pt found sitting in kitchen chair, Pale, cool and clammy, fully alert and oriented, c/o dizziness and abdo pn. No palpable radial pulses, BP of 80 systolic on auscultation on R arm. Fore and aft to 35A-trandelenburgh - dizziness subsided; high conc. 02 via PNRB; cardiac monitor 3 lead- 1st degree block, rate of 70-80 bpm, regular, no ectopi. No palpable radial or brachial pulses, no BP obtainable bilaterally on arms. good carotid and femoral pulses. pedal pulses unobtainable due to leg and pedal edema (as per normal according to pt). No vomiting, no sob, no chest pain, no dysuria, normal BM previous day, pt states abdomen may be slightly more distended then usual, firm but no rigity to palp, no pulsating masses. PMHx: DVT, HTN Meds: adalat, thiazide, Vitamins, a couple other BP meds (I don't remember) Allergies:Warfarin, Penicillen, Sulpha drugs, Nitrofurunate. What do y'all think? Link to comment Share on other sites More sharing options...
medic53226 Posted June 1, 2006 Share Posted June 1, 2006 I had a pt that had this problem, would bet that is could be diverticulitis beacuse it follows the same path, That is what I think. My pt had vagaled down and was hypotensive, pale, cool, clammy. She looked dead and when we spoke to her she would answer as if nothing was wrong, she had abd pain, and was to weak to walk, had trouble with her BM. It was he LLQ. This is my guess. Link to comment Share on other sites More sharing options...
Asysin2leads Posted June 1, 2006 Share Posted June 1, 2006 Aneurysm of the renal artery. That's probably not right but it sounds good. Link to comment Share on other sites More sharing options...
ERDoc Posted June 1, 2006 Share Posted June 1, 2006 This case just shouts BAD!!!! First off, we have a 90-something year old with belly pain and bad vital signs. Divertic is a possibility, but I wouldn't want to hang my hat on it yet. It would be nice if our ambulance has an US machine, we could do a FAST exam to look for evidence of blood in the belly (really bad given the coumadin). Again, all I think of with this scenario is BAD!!! Link to comment Share on other sites More sharing options...
mediccjh Posted June 1, 2006 Share Posted June 1, 2006 I'm gonna agree w/ Asys and say it's an aneurysm. Any follow-up? Link to comment Share on other sites More sharing options...
chbare Posted June 1, 2006 Share Posted June 1, 2006 Aneurysm until proven otherwise, as of now. Pulsatile abdominal mass? Does her voice sound hoarse? Do the lower extremities appear mottled or cyanotic? BGL? I would want to be very judicious about IV fluids. Take care, chbare. Link to comment Share on other sites More sharing options...
AZCEP Posted June 1, 2006 Share Posted June 1, 2006 Maintain blood pressure where it is, rapid transport to a vascular surgeon. US as you are wheeling to the OR. Got to agree with ER Doc, BAD-BAD-BAD. Link to comment Share on other sites More sharing options...
Just Plain Ruff Posted June 1, 2006 Share Posted June 1, 2006 I was thinking the same thing but going a little further, I've seen patients that old how have a urinary infection and became septic. Had one present this way a year or so ago The other thought would be diverticulitis that might have perforated her bowel? Link to comment Share on other sites More sharing options...
ERDoc Posted June 1, 2006 Share Posted June 1, 2006 Let's face it, the ddx on this case is huge, and we need to do a little workup, especially before we run to the OR. The first things we need to do as soon as the pt comes through the doors is a bedside US to look for free fluid in the abd and to look for an aneurysm and we need an EKG (she wouldn't be the first to present with atypical MI symptoms, it's pretty common in the elderly). Other things we would need to worry about (most of which people have already mentioned) are divertics, possibly with perforation (will need an upright chest xray), UTI (let's get a UA), appy or dissection (will need a CT), micturition syncope, as well as other less threatening things. Link to comment Share on other sites More sharing options...
hammerpcp Posted June 1, 2006 Author Share Posted June 1, 2006 Pt has no good veins, IV attemps x3 enroute failed. Why bgl? We didn't take one. No indications for it as far as I can see. ECG 12 lead shows 1st degree HB, otherwise nomal. Prob. not sepsis- no recent hx of any signs/symptoms of infection. BP in legs- L 90 sys, R 130 sys (or vise versa, I don't remember). Micturation syncope?....lasting approx 5 hours? I dunno, you're the doc. Any more ideas? Link to comment Share on other sites More sharing options...
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