ERDoc

My belly pain one is still unsolved. Feel free to give an opinion on the workup that needs to be done.

And this one serves no purpose other than to give post #800.

Let's keep this one going. I have enjoyed watching my post count skyrocket.

This pt is SAH until proven otherwise (this is getting monotonous). You're right it does say it all. This guys pressure was so high that it was able to rupture blood vessels in his nose, so there is a good chance that it can rupture blood vessels in his brain. You've treated the symptoms, not the problem. So what?

What do you mean we're not perfect???? :x DocZilla and I will conference on this one and get back to you.

This is not a simple hypertensive crisis. This is SAH until proven otherwise. You would not find one competent ER doctor out there that would say, "Hey, it's just his high BP. Let's bring it down and send him home." This guy is going to get a CT and if that is negative an LP. Only then can you say it is not a SAH.

Ditto

There is more to this pt than just his blood pressure and you seem to forget that. Decreasing his BP will affect his other vitals and other organ systems. You need to consider that in your treatment.

Yes they do. Again, you are just 100% wrong. Yes it is, until proven otherwise. Are you saying that it would be OK to let the pressure say high if it was a hemorrhage? I normally don't sink to the level of name calling, but you are a tool and obviously not competent. You are a danger to your pts and thankfully have a doctor to watch over you. That is probably one of the only things you have said that even comes close to being correct, +2 for you.

Those in glass houses, oh never mind.

There is no nice way to sugar coat this one. You are 100% wrong. This is basic physiology that you should have learned in your medic class (assuming you really are one). When you vasodilate, the heart will pump faster. Think of septic shock. You decrase system vascular resistance by way of massive vasodilation. To compensate, your heart rate increases. The same thing happens with vasodilation from nitrates. You increase the heart rate. To see the effects of an increased heart rate, see my last post.

You are not able to control anything with SL nitro. There is a reason that IV forumlations are made. You are putting so much more stress on an already weakened system. Drop their pressure, lay them down, give them fluids, pressure climbing again, sit them back, etc. Supine in contraindicated in a SAH, so why put them in a position where they need to be supine.

Man, I can't believe I'm getting involved with this one, but if DocZilla can step up I guess I can too. You CANNOT rule out a SAH based on the history. As I mentioned in a previous post I had a pt with a SAH that was pain free when he got to the ER. Withsome with a BP that high, you are building a pressure head in the vessels in the brain (ie Circle of Willis). This guy probably has a berry aneurysm and when the pressure is building it is causing the pain. That pressure keeps building and building causing more and more pain. Eventually the aneurysm busts. This is what causes the sudden and severe headache. Now you have released the pressure off of that vessel, so the headache is going to subside. The nosebleed was also another way for the pressure to be relieved. If the pressure was high enough to bust blood vessels in the nose, why not the brain? Think of it this way. Let's use a pimple as an example. A pimple becomed more and more painful as it gets bigger because there is a buildup of pressure inside the capsule. The most painful part of a pimple is when you apply a great deal of pressure to pop it. Once it is popped and you havae released that presure there is relief of pain. Lowering the BP in the field is not a bad idea. Using nitro to due so is malpractice. There are two forces acting with a SAH. You have a high blood pressure which is causing a buildup of pressure and you have a pulse rate which is hitting this weakened vessel like a hammer. Obviously, if you lower the pressure that is a good thing, but you also need to decrease the heart rate so that you decrease the hammering effect on the weak area. Nitro will bring your blood pressure down, but you will get a reflex tachycardia that will hammer away at the vessel so you have essentially done nothing to help your pt. You have gotten rid of one problem by causing another. Beta blockers are probably the best choice in the field because they lower heart rate and BP. That being said, if you use them in conjunction with nitro you will be able to treat the pt better. Another issue is how far do you drop the BP. We generally do not drop it any more than 20% in the acute setting. The brain works via autoregulation to maintain an adequate cerebral blood flow over a wide range of cerebral perfusion pressures. Your cerebral perfusion pressure is your MABP-ICP. Your ICP will stay constant. So dropping your MABP will decrease your cerberal perfusion pressure. The brain is only able to autoregulate to a certain degree, after which the lower your CPP goes, the lower your cerebral blood flow goes. This means that if you drop the pressure significantly by giving uncontrolled nitrates (ie SL ntg) you will overpower the brains ability to autoregulate and you will drop their cerebral blood flow in a linear fashion. Check out this website for a graph that explains what I am talking about. Autoregulation occurs at the plateau. http://www.medana.unibas.ch/eng/tcd/tcd2.htm In the hospital there is a reason we use Nipride (which is a nitrate) and esmolol. Both are quick on and quick off and you have very good control over them.

The winner is EMS-Cat. This gentleman has mumps. This is a classic presentation of parotitis, orchitis and fever with a fairly abrupt onset. He said his immunizations were up to date, but couldn't say when or where, so who knows what he has actually gotten. This is not a very typical presentation for Lyme, but you wouldn't be faulted for putting in on your differential. Feel free to open the floor for discussion.

Wow, I forgot about this scenario with all the talk of heuvos and pickles on the other scenario. So, does anyone want to step up and say what they think it is and how they want to work it up?

Well, we are on the 3rd page of this scenario. It's time for someone to step up and say what it is. Go for chbare.

I gave the labs that were asked for on page 2. There is nothing really remarkable. This case can be diagnosed clinically. You have a guy from Mexico with no rpimary care (other than a walk-in clinic) with orchitis, parotitis and a fever. What is going on here? Hint: The answer has already been mentioned.

Someone had asked to transiluminate the testicles with a flashlight, which was negative. So, you have an otherwise healthy immigrant with fairly sudden onset of fever, testicular pain and TMJ pain. This dx is a clinical one and is confirmed with labs. Anyone have any guesses?

No meds. No blue vision. CT was neg, so you don't need an US (it isn't very sensitive for disection anyway).

US is neg except for some fullness in the testes. No free air.

Your UA is neg. Flashlight is normal. He says his immuniazations are up to date. Your CT with IV contrast shows nothing intrabdomenally, but there is some mild stranding around both testes.

Your PE shows: 128/88 108 16 99%RA PERRLA, EOMI, MMM, No pharyngeal erythema or exudates, tenderness and fullness over the TMJs b/l, your partner ate the pcikle that you had with your lunch so you cannot perform a pickle test -JVD or carotid bruits, +submandibular LAD LS CTA b/l with good AE RRR no m/r/g abd soft, nontender, nl BS, no CVAT Genital exam as mentioned before Rectal exam deferred Extremities unremarkable Skin show no rashes Someone was looking for labs. I'm going to assume you wanted a CBC and chem. WBC is 6.5, plt count is 615 otherwise they are wnl. What kind of imaging studies do you want? Do you want any other labs?

It can be. I once had a guy (sorry to bore you guys with another story) who came in with a sudden onset of severe occipital severe headache. Was feeling better by the time he got to the ER. After being in the ER for a short time the headache came back. He ended up with a huge bleed on CT and was in the SICU for a few days.

Pain does not radiate and is worse when in a sitting position. Better when laying or standing. No bruising. He has a fever of 101.9. States it started about the same time as the pain. There is no bruising in the area.

You should get this guy to the ER as quickly as possible. He absolutely has evidence of end organ damage. He is c/o a 10/10, sudden onset headache. This is SAH until proven otherwise. He needs his BP lowered and a CT with a possible LP.