Clinical Case

[cozmokramer]

Not a long time poster but long time lurker. I always love clinical cases so I thought I would give this a go. I am a 3rd year resident doing some moonlighting and had this patient present to the somewhat rural ED where I was moonlighting. More geared to medical students and interns to generate a discussion on medical resuscitation and troubleshooting when things don't work out like you want them.

Got grabbed by nursing staff as they wheeled a patient from triage back to our one trauma room (not brought by EMS) . She looks somewhere between 30-40 years old and looks sick. There is a boyfriend who has been with her for about one month accompanying her. My first question to the boyfriend was "what is going on?" He didn't offer much other than she told him her stomach hurt. The patient is somewhat confused but can answer yes/no questions and the boyfriend is sitting in the room. And go!

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[dotcb]

Please give us the vital signs, history, and exam.

 

[emergentmd]

Pan lab, tox, etoh, CT head, CT abd, CXR. 2 IV, fluids, ACLS, admit.

 

[Arcan57]

It's TTP.

 

[d2305]

Ectopic until proved otherwise vice PID. Check for retained tampon also.

 

[RustedFox]

Vital signs and tooth:tattoo ratio, please.

EDIT: vital signs INCLUDING tooth:tattoo ratio, please.

 

[gro2001]

Vital signs and tooth:tattoo ratio, please.

EDIT: vital signs INCLUDING tooth:tattoo ratio, please.

You could have just said a COMPLETE set of vitals

 

[Perrin]

I'd start rehearsing my acceptance speech for the Nobel Prize in Medicine for seeing a female with abdominal pain!

Seriously though, I'd ask the boyfriend if he wanted to check in as well for his 2 years of tooth pain.

 

[Doctor Bob]

My initial thoughts when I read this case...

1. Probably a drug seeker; make sure that's a discharge diagnosis so they don't get a press-ganey survey.
2. Call security on the nurse for "grabbing me"
3. Call surgery to admit.
4. Check that the safety screening questions have been entered into the computer, and make sure somebody posts a sign over the head of the bed with the patient's fall risk score on it.
5. CBC, CMP, lipase, lactate, d-dimer, ESR, CRP, HCG (qual and quant), UA, UCulture, Blood culture x 2, GGT, procalcitonin, hepatitis panel, urine galactomannan, SPEP/UPEP, CT scan chest/abd/pelv with triple phase contrast, RUQ sono with liver doppler, pelvic sono complete, 2L NS bolus and 20mg of lasix then 250mg of 5% albumin, 20mg of nubain.
6. Once all that's done... then go see the patient.

 

[bikERdoc]

My initial thoughts when I read this case...

1. Probably a drug seeker; make sure that's a discharge diagnosis so they don't get a press-ganey survey.
2. Call security on the nurse for "grabbing me"
3. Call surgery to admit.
4. Check that the safety screening questions have been entered into the computer, and make sure somebody posts a sign over the head of the bed with the patient's fall risk score on it.
5. CBC, CMP, lipase, lactate, d-dimer, ESR, CRP, HCG (qual and quant), UA, UCulture, Blood culture x 2, GGT, procalcitonin, hepatitis panel, urine galactomannan, SPEP/UPEP, CT scan chest/abd/pelv with triple phase contrast, RUQ sono with liver doppler, pelvic sono complete, 2L NS bolus and 20mg of lasix then 250mg of 5% albumin, 20mg of nubain.
6. Once all that's done... then go see the patient.

Lol. What?! Dude, you totally forgot PET scan, MRCP/ERCP, CA-125, and AFP.

How about a urine HCG, basics, type and screen, 2 IVs, and a quick bedside US. It's most likely a ruptured ectopic, appy, or ovarian issue. Biliary path doesn't typically present as that "sick" in younger population, although I've seen it before.

 

[gro2001]

Not a long time poster but long time lurker. I always love clinical cases so I thought I would give this a go. I am a 3rd year resident doing some moonlighting and had this patient present to the somewhat rural ED where I was moonlighting. More geared to medical students and interns to generate a discussion on medical resuscitation and troubleshooting when things don't work out like you want them.

Got grabbed by nursing staff as they wheeled a patient from triage back to our one trauma room (not brought by EMS) . She looks somewhere between 30-40 years old and looks sick. There is a boyfriend who has been with her for about one month accompanying her. My first question to the boyfriend was "what is going on?" He didn't offer much other than she told him her stomach hurt. The patient is somewhat confused but can answer yes/no questions and the boyfriend is sitting in the room. And go!

Ok, I'll play.

Your mantra should be: ABCIVO2Monitor...

Airway - Sounds like airway is intact for now

Breathing - Sounds ok for now too

Circulation - What do you mean by looks sick? Pale? Cyanotic? As I ask for/wait for a set of vitals and for her to be put on the monitor, I would reach out an feel whether she is cold and clammy or burning up and what her pulse/cap refill is like

Simultaneously the nurses are putting in an IV in each anticubital fossa (and drawing a 'rainbow' of labs) and placing her on a monitor. They are probably instinctively connecting a liter or two of NS to some tubing and throwing some O2 on her, while the tech waddles over with the fingerstick machine. While I get the ultrasound machine over to the bed, I should be hearing/seeing some vital signs and a fingerstick result. Need those to proceed.

 

[southerndoc]

Not to side track the discussion, but does a diagnosis of drug-seeking behavior actually prevent a patient from getting a PG survey?

 

[Doctor Bob]

Lol. What?! Dude, you totally forgot PET scan, MRCP/ERCP, CA-125, and AFP.

Crap, you're right. Although in my defense, the nurse should have ordered those from triage already...

Ok, I'll play.

Noooo... you're making the rest of us look bad

Not to side track the discussion, but does a diagnosis of drug-seeking behavior actually prevent a patient from getting a PG survey?

I've never verified this for myself. It's one of those things I hear around the department a lot... not sure if it's really true or just wishful thinking.

 

[Vandalia]

Not to side track the discussion, but does a diagnosis of drug-seeking behavior actually prevent a patient from getting a PG survey?

At least in some places. I don't know if it is universal or PG standard or just what our places requested.

 

[Arcan57]

Depends on your hospital's contract with PG. Ask whatever the equivalent of your hospital's patient experience rep who actually gets surveyed. That's the only way to be sure.

 

[cbrons]

Not to side track the discussion, but does a diagnosis of drug-seeking behavior actually prevent a patient from getting a PG survey?

Is there actually a diagnosis of "Drug-seeking behavior"? I.e. can you add this to their "Problem List" on epic?

 

[southerndoc]

Is there actually a diagnosis of "Drug-seeking behavior"? I.e. can you add this to their "Problem List" on epic?

Yes, Z72.89 is the ICD-10 code.

 

[TooMuchResearch]

Is there actually a diagnosis of "Drug-seeking behavior"? I.e. can you add this to their "Problem List" on epic?

Yes, it's a diagnosis. I don't touch the problem list. That sounds like an inpatient or primary doctor job.