Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, wegandy1938@... writes: 44 year old male calls 911 complaining of dizziness, nausea, and vomiting for the last four days. Save for the 9-1-1 call you just described me after yesterday. Louis N. Molino, Sr., CET FF/NREMT-B/FSI/EMSI Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant LNMolino@... (Cell Phone) (IFW/FSS Office)/ (IFWF/SS Fax) " A Texan with a Jersey Attitude " " Great minds discuss ideas; Average minds discuss events; Small minds discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) The comments contained in this E-mail are the opinions of the author and the author alone. I in no way ever intend to speak for any person or organization that I am in any way whatsoever involved or associated with unless I specifically state that I am doing so. Further this E-mail is intended only for its stated recipient and may contain private and or confidential materials retransmission is strictly prohibited unless placed in the public domain by the original author. **************Dell Days of Deals! June 15-24 - A New Deal Everyday! (http://pr.atwola.com/promoclk/100126575x1222677718x1201465083/aol?redir=http:%2\ F%2F ad.doubleclick.net%2Fclk%3B215692163%3B38015526%3Be) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, wegandy1938@... writes: 44 year old male calls 911 complaining of dizziness, nausea, and vomiting for the last four days. Save for the 9-1-1 call you just described me after yesterday. Louis N. Molino, Sr., CET FF/NREMT-B/FSI/EMSI Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant LNMolino@... (Cell Phone) (IFW/FSS Office)/ (IFWF/SS Fax) " A Texan with a Jersey Attitude " " Great minds discuss ideas; Average minds discuss events; Small minds discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) The comments contained in this E-mail are the opinions of the author and the author alone. I in no way ever intend to speak for any person or organization that I am in any way whatsoever involved or associated with unless I specifically state that I am doing so. Further this E-mail is intended only for its stated recipient and may contain private and or confidential materials retransmission is strictly prohibited unless placed in the public domain by the original author. **************Dell Days of Deals! June 15-24 - A New Deal Everyday! (http://pr.atwola.com/promoclk/100126575x1222677718x1201465083/aol?redir=http:%2\ F%2F ad.doubleclick.net%2Fclk%3B215692163%3B38015526%3Be) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, wegandy1938@... writes: 44 year old male calls 911 complaining of dizziness, nausea, and vomiting for the last four days. Save for the 9-1-1 call you just described me after yesterday. Louis N. Molino, Sr., CET FF/NREMT-B/FSI/EMSI Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant LNMolino@... (Cell Phone) (IFW/FSS Office)/ (IFWF/SS Fax) " A Texan with a Jersey Attitude " " Great minds discuss ideas; Average minds discuss events; Small minds discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) The comments contained in this E-mail are the opinions of the author and the author alone. I in no way ever intend to speak for any person or organization that I am in any way whatsoever involved or associated with unless I specifically state that I am doing so. Further this E-mail is intended only for its stated recipient and may contain private and or confidential materials retransmission is strictly prohibited unless placed in the public domain by the original author. **************Dell Days of Deals! June 15-24 - A New Deal Everyday! (http://pr.atwola.com/promoclk/100126575x1222677718x1201465083/aol?redir=http:%2\ F%2F ad.doubleclick.net%2Fclk%3B215692163%3B38015526%3Be) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 Joe, Your questions answered below. Gene > > > > What has he been eating the last few days, > GG: Since he has been unable to keep food down, he has been essentially fasting for the last few days > any history of gallbladder > trouble, > GG: No history of gallbladder trouble. > > > stool characteristics (diarrhea, bloody? constipation, unsual > colors, any changes in bowel habits), > GG: Stools normal, no blood, not clay colored, diarrhea, not constipation. > what's the emesis look like? > GG: The food he ate. > When you > say " Well nourished " are you being polite? > GG: Nope. Not being polite. Just a normal 44 year old. Neither skinny nor obese. > > Jaundice occurs when the body cannot eliminate bilirubin. Through a long > pathway it eventually ends up in bile, and can accumulate in the body if > there's an obstruction in the biliary tree. > GG: Indeed. > > A common cause would be gallstones, which is my preliminary guess until > further information becomes available. > GG: Great guess, but no prize this time. Keep trying. > > Joe Percer, LP > > > > > > > > > Hello boys and girls. > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > thought you could. > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > vomiting > > for the last four days. > > > > On arrival you find an overall normal looking male who says he has been > > dizzy, has had nausea and vomiting for four days and not able to keep > much > > of > > anything down. > > > > He takes lisinopril for mild hypertension and a baby aspirin every day > at > > his doctor's suggestion. He denies allergies, any significant past > medical > > history, and any provoking causes. > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > except > > > > for some jaundice that shows up in the sclera and conjunctiva, breath > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > tenderness in > > the supraumbilical region to palpation, which the patient describes as > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > Psoas, > > obturator, and Rovsing's signs are negative. Torso appears slightly > > jaundiced. > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > > 99.8 F. > > > > What's most likely wrong with this patient? Of what significance is the > > jaundice? > > > > What questions can you ask to get a better history? > > > > Gene G. > > > > > > ************ * > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > ( > > > http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.http://p\ rht > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 WOW, Lou. Take care of yourself. Gene > > > > In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, > wegandy1938@wegandy writes: > > 44 year old male calls 911 complaining of dizziness, nausea, and vomiting > for the last four days. > Save for the 9-1-1 call you just described me after yesterday. > > Louis N. Molino, Sr., CET > FF/NREMT-B/FSI/ FF/ > Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine > > LNMolino@... > > (Cell Phone) > (IFW/FSS Office)/ > (IFWF/SS Fax) > > " A Texan with a Jersey Attitude " > > " Great minds discuss ideas; Average minds discuss events; Small minds > discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) > > The comments contained in this E-mail are the opinions of the author and > the author alone. I in no way ever intend to speak for any person or > organization that I am in any way whatsoever involved or associated with > unless I > specifically state that I am doing so. Further this E-mail is intended > only > for its stated recipient and may contain private and or confidential > materials retransmission is strictly prohibited unless placed in the > public > domain by the original author. > > ************ ************ **Dell Days of Deals! June 15-24 - A N > ( > http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.http://p\ rht > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 WOW, Lou. Take care of yourself. Gene > > > > In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, > wegandy1938@wegandy writes: > > 44 year old male calls 911 complaining of dizziness, nausea, and vomiting > for the last four days. > Save for the 9-1-1 call you just described me after yesterday. > > Louis N. Molino, Sr., CET > FF/NREMT-B/FSI/ FF/ > Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine > > LNMolino@... > > (Cell Phone) > (IFW/FSS Office)/ > (IFWF/SS Fax) > > " A Texan with a Jersey Attitude " > > " Great minds discuss ideas; Average minds discuss events; Small minds > discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) > > The comments contained in this E-mail are the opinions of the author and > the author alone. I in no way ever intend to speak for any person or > organization that I am in any way whatsoever involved or associated with > unless I > specifically state that I am doing so. Further this E-mail is intended > only > for its stated recipient and may contain private and or confidential > materials retransmission is strictly prohibited unless placed in the > public > domain by the original author. > > ************ ************ **Dell Days of Deals! June 15-24 - A N > ( > http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.http://p\ rht > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 It was a JOKE gene I did turn 44 yesterday and I DO FEEL OLD but that's more from the 30 hour days and dealing with contract stuff which I hate (the money makes it worth it). Louis N. Molino, Sr., CET FF/NREMT-B/FSI/EMSI Freelance Consultant/Trainer/Author/Journalist/Fire Protection Consultant LNMolino@... (Cell Phone) (IFW/FSS Office)/ (IFWF/SS Fax) " A Texan with a Jersey Attitude " " Great minds discuss ideas; Average minds discuss events; Small minds discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) The comments contained in this E-mail are the opinions of the author and the author alone. I in no way ever intend to speak for any person or organization that I am in any way whatsoever involved or associated with unless I specifically state that I am doing so. Further this E-mail is intended only for its stated recipient and may contain private and or confidential materials retransmission is strictly prohibited unless placed in the public domain by the original author. In a message dated 6/18/2009 10:17:34 P.M. Central Daylight Time, wegandy1938@... writes: WOW, Lou. Take care of yourself. Gene > > > > In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, > wegandy1938@wegandy writes: > > 44 year old male calls 911 complaining of dizziness, nausea, and vomiting > for the last four days. > Save for the 9-1-1 call you just described me after yesterday. > > Louis N. Molino, Sr., CET > FF/NREMT-B/FSI/ FF/ > Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine > > LNMolino@... > > (Cell Phone) > (IFW/FSS Office)/ > (IFWF/SS Fax) > > " A Texan with a Jersey Attitude " > > " Great minds discuss ideas; Average minds discuss events; Small minds > discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) > > The comments contained in this E-mail are the opinions of the author and > the author alone. I in no way ever intend to speak for any person or > organization that I am in any way whatsoever involved or associated with > unless I > specifically state that I am doing so. Further this E-mail is intended > only > for its stated recipient and may contain private and or confidential > materials retransmission is strictly prohibited unless placed in the > public > domain by the original author. > > ************ ************ **Dell Days of Deals! June 15-24 - A N > ( > http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.http://p\ rht > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 So are you here or off in Berzerkistan or somewhere? GG > > > > It was a JOKE gene I did turn 44 yesterday and I DO FEEL OLD but that's > more from the 30 hour days and dealing with contract stuff which I hate > (the > money makes it worth it). > > > > Louis N. Molino, Sr., CET > FF/NREMT-B/FSI/ FF/ > Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine > > LNMolino@... > > (Cell Phone) > (IFW/FSS Office)/ > (IFWF/SS Fax) > > " A Texan with a Jersey Attitude " > > " Great minds discuss ideas; Average minds discuss events; Small minds > discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) > > The comments contained in this E-mail are the opinions of the author and > the author alone. I in no way ever intend to speak for any person or > organization that I am in any way whatsoever involved or associated with > unless I > specifically state that I am doing so. Further this E-mail is intended > only > for its stated recipient and may contain private and or confidential > materials retransmission is strictly prohibited unless placed in the > public > domain by the original author. > > In a message dated 6/18/2009 10:17:34 P.M. Central Daylight Time, > wegandy1938@wegandy writes: > > WOW, Lou. Take care of yourself. > > Gene > > > > > > > > > > In a message dated 6/18/2009 9:00:42 P.M. Central Daylight Time, > > wegandy1938@ wegandy1938@ > > > 44 year old male calls 911 complaining of dizziness, nausea, and > vomiting > > for the last four days. > > Save for the 9-1-1 call you just described me after yesterday. > > > > Louis N. Molino, Sr., CET > > FF/NREMT-B/FSI/ FF/ > > Freelance Consultant/Trainer/ Freelance Cons Freelance Consultant/Traine > > > > LNMolino@... > > > > (Cell Phone) > > (IFW/FSS Office)/ > > (IFWF/SS Fax) > > > > " A Texan with a Jersey Attitude " > > > > " Great minds discuss ideas; Average minds discuss events; Small minds > > discuss people " Eleanor Roosevelt - US diplomat & reformer (1884 - 1962) > > > > The comments contained in this E-mail are the opinions of the author and > > the author alone. I in no way ever intend to speak for any person or > > organization that I am in any way whatsoever involved or associated with > > unless I > > specifically state that I am doing so. Further this E-mail is intended > > only > > for its stated recipient and may contain private and or confidential > > materials retransmission is strictly prohibited unless placed in the > > public > > domain by the original author. > > > > ************ ************ **Dell Days of Deals! June 15-24 - A N > > ( > > > > http://pr.atwola.http://pr.http://prhttp://pr.atwolhttp://pr.atwolahttp://pr.htt\ p:/ > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 18, 2009 Report Share Posted June 18, 2009 What has he been eating the last few days, any history of gallbladder trouble, stool characteristics (diarrhea, bloody? constipation, unsual colors, any changes in bowel habits), what's the emesis look like? When you say " Well nourished " are you being polite? Jaundice occurs when the body cannot eliminate bilirubin. Through a long pathway it eventually ends up in bile, and can accumulate in the body if there's an obstruction in the biliary tree. A common cause would be gallstones, which is my preliminary guess until further information becomes available. Joe Percer, LP > > > Hello boys and girls. > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > thought you could. > > 44 year old male calls 911 complaining of dizziness, nausea, and vomiting > for the last four days. > > On arrival you find an overall normal looking male who says he has been > dizzy, has had nausea and vomiting for four days and not able to keep much > of > anything down. > > He takes lisinopril for mild hypertension and a baby aspirin every day at > his doctor's suggestion. He denies allergies, any significant past medical > history, and any provoking causes. > > Your physical exam reveals a well nourished male, HEENT unremarkable except > > for some jaundice that shows up in the sclera and conjunctiva, breath > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > tenderness in > the supraumbilical region to palpation, which the patient describes as > soreness from throwing up. No Cullen's sign. No rebound tenderness. Psoas, > obturator, and Rovsing's signs are negative. Torso appears slightly > jaundiced. > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > 99.8 F. > > What's most likely wrong with this patient? Of what significance is the > jaundice? > > What questions can you ask to get a better history? > > Gene G. > > > ************** > Dell Days of Deals! June 15-24 - A New Deal Everyday! > ( > http://pr.atwola.com/promoclk/100126575x1222677718x1201465083/aol?redir=http:%2F\ %2F > ad.doubleclick.net%2Fclk%3B215692163%3B38015526%3Be) > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 Gene, I would like to know how long he has been ill, and see if there is any history of blood transfusions or anemia. I had a patient recently that had a history of hyperbilirubinemia, and had a bunch of blood transfusions. This patient has most of the s/s that your patient does. Ron In a message dated 6/18/2009 9:00:51 P.M. Central Daylight Time, wegandy1938@... writes: What's most likely wrong with this patient? Of what significance is the jaundice? What questions can you ask to get a better history? **************Download the AOL Classifieds Toolbar for local deals at your fingertips. (http://toolbar.aol.com/aolclassifieds/download.html?ncid=emlcntusdown00000004) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 Gene, I would like to know how long he has been ill, and see if there is any history of blood transfusions or anemia. I had a patient recently that had a history of hyperbilirubinemia, and had a bunch of blood transfusions. This patient has most of the s/s that your patient does. Ron In a message dated 6/18/2009 9:00:51 P.M. Central Daylight Time, wegandy1938@... writes: What's most likely wrong with this patient? Of what significance is the jaundice? What questions can you ask to get a better history? **************Download the AOL Classifieds Toolbar for local deals at your fingertips. (http://toolbar.aol.com/aolclassifieds/download.html?ncid=emlcntusdown00000004) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 Gene, I would like to know how long he has been ill, and see if there is any history of blood transfusions or anemia. I had a patient recently that had a history of hyperbilirubinemia, and had a bunch of blood transfusions. This patient has most of the s/s that your patient does. Ron In a message dated 6/18/2009 9:00:51 P.M. Central Daylight Time, wegandy1938@... writes: What's most likely wrong with this patient? Of what significance is the jaundice? What questions can you ask to get a better history? **************Download the AOL Classifieds Toolbar for local deals at your fingertips. (http://toolbar.aol.com/aolclassifieds/download.html?ncid=emlcntusdown00000004) Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 interesting puzzler.... Good old SAMPLE history always does the trick. But from the information maybe this person is on some type of treatment for hepatitis that may be interacting with the medications causing an unlikely effect on the patient. Maybe hepatic toxicity. > > > Hello boys and girls. > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > thought you could. > > 44 year old male calls 911 complaining of dizziness, nausea, and vomiting > for the last four days. > > On arrival you find an overall normal looking male who says he has been > dizzy, has had nausea and vomiting for four days and not able to keep much > of > anything down. > > He takes lisinopril for mild hypertension and a baby aspirin every day at > his doctor's suggestion. He denies allergies, any significant past medical > history, and any provoking causes. > > Your physical exam reveals a well nourished male, HEENT unremarkable except > > for some jaundice that shows up in the sclera and conjunctiva, breath > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > tenderness in > the supraumbilical region to palpation, which the patient describes as > soreness from throwing up. No Cullen's sign. No rebound tenderness. Psoas, > obturator, and Rovsing's signs are negative. Torso appears slightly > jaundiced. > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > 99.8 F. > > What's most likely wrong with this patient? Of what significance is the > jaundice? > > What questions can you ask to get a better history? > > Gene G. > > > ************** > Dell Days of Deals! June 15-24 - A New Deal Everyday! > ( > http://pr.atwola.com/promoclk/100126575x1222677718x1201465083/aol?redir=http:%2F\ %2F > ad.doubleclick.net%2Fclk%3B215692163%3B38015526%3Be) > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 Gene, How long has he been taking the lisinopril? What is the dose of the lisinopirl? Given history of lisionpril usage, have a high suspicion of cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > Hello boys and girls. > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > thought you could. > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > vomiting > > for the last four days. > > > > On arrival you find an overall normal looking male who says he has been > > dizzy, has had nausea and vomiting for four days and not able to keep > much > > of > > anything down. > > > > He takes lisinopril for mild hypertension and a baby aspirin every day > at > > his doctor's suggestion. He denies allergies, any significant past > medical > > history, and any provoking causes. > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > except > > > > for some jaundice that shows up in the sclera and conjunctiva, breath > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > tenderness in > > the supraumbilical region to palpation, which the patient describes as > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > Psoas, > > obturator, and Rovsing's signs are negative. Torso appears slightly > > jaundiced. > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > > 99.8 F. > > > > What's most likely wrong with this patient? Of what significance is the > > jaundice? > > > > What questions can you ask to get a better history? > > > > Gene G. > > > > > > ************ * > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > ( > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: //pr.atwolahttp: //pr.http: //prht > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 Answers below. GG > > > > Gene, > > I would like to know how long he has been ill, and see if there is any > history of blood transfusions or anemia. > Began having nausea/vomiting/diarrhea after a church " potluck " social about 4 days ago. Hasn't been able to keep anything down since. No hx of blood tx or anemia. > > I had a patient recently that had a history of hyperbilirubinemia, and had > a bunch of blood transfusions. > This patient has most of the s/s that your patient does. > > Ron > > > In a message dated 6/18/2009 9:00:51 P.M. Central Daylight Time, > wegandy1938@wegandy writes: > > What's most likely wrong with this patient? Of what significance is the > jaundice? > > What questions can you ask to get a better history? > > > ************ ************ **Download the AOL Classifieds Toolbar for > lo > fingertips. > ( > http://toolbar.http://toolbar.http://toolbar.http://toohttp://toolbar.http) > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 Good thoughts. A good SAMPLE hx will disclose that he has chronic bilirubinuria and no hx of hepatitis. GG > > > > interesting puzzler.... > > Good old SAMPLE history always does the trick. But from the information > maybe this person is on some type of treatment for hepatitis that may be > interacting with the medications causing an unlikely effect on the > patient. Maybe hepatic toxicity. > > > > > > > > > Hello boys and girls. > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > thought you could. > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > vomiting > > for the last four days. > > > > On arrival you find an overall normal looking male who says he has been > > dizzy, has had nausea and vomiting for four days and not able to keep > much > > of > > anything down. > > > > He takes lisinopril for mild hypertension and a baby aspirin every day > at > > his doctor's suggestion. He denies allergies, any significant past > medical > > history, and any provoking causes. > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > except > > > > for some jaundice that shows up in the sclera and conjunctiva, breath > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > tenderness in > > the supraumbilical region to palpation, which the patient describes as > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > Psoas, > > obturator, and Rovsing's signs are negative. Torso appears slightly > > jaundiced. > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > > 99.8 F. > > > > What's most likely wrong with this patient? Of what significance is the > > jaundice? > > > > What questions can you ask to get a better history? > > > > Gene G. > > > > > > ************ * > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > ( > > > http://pr.atwola.http://pr.atwhttp://pr.atwolahttp://pr.atwolahttp://pr.http://p\ rht > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 19, 2009 Report Share Posted June 19, 2009 He takes 10 mg qd of lisinopril. Great idea about the cholestatic jaundice, which would, indeed, be a major emergency. But it's not that. It's much simpler. In another post I gave a major hint. He has chronic bilirubinemia and bilirubinuria. Hint, since you've done so much thinking about this: In this case there are both horses and a zebra. (Remember the saying, " When you hear hoofbeats, look for horses, not zebras? " GG > > > > Gene, > How long has he been taking the lisinopril? What is the dose of the > lisinopirl? Given history of lisionpril usage, have a high suspicion of > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > Hello boys and girls. > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > > thought you could. > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > vomiting > > > for the last four days. > > > > > > On arrival you find an overall normal looking male who says he has > been > > > dizzy, has had nausea and vomiting for four days and not able to keep > > much > > > of > > > anything down. > > > > > > He takes lisinopril for mild hypertension and a baby aspirin every day > > at > > > his doctor's suggestion. He denies allergies, any significant past > > medical > > > history, and any provoking causes. > > > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > > except > > > > > > for some jaundice that shows up in the sclera and conjunctiva, breath > > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > > tenderness in > > > the supraumbilical region to palpation, which the patient describes as > > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > > Psoas, > > > obturator, and Rovsing's signs are negative. Torso appears slightly > > > jaundiced. > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > > > 99.8 F. > > > > > > What's most likely wrong with this patient? Of what significance is > the > > > jaundice? > > > > > > What questions can you ask to get a better history? > > > > > > Gene G. > > > > > > > > > ************ * > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > ( > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: //pr.atwolahttp: > //pr.http: //prht > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 I am thinking,ASA is causing Acute Hemolytic Anemia. The spleen is painful due to anlargement and the body cannot eliminate the bili fast enough. Nausea/vomiting is being caused by the K+ released due to the hemolysis. > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > > > thought you could. > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > vomiting > > > > for the last four days. > > > > > > > > On arrival you find an overall normal looking male who says he has > > been > > > > dizzy, has had nausea and vomiting for four days and not able to keep > > > much > > > > of > > > > anything down. > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin every day > > > at > > > > his doctor's suggestion. He denies allergies, any significant past > > > medical > > > > history, and any provoking causes. > > > > > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > > > except > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, breath > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > > > tenderness in > > > > the supraumbilical region to palpation, which the patient describes as > > > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > > > Psoas, > > > > obturator, and Rovsing's signs are negative. Torso appears slightly > > > > jaundiced. > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > > > > 99.8 F. > > > > > > > > What's most likely wrong with this patient? Of what significance is > > the > > > > jaundice? > > > > > > > > What questions can you ask to get a better history? > > > > > > > > Gene G. > > > > > > > > > > > > ************ * > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > ( > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: //pr.atwolahttp: > > //pr.http: //prht > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 Does he have an obstruction? hjb Re: A new puzzler He takes 10 mg qd of lisinopril. Great idea about the cholestatic jaundice, which would, indeed, be a major emergency. But it's not that. It's much simpler. In another post I gave a major hint. He has chronic bilirubinemia and bilirubinuria. Hint, since you've done so much thinking about this: In this case there are both horses and a zebra. (Remember the saying, " When you hear hoofbeats, look for horses, not zebras? " GG > > > > Gene, > How long has he been taking the lisinopril? What is the dose of the > lisinopirl? Given history of lisionpril usage, have a high suspicion of > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > Hello boys and girls. > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > > thought you could. > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > vomiting > > > for the last four days. > > > > > > On arrival you find an overall normal looking male who says he has > been > > > dizzy, has had nausea and vomiting for four days and not able to keep > > much > > > of > > > anything down. > > > > > > He takes lisinopril for mild hypertension and a baby aspirin every day > > at > > > his doctor's suggestion. He denies allergies, any significant past > > medical > > > history, and any provoking causes. > > > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > > except > > > > > > for some jaundice that shows up in the sclera and conjunctiva, breath > > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > > tenderness in > > > the supraumbilical region to palpation, which the patient describes as > > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > > Psoas, > > > obturator, and Rovsing's signs are negative. Torso appears slightly > > > jaundiced. > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, temp. > > > 99.8 F. > > > > > > What's most likely wrong with this patient? Of what significance is > the > > > jaundice? > > > > > > What questions can you ask to get a better history? > > > > > > Gene G. > > > > > > > > > ************ * > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > ( > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: //pr.atwolahttp: > //pr.http: //prht > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 Good thinking, but it's not what's happening. The patient's hemoglobin and hematocrit are within normal limits. Hint: look for a non-acute cause. GG > > > > I am thinking,ASA is causing Acute Hemolytic Anemia. The spleen is painful > due to anlargement and the body cannot eliminate the bili fast enough. > > Nausea/vomiting is being caused by the K+ released due to the hemolysis. > > > > > > > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > > > > thought you could. > > > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > > vomiting > > > > > for the last four days. > > > > > > > > > > On arrival you find an overall normal looking male who says he has > > > been > > > > > dizzy, has had nausea and vomiting for four days and not able to > keep > > > > much > > > > > of > > > > > anything down. > > > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin every > day > > > > at > > > > > his doctor's suggestion. He denies allergies, any significant past > > > > medical > > > > > history, and any provoking causes. > > > > > > > > > > Your physical exam reveals a well nourished male, HEENT > unremarkable > > > > except > > > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, > breath > > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > > > > tenderness in > > > > > the supraumbilical region to palpation, which the patient > describes as > > > > > soreness from throwing up. No Cullen's sign. No rebound > tenderness. > > > > Psoas, > > > > > obturator, and Rovsing's signs are negative. Torso appears > slightly > > > > > jaundiced. > > > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, > temp. > > > > > 99.8 F. > > > > > > > > > > What's most likely wrong with this patient? Of what significance > is > > > the > > > > > jaundice? > > > > > > > > > > What questions can you ask to get a better history? > > > > > > > > > > Gene G. > > > > > > > > > > > > > > > ************ * > > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > > ( > > > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: > //pr.atwolahttp: > > > //pr.http: //prht > > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 He does not have an obstruction. Look at his past medical history. GG > > > > Does he have an obstruction? > > hjb > Re: A new puzzler > > He takes 10 mg qd of lisinopril. Great idea about the cholestatic > jaundice, > which would, indeed, be a major emergency. But it's not that. It's much > simpler. > > In another post I gave a major hint. He has chronic bilirubinemia and > bilirubinuria. > > Hint, since you've done so much thinking about this: In this case there > are both horses and a zebra. > > (Remember the saying, " When you hear hoofbeats, look for horses, not > zebras? " > > GG > In a message dated 6/19/09 10:54:02 AM, stevenhobbs@stevenhobbste writes: > > > > > > > > > Gene, > > How long has he been taking the lisinopril? What is the dose of the > > lisinopirl? Given history of lisionpril usage, have a high suspicion of > > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > > > thought you could. > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > vomiting > > > > for the last four days. > > > > > > > > On arrival you find an overall normal looking male who says he has > > been > > > > dizzy, has had nausea and vomiting for four days and not able to > keep > > > much > > > > of > > > > anything down. > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin every > day > > > at > > > > his doctor's suggestion. He denies allergies, any significant past > > > medical > > > > history, and any provoking causes. > > > > > > > > Your physical exam reveals a well nourished male, HEENT unremarkable > > > except > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, > breath > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > > > tenderness in > > > > the supraumbilical region to palpation, which the patient describes > as > > > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > > > Psoas, > > > > obturator, and Rovsing's signs are negative. Torso appears slightly > > > > jaundiced. > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, > temp. > > > > 99.8 F. > > > > > > > > What's most likely wrong with this patient? Of what significance is > > the > > > > jaundice? > > > > > > > > What questions can you ask to get a better history? > > > > > > > > Gene G. > > > > > > > > > > > > ************ * > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > ( > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: > //pr.atwolahttp: > > //pr.http: //prht > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 Comments below: GG > > > > Well, > > My differential diagnosis at this point are: > > drug induced hepatitis, > GG: Not hepatitis > liver abscess, > GG: Not liver abscess > some infectious disease process such as hep A or salmonella.. > GG: Yes, SALMONELLA from the bad potato salad at the church social. Now, explain the bilirubinuria and bilirubinemia and you'll have the whole picture. Hint: Does the increased bilirubin have anything to do with the salmonella infection? Could it be a completely different cause? > > Any chance you've got a CT-Abdomen or Liver biopsy floating around in your > brain? How about some Labs, since you know the hemoglobin/hematocr brai > CT of ABD was unremarkable. No liver biopsy done. Urine dipstick positive for bilirubin; blood analysis shows 30 mmol/dL of bilirubin (< 20 normal). Ask the SAMPLE questions and I'll give you the answer, well if you ask them right. LOL. GG > > Any sign of hepatomegaly, or splenomegaly on the physical exam? > > Joe > > > > > > > > > He does not have an obstruction. Look at his past medical history. > > > > GG > > > > In a message dated 6/22/09 6:43:02 AM, hbarber@...< > hbarber%40cableonehbar>writes: > > > > > > > > > > > > > > Does he have an obstruction? > > > > > > hjb > > > Re: A new puzzler > > > > > > He takes 10 mg qd of lisinopril. Great idea about the cholestatic > > > jaundice, > > > which would, indeed, be a major emergency. But it's not that. It's > much > > > simpler. > > > > > > In another post I gave a major hint. He has chronic bilirubinemia and > > > bilirubinuria. > > > > > > Hint, since you've done so much thinking about this: In this case > there > > > are both horses and a zebra. > > > > > > (Remember the saying, " When you hear hoofbeats, look for horses, not > > > zebras? " > > > > > > GG > > > In a message dated 6/19/09 10:54:02 AM, stevenhobbs@ In a message da > In > > > > > > > > > > > > > > > > > > > Gene, > > > > How long has he been taking the lisinopril? What is the dose of the > > > > lisinopirl? Given history of lisionpril usage, have a high suspicion > of > > > > > > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? > I > > > > > > thought you could. > > > > > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > > > vomiting > > > > > > for the last four days. > > > > > > > > > > > > On arrival you find an overall normal looking male who says he > has > > > > been > > > > > > dizzy, has had nausea and vomiting for four days and not able to > > > keep > > > > > much > > > > > > of > > > > > > anything down. > > > > > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin > every > > > day > > > > > at > > > > > > his doctor's suggestion. He denies allergies, any significant > past > > > > > medical > > > > > > history, and any provoking causes. > > > > > > > > > > > > Your physical exam reveals a well nourished male, HEENT > > unremarkable > > > > > except > > > > > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, > > > breath > > > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, > slight > > > > > > tenderness in > > > > > > the supraumbilical region to palpation, which the patient > describes > > > > > as > > > > > > soreness from throwing up. No Cullen's sign. No rebound > tenderness. > > > > > Psoas, > > > > > > obturator, and Rovsing's signs are negative. Torso appears > slightly > > > > > > jaundiced. > > > > > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, > > > temp. > > > > > > 99.8 F. > > > > > > > > > > > > What's most likely wrong with this patient? Of what significance > is > > > > the > > > > > > jaundice? > > > > > > > > > > > > What questions can you ask to get a better history? > > > > > > > > > > > > Gene G. > > > > > > > > > > > > > > > > > > ************ * > > > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > > > ( > > > > > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: > > > //pr.atwolahttp: > > > > //pr.http: //prht > > > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 Comments below: GG > > > > Well, > > My differential diagnosis at this point are: > > drug induced hepatitis, > GG: Not hepatitis > liver abscess, > GG: Not liver abscess > some infectious disease process such as hep A or salmonella.. > GG: Yes, SALMONELLA from the bad potato salad at the church social. Now, explain the bilirubinuria and bilirubinemia and you'll have the whole picture. Hint: Does the increased bilirubin have anything to do with the salmonella infection? Could it be a completely different cause? > > Any chance you've got a CT-Abdomen or Liver biopsy floating around in your > brain? How about some Labs, since you know the hemoglobin/hematocr brai > CT of ABD was unremarkable. No liver biopsy done. Urine dipstick positive for bilirubin; blood analysis shows 30 mmol/dL of bilirubin (< 20 normal). Ask the SAMPLE questions and I'll give you the answer, well if you ask them right. LOL. GG > > Any sign of hepatomegaly, or splenomegaly on the physical exam? > > Joe > > > > > > > > > He does not have an obstruction. Look at his past medical history. > > > > GG > > > > In a message dated 6/22/09 6:43:02 AM, hbarber@...< > hbarber%40cableonehbar>writes: > > > > > > > > > > > > > > Does he have an obstruction? > > > > > > hjb > > > Re: A new puzzler > > > > > > He takes 10 mg qd of lisinopril. Great idea about the cholestatic > > > jaundice, > > > which would, indeed, be a major emergency. But it's not that. It's > much > > > simpler. > > > > > > In another post I gave a major hint. He has chronic bilirubinemia and > > > bilirubinuria. > > > > > > Hint, since you've done so much thinking about this: In this case > there > > > are both horses and a zebra. > > > > > > (Remember the saying, " When you hear hoofbeats, look for horses, not > > > zebras? " > > > > > > GG > > > In a message dated 6/19/09 10:54:02 AM, stevenhobbs@ In a message da > In > > > > > > > > > > > > > > > > > > > Gene, > > > > How long has he been taking the lisinopril? What is the dose of the > > > > lisinopirl? Given history of lisionpril usage, have a high suspicion > of > > > > > > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? > I > > > > > > thought you could. > > > > > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > > > vomiting > > > > > > for the last four days. > > > > > > > > > > > > On arrival you find an overall normal looking male who says he > has > > > > been > > > > > > dizzy, has had nausea and vomiting for four days and not able to > > > keep > > > > > much > > > > > > of > > > > > > anything down. > > > > > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin > every > > > day > > > > > at > > > > > > his doctor's suggestion. He denies allergies, any significant > past > > > > > medical > > > > > > history, and any provoking causes. > > > > > > > > > > > > Your physical exam reveals a well nourished male, HEENT > > unremarkable > > > > > except > > > > > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, > > > breath > > > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, > slight > > > > > > tenderness in > > > > > > the supraumbilical region to palpation, which the patient > describes > > > > > as > > > > > > soreness from throwing up. No Cullen's sign. No rebound > tenderness. > > > > > Psoas, > > > > > > obturator, and Rovsing's signs are negative. Torso appears > slightly > > > > > > jaundiced. > > > > > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, > > > temp. > > > > > > 99.8 F. > > > > > > > > > > > > What's most likely wrong with this patient? Of what significance > is > > > > the > > > > > > jaundice? > > > > > > > > > > > > What questions can you ask to get a better history? > > > > > > > > > > > > Gene G. > > > > > > > > > > > > > > > > > > ************ * > > > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > > > ( > > > > > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: > > > //pr.atwolahttp: > > > > //pr.http: //prht > > > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 Comments below: GG > > > > Well, > > My differential diagnosis at this point are: > > drug induced hepatitis, > GG: Not hepatitis > liver abscess, > GG: Not liver abscess > some infectious disease process such as hep A or salmonella.. > GG: Yes, SALMONELLA from the bad potato salad at the church social. Now, explain the bilirubinuria and bilirubinemia and you'll have the whole picture. Hint: Does the increased bilirubin have anything to do with the salmonella infection? Could it be a completely different cause? > > Any chance you've got a CT-Abdomen or Liver biopsy floating around in your > brain? How about some Labs, since you know the hemoglobin/hematocr brai > CT of ABD was unremarkable. No liver biopsy done. Urine dipstick positive for bilirubin; blood analysis shows 30 mmol/dL of bilirubin (< 20 normal). Ask the SAMPLE questions and I'll give you the answer, well if you ask them right. LOL. GG > > Any sign of hepatomegaly, or splenomegaly on the physical exam? > > Joe > > > > > > > > > He does not have an obstruction. Look at his past medical history. > > > > GG > > > > In a message dated 6/22/09 6:43:02 AM, hbarber@...< > hbarber%40cableonehbar>writes: > > > > > > > > > > > > > > Does he have an obstruction? > > > > > > hjb > > > Re: A new puzzler > > > > > > He takes 10 mg qd of lisinopril. Great idea about the cholestatic > > > jaundice, > > > which would, indeed, be a major emergency. But it's not that. It's > much > > > simpler. > > > > > > In another post I gave a major hint. He has chronic bilirubinemia and > > > bilirubinuria. > > > > > > Hint, since you've done so much thinking about this: In this case > there > > > are both horses and a zebra. > > > > > > (Remember the saying, " When you hear hoofbeats, look for horses, not > > > zebras? " > > > > > > GG > > > In a message dated 6/19/09 10:54:02 AM, stevenhobbs@ In a message da > In > > > > > > > > > > > > > > > > > > > Gene, > > > > How long has he been taking the lisinopril? What is the dose of the > > > > lisinopirl? Given history of lisionpril usage, have a high suspicion > of > > > > > > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? > I > > > > > > thought you could. > > > > > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > > > vomiting > > > > > > for the last four days. > > > > > > > > > > > > On arrival you find an overall normal looking male who says he > has > > > > been > > > > > > dizzy, has had nausea and vomiting for four days and not able to > > > keep > > > > > much > > > > > > of > > > > > > anything down. > > > > > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin > every > > > day > > > > > at > > > > > > his doctor's suggestion. He denies allergies, any significant > past > > > > > medical > > > > > > history, and any provoking causes. > > > > > > > > > > > > Your physical exam reveals a well nourished male, HEENT > > unremarkable > > > > > except > > > > > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, > > > breath > > > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, > slight > > > > > > tenderness in > > > > > > the supraumbilical region to palpation, which the patient > describes > > > > > as > > > > > > soreness from throwing up. No Cullen's sign. No rebound > tenderness. > > > > > Psoas, > > > > > > obturator, and Rovsing's signs are negative. Torso appears > slightly > > > > > > jaundiced. > > > > > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, > > > temp. > > > > > > 99.8 F. > > > > > > > > > > > > What's most likely wrong with this patient? Of what significance > is > > > > the > > > > > > jaundice? > > > > > > > > > > > > What questions can you ask to get a better history? > > > > > > > > > > > > Gene G. > > > > > > > > > > > > > > > > > > ************ * > > > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > > > ( > > > > > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: > > > //pr.atwolahttp: > > > > //pr.http: //prht > > > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
Guest guest Posted June 22, 2009 Report Share Posted June 22, 2009 Well, My differential diagnosis at this point are: drug induced hepatitis, liver abscess, some infectious disease process such as hep A or salmonella... Any chance you've got a CT-Abdomen or Liver biopsy floating around in your brain? How about some Labs, since you know the hemoglobin/hematocrit... Any sign of hepatomegaly, or splenomegaly on the physical exam? Joe > > > He does not have an obstruction. Look at his past medical history. > > GG > > In a message dated 6/22/09 6:43:02 AM, hbarber@...writes: > > > > > > > > > Does he have an obstruction? > > > > hjb > > Re: A new puzzler > > > > He takes 10 mg qd of lisinopril. Great idea about the cholestatic > > jaundice, > > which would, indeed, be a major emergency. But it's not that. It's much > > simpler. > > > > In another post I gave a major hint. He has chronic bilirubinemia and > > bilirubinuria. > > > > Hint, since you've done so much thinking about this: In this case there > > are both horses and a zebra. > > > > (Remember the saying, " When you hear hoofbeats, look for horses, not > > zebras? " > > > > GG > > In a message dated 6/19/09 10:54:02 AM, stevenhobbs@stevenhobbstewrites: > > > > > > > > > > > > > > Gene, > > > How long has he been taking the lisinopril? What is the dose of the > > > lisinopirl? Given history of lisionpril usage, have a high suspicion of > > > > cholestatic jaundice leading to fulminant hepatic necrosis. > > > > > > > > > > > > > > > > > > > > > > > > > Hello boys and girls. > > > > > > > > > > Uncle Gene is back with a nice new puzzler. Can you say puzzler? I > > > > > thought you could. > > > > > > > > > > 44 year old male calls 911 complaining of dizziness, nausea, and > > > > vomiting > > > > > for the last four days. > > > > > > > > > > On arrival you find an overall normal looking male who says he has > > > been > > > > > dizzy, has had nausea and vomiting for four days and not able to > > keep > > > > much > > > > > of > > > > > anything down. > > > > > > > > > > He takes lisinopril for mild hypertension and a baby aspirin every > > day > > > > at > > > > > his doctor's suggestion. He denies allergies, any significant past > > > > medical > > > > > history, and any provoking causes. > > > > > > > > > > Your physical exam reveals a well nourished male, HEENT > unremarkable > > > > except > > > > > > > > > > for some jaundice that shows up in the sclera and conjunctiva, > > breath > > > > > sounds clear and equal bilaterally, heart sounds S1 and S2, slight > > > > > tenderness in > > > > > the supraumbilical region to palpation, which the patient describes > > > as > > > > > soreness from throwing up. No Cullen's sign. No rebound tenderness. > > > > Psoas, > > > > > obturator, and Rovsing's signs are negative. Torso appears slightly > > > > > jaundiced. > > > > > > > > > > HR 100, monitor shows sinus rhythm, Respirations 16, BP 110/66, > > temp. > > > > > 99.8 F. > > > > > > > > > > What's most likely wrong with this patient? Of what significance is > > > the > > > > > jaundice? > > > > > > > > > > What questions can you ask to get a better history? > > > > > > > > > > Gene G. > > > > > > > > > > > > > > > ************ * > > > > > Dell Days of Deals! June 15-24 - A New Deal Everyday! > > > > > ( > > > > > > > > > http://pr.atwola. http://pr. atwhttp:/ /pr.atwolahttp: > > //pr.atwolahttp: > > > //pr.http: //prht > > > > > ad.doubleclick. ad.double ad.doublecl ad.doublec ad. > > > > > > > > > > Quote Link to comment Share on other sites More sharing options...
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