Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 His pain was in the left lower quadrant. Bledsoe, DO, FACEP Midlothian, TX Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Don't recall mention of last stool or quality. Bowel Obstruction with either desiccated stool or some type of bezoar? No evil can happen to a good man, either in life or after death. Plato (428 BC - 348 BC), Dialogues, Apology Larry RN NREMTP Nurse, Teacher, Medic Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Diarrhea intermittently. Bledsoe, DO, FACEP Midlothian, TX Re: Interesting Case Don't recall mention of last stool or quality. Bowel Obstruction with either desiccated stool or some type of bezoar? No evil can happen to a good man, either in life or after death. Plato (428 BC - 348 BC), Dialogues, Apology Larry RN NREMTP Nurse, Teacher, Medic Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 What is his history? Is he taking any meds? What is his ethnicity? Family Hx of SCA? What has he been eating/drinking? Can he localize the pain? What is his urinary frequency and output? Is there hematuria? Is there drowsiness, fatigue, lethargy? You will have to explain to me what is meant by a " left shift " in the WBC. Donn Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 What is his history? Normal guy until he became ill, about 3 days before admission. Is he taking any meds? None prior to admission. What is his ethnicity? Mexican-American Male Family Hx: Diabetes, hypercholesterolemia of SCA? No hx of sick as hell anemia What has he been eating/drinking? Nothing remarkable--not alcoholic--social drinker Can he localize the pain? LLQ What is his urinary frequency and output? Decreased secondary to dehydration Is there hematuria? No Is there drowsiness, fatigue, lethargy? No You will have to explain to me what is meant by a " left shift " in the WBC. An increase in neutrophils and immature forms (segs) associated with infection, usually bacterial, although stress and vomiting (which is stress) can cause it. Bledsoe, DO, FACEP Midlothian, TX Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Okay, here is my best SWAG. He is wrong ethnicity for SCA and too young for diverticulitis, so I would consider something simple, like maybe nephrolithiasis? If not, then possibly renal colic? Orchitis? Seminal vesiculitis? A bowl of bad chili? Several bowls of good chili? Donn Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 With this new info, I still hold my previous cards - Obstruction vs. bezoar; but I also want to add bowel infarct, too. No evil can happen to a good man, either in life or after death. Plato (428 BC - 348 BC), Dialogues, Apology Larry RN NREMTP Nurse, Teacher, Medic Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 I had a friend in the service (USCG) 23 y/o male diagnosed and treated for diverticulitis. I don't think it is completely age oriented. Mark Holcombe, EMTP ________________________________________________________________ Sign Up for Juno Platinum Internet Access Today Only $9.95 per month! Visit www.juno.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 lanelson1@... >> but I also want to add bowel infarct, too. Secondary to multiple bowls of good chili, of course. Regards, Donn Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 On Thu, 20 Feb 2003 20:54:42 -0600 " D.E. \(Donn\) " writes: > Secondary to multiple bowls of good chili, of course. > > Regards, > Donn > I'd believe that - :-) No evil can happen to a good man, either in life or after death. Plato (428 BC - 348 BC), Dialogues, Apology Larry RN NREMTP Nurse, Teacher, Medic Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Mark, In my experience I've never encountered a patient this young with diverticulitis, but the literature corroborates your point. Still, I think it is probably unusual enough that we should consider other possibilities. The good Doctor mentions that this case is from his internship in West Texas in the mid-80's. I wonder if there is any possibility that this young man somehow became infected with brucelosis? Time and geography would be about right. Best regards, D.E. (Donn) . LP, REMT-P ========================== Make plans now to attend the 2nd annual " Gene Weatherall Memorial EMS Reunion & Chili Cook-off " Commonly known as " EMSTOCK 2003 " May 9 - 10 - 11, 2003 Midlothian, Texas All public health and public safety workers welcome! http://www.emstock.com For information contact donn@... ========================== Re:RE: Interesting Case I had a friend in the service (USCG) 23 y/o male diagnosed and treated for diverticulitis. I don't think it is completely age oriented. Mark Holcombe, EMTP ________________________________________________________________ Sign Up for Juno Platinum Internet Access Today Only $9.95 per month! Visit www.juno.com Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Larry, Normal flat and upright abdomen per shadow merchant. No air-fluid levels, no ileus, no visible nephrolithiasis, no volvulus. Bowel ischemia very unlikely in this age short of SBO. But, no air-fluid levels. No free air. Hint: There is an important clue in the physical exam! Bledsoe, DO, FACEP Midlothian, TX Re: Interesting Case With this new info, I still hold my previous cards - Obstruction vs. bezoar; but I also want to add bowel infarct, too. No evil can happen to a good man, either in life or after death. Plato (428 BC - 348 BC), Dialogues, Apology Larry RN NREMTP Nurse, Teacher, Medic Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 IVP negative (couldn't get IVP until patient was rehydrated). No hematuria. Normal GU (penis, testicles, prostate, epididymis). No femoral or inguinal hernias. Bledsoe, DO, FACEP Midlothian, TX Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Did the guy survive? The clue has to be... CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. I'm taking a shot in the dark. Was this guy experiencing a thoracic-aortic aneurysm? Donn Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 Did the guy survive? Yes, as far as I know he is somewhere in Odessa hoping to be a CISM debriefer. The clue has to be... CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. I'm taking a shot in the dark. Was this guy experiencing a thoracic-aortic aneurysm? No. Donn Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 No aneurysm. Bledsoe, DO, FACEP Midlothian, TX Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 20, 2003 Report Share Posted February 20, 2003 I'm back to the chili. Or else the CISM gave him gas. Donn Re: Interesting Case An acute appendix. Interesting Case Since everybody is throwing out interesting cases, here is a case from my internship in West Texas in 1987: 22 year old male with nausea and vomiting calls EMS. They administer Phenergan and fluids and take to the ED. In the ED, his work-up is unremarkable except a slightly elevated white blood cell count that the ED attending felt was due to the vomiting. After 2 liters of saline and some additional Phenergan, the patient is sent home. 30 hours later, at 3:00 AM, he summons EMS. He has had 12 hours of nausea and vomiting and complains of abdominal pain. Paramedics start another IV and transport him to the ED In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 (consistent with dehydration). Liver function tests are normal. Gall Bladder sonogram is normal. A flat and upright abdominal x-ray is normal as is the CXR (per the radiologist). On physical exam: HEENT: Mucosa dry. No icterus CHEST: Heart sounds diminished. Bilateral rhonchi that clear with coughing. ABD: Markedly diminished bowel sounds. No bruising. No CVA or flank tenderness. Maked left lower quadrant tenderness with a hint of rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. GU: Normal male. No torsion. EXT: Normal. Pulses equal. No edema NEURO: Normal. CNII-XII intact. Normal motor ands sensory. Gait testing painful. Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 99% o 2 LPM. Surgeon sees patient and decides to let the illness declare itself. The next morning, the patient is sicker and we take him to surgery and find what? Bledsoe, DO, FACEP Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 Ok doc...I'm gonna throw this one out here because I believe I've heard this one before--but maybe I'm totally wrong. Is it possible he has a bowl perferation from a foreign object he put in his anus that got lost?? If this is the case I read about, it was a bic pen specifically. My other guess would go with the diverticulitis. In a message dated 2/20/2003 10:02:50 PM Eastern Standard Time, donn@... writes: > Mark, > > In my experience I've never encountered a patient this young with > diverticulitis, but the literature corroborates your point. Still, I think > it is probably unusual enough that we should consider other possibilities. > > The good Doctor mentions that this case is from his internship in West Texas > in the mid-80's. I wonder if there is any possibility that this young man > somehow became infected with brucelosis? Time and geography would be about > right. > > Best regards, > D.E. (Donn) . LP, REMT-P > > ========================== > Make plans now to attend the 2nd annual > " Gene Weatherall Memorial EMS Reunion & Chili Cook-off " > Commonly known as " EMSTOCK 2003 " > May 9 - 10 - 11, 2003 > Midlothian, Texas > All public health and public safety workers welcome! > http://www.emstock.com > For information contact donn@... > ========================== > > > > Re:RE: Interesting Case > > > I had a friend in the service (USCG) 23 y/o male diagnosed and treated for > diverticulitis. I don't think it is completely age oriented. > > > Mark Holcombe, EMTP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 Ok....I retract my last guess LOL If the guy survived, then it wasn't the case I was thinking of. So--next guess from here would be pulmonary emboli? What was the deal with the physical exam? Did he have any contusions etc? Any sub cutaneous emphysema? Is he a drug user? Does he smoke? Ummm....dang...more hints please. Dana In a message dated 2/20/2003 11:23:04 PM Eastern Standard Time, mreed_911@... writes: > And my guess would be hypotension-related bowel ischemia precipitated by > adrenal insufficiency. > > Wild guess. > > Rule out? Pancreatitis. AST/ALT/Amylase/Lipase? > > Mike > > --- " D.E. (Donn) " wrote: > > Did the guy survive? > > > > The clue has to be... CHEST: Heart sounds diminished. Bilateral rhonchi > > that clear with coughing. > > > > I'm taking a shot in the dark. Was this guy experiencing a > > thoracic-aortic > > aneurysm? > > > > Donn > > > > Re: Interesting Case > > > > An acute appendix. > > Interesting Case > > > > > > Since everybody is throwing out interesting cases, here is a case from > > my > > internship in West Texas in 1987: > > > > > > > > 22 year old male with nausea and vomiting calls EMS. They administer > > Phenergan and fluids and take to the ED. In the ED, his work-up is > > unremarkable except a slightly elevated white blood cell count that > > the ED > > attending felt was due to the vomiting. After 2 liters of saline and > > some > > additional Phenergan, the patient is sent home. 30 hours later, at > > 3:00 > > AM, > > he summons EMS. He has had 12 hours of nausea and vomiting and > > complains > > of > > abdominal pain. Paramedics start another IV and transport him to the > > ED > > > > > > > > In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H > > is > > OK. His electrolytes are normal except a BUN of 61 and a Creatinine of > > 1.1 > > (consistent with dehydration). Liver function tests are normal. Gall > > Bladder > > sonogram is normal. A flat and upright abdominal x-ray is normal as is > > the > > CXR (per the radiologist). On physical exam: > > > > HEENT: Mucosa dry. No icterus > > > > CHEST: Heart sounds diminished. Bilateral rhonchi that > > clear > > with coughing. > > > > ABD: Markedly diminished bowel sounds. No bruising. No CVA > > or > > flank tenderness. Maked left lower quadrant tenderness with a hint of > > rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. > > > > GU: Normal male. No torsion. > > > > EXT: Normal. Pulses equal. No edema > > > > NEURO: Normal. CNII-XII intact. Normal motor ands sensory. > > Gait > > testing painful. > > > > Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, > > SpO2 > > 99% o 2 LPM. > > > > > > > > Surgeon sees patient and decides to let the illness declare itself. > > The > > next morning, the patient is sicker and we take him to surgery and > > find > > what? > > > > > > > > Bledsoe, DO, FACEP > > > > Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 Ok....I retract my last guess LOL If the guy survived, then it wasn't the case I was thinking of. So--next guess from here would be pulmonary emboli? NO What was the deal with the physical exam? Find it! Did he have any contusions etc? No Any subcutaneous emphysema? No Is he a drug user? No Does he smoke? Yes (1 pack a day--he says) Ummm....dang...more hints please. Dana In a message dated 2/20/2003 11:23:04 PM Eastern Standard Time, mreed_911@... writes: > And my guess would be hypotension-related bowel ischemia precipitated by > adrenal insufficiency. > > Wild guess. > > Rule out? Pancreatitis. AST/ALT/Amylase/Lipase? > > Mike > > --- " D.E. (Donn) " wrote: > > Did the guy survive? > > > > The clue has to be... CHEST: Heart sounds diminished. Bilateral rhonchi > > that clear with coughing. > > > > I'm taking a shot in the dark. Was this guy experiencing a > > thoracic-aortic > > aneurysm? > > > > Donn > > > > Re: Interesting Case > > > > An acute appendix. > > Interesting Case > > > > > > Since everybody is throwing out interesting cases, here is a case from > > my > > internship in West Texas in 1987: > > > > > > > > 22 year old male with nausea and vomiting calls EMS. They administer > > Phenergan and fluids and take to the ED. In the ED, his work-up is > > unremarkable except a slightly elevated white blood cell count that > > the ED > > attending felt was due to the vomiting. After 2 liters of saline and > > some > > additional Phenergan, the patient is sent home. 30 hours later, at > > 3:00 > > AM, > > he summons EMS. He has had 12 hours of nausea and vomiting and > > complains > > of > > abdominal pain. Paramedics start another IV and transport him to the > > ED > > > > > > > > In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H > > is > > OK. His electrolytes are normal except a BUN of 61 and a Creatinine of > > 1.1 > > (consistent with dehydration). Liver function tests are normal. Gall > > Bladder > > sonogram is normal. A flat and upright abdominal x-ray is normal as is > > the > > CXR (per the radiologist). On physical exam: > > > > HEENT: Mucosa dry. No icterus > > > > CHEST: Heart sounds diminished. Bilateral rhonchi that > > clear > > with coughing. > > > > ABD: Markedly diminished bowel sounds. No bruising. No CVA > > or > > flank tenderness. Maked left lower quadrant tenderness with a hint of > > rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. > > > > GU: Normal male. No torsion. > > > > EXT: Normal. Pulses equal. No edema > > > > NEURO: Normal. CNII-XII intact. Normal motor ands sensory. > > Gait > > testing painful. > > > > Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, > > SpO2 > > 99% o 2 LPM. > > > > > > > > Surgeon sees patient and decides to let the illness declare itself. > > The > > next morning, the patient is sicker and we take him to surgery and > > find > > what? > > > > > > > > Bledsoe, DO, FACEP > > > > Midlothian, TX Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 no Re:RE: Interesting Case > > > I had a friend in the service (USCG) 23 y/o male diagnosed and treated for > diverticulitis. I don't think it is completely age oriented. > > > Mark Holcombe, EMTP Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 Could it possibly be one of the carditis's, endo, peri. ect. " Dr. Bledsoe " wrote: > What is his history? Normal guy until he became ill, about 3 days before > admission. > > Is he taking any meds? None prior to admission. > > What is his ethnicity? Mexican-American Male > > Family Hx: Diabetes, hypercholesterolemia > > of SCA? No hx of sick as hell anemia > > What has he been eating/drinking? Nothing remarkable--not alcoholic--social > drinker > > Can he localize the pain? LLQ > > What is his urinary frequency and output? Decreased secondary to dehydration > > Is there hematuria? No > > Is there drowsiness, fatigue, lethargy? No > > You will have to explain to me what is meant by a " left shift " in the WBC. > An increase in neutrophils and immature forms (segs) associated with > infection, usually bacterial, although stress and vomiting (which is stress) > can cause it. > > Bledsoe, DO, FACEP > Midlothian, TX > > Re: Interesting Case > > An acute appendix. > Interesting Case > > Since everybody is throwing out interesting cases, here is a case from my > internship in West Texas in 1987: > > 22 year old male with nausea and vomiting calls EMS. They administer > Phenergan and fluids and take to the ED. In the ED, his work-up is > unremarkable except a slightly elevated white blood cell count that the ED > attending felt was due to the vomiting. After 2 liters of saline and some > additional Phenergan, the patient is sent home. 30 hours later, at 3:00 > AM, > he summons EMS. He has had 12 hours of nausea and vomiting and complains > of > abdominal pain. Paramedics start another IV and transport him to the ED > > In the ED he appears toxic. His WBC is 17.6 with a left shift. His H & H is > OK. His electrolytes are normal except a BUN of 61 and a Creatinine of 1.1 > (consistent with dehydration). Liver function tests are normal. Gall > Bladder > sonogram is normal. A flat and upright abdominal x-ray is normal as is the > CXR (per the radiologist). On physical exam: > > HEENT: Mucosa dry. No icterus > > CHEST: Heart sounds diminished. Bilateral rhonchi that clear > with coughing. > > ABD: Markedly diminished bowel sounds. No bruising. No CVA or > flank tenderness. Maked left lower quadrant tenderness with a hint of > rebound. No Psoas sign. Rectal unremarkable and Hemocult negative. > > GU: Normal male. No torsion. > > EXT: Normal. Pulses equal. No edema > > NEURO: Normal. CNII-XII intact. Normal motor ands sensory. > Gait > testing painful. > > Vitals: 110/60, Pulse 130, respirations 20, Temp 100.9 F, SpO2 > 99% o 2 LPM. > > Surgeon sees patient and decides to let the illness declare itself. The > next morning, the patient is sicker and we take him to surgery and find > what? > > Bledsoe, DO, FACEP > > Midlothian, TX > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 A volvulus with diaphramatic rupture- my total stab in the dark. Quote Link to comment Share on other sites More sharing options...
Guest guest Posted February 21, 2003 Report Share Posted February 21, 2003 When was his last BM? Possibly Gastroenteritis or intestinal parasite? ------------------------------------------------- Alan M. , AAS, L.P. Rural Health/Rural EMS Specialist Office of Rural Community Affairs P.O.Box 12877 Austin, Texas 78711-2877 Phone: Fax: Toll Free 1- Email: alewis@... I Thessalonians 5:28 Quote Link to comment Share on other sites More sharing options...
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