chbare

You are on the right track. Let's say we get ahold of his brother and his brother has hemochromatosis. With that additional bit of information, what tests could you order? In addition, do you think you have enough information to evac this guy out of country? Take care, chbare.

Yep. Take care, chbare.

Would you identify the units of measurement as well? This can vary from country to country depending on the lab test. Using a reference range of 285-295 mOsm/kg for the normal serum osmolality, it would appear to be a bit on the low side. Since you need a serum sodium, glucose, and BUN to calculate serum osmolality, would these findings be available? (I do notice the BGL of 6.) The serum sodium would be of particular interest. Take care, chbare.

How would you go about ruling this in or out? Take care, chbare. He does not have a mass. It is in fact generalized hepatomegaly. No US capabilities, no diarrhea, O&P is negative. His brother is back in the States. You cannot get ahold of him; however, I almost guarantee you will get through as soon as we have a diagnosis. I bet he will confirm it by having the same problem. Take care, chbare.

You may think. However, with all the labs and distracting stuff, focus on the history and physical exam. This will most likely be the most important part to solving the riddle. This is one condition that you must suspect and have on your list of differentials, or you may not even think about ordering the proper diagnostics to definitively make the diagnosis. Take care, chbare.

Not unreasonable to consider these diseases at all. These are not the cause of his signs and symptoms; however, good call on conditions to rule out. Take care, chbare.

Promethazine also antagonizes dopamine, hence the association of EPS, NMS, and the such. Take care, chbare.

I would steer clear of Maxeran. (Reglan for your southern mates, or Maxolon in other countries.) Without a really clear history and the presence of seizures, this medication could precipitate additional problems. In addition, the risk of EPS may be higher in this patient, as we do not yet have a clear idea of what is going on, or what other substances are on board. I have my suspicions, but will keep them to my self for now. Take care, chbare.

Strange, I had a post disappear in one of my scenarios earlier today. I have a sneaky suspicion that I will hide as not to ruin what looks to be a great and relevant scenario. Take care, chbare.

Ok, with the liver issues, I can see a CMP and even a CBC. However, what are you looking at performing a lumbar puncture (LP)? In addition, the typical urine tox screen will not detect heavy metal contamination. I will give it to you on the basis of looking for hepatotoxic substances. You are able to obtain the following labs within 12 hours: CBC Hemoglobin: 13.5 g/dl Hematocrit: 42% WBC: 9.5 K/mm3 PLT: 190 k/ml Chemistry NA+: 137 mEq/L K+: 3.7 mEq/L CL-: 102 mEq/L BUN: 9.7 mg/dl Creatinine: 0.9 mg/dl BGL: 105 ~ 5.8 mmol/L AST: 50 U/L ALT: 52 U/L UDS APAP (-) ASA (-) THC (-) Cocaine (-) Amphetamines (-) Opiates (-) LSD (-) Blood ETOH: 0 mg/dl Take care, chbare.

I am not seeing P waves. I specifically stated in an earlier post that I cannot identify any well defined P wave. If you twisted my arm and made me man up to an answer, I would say atrial fibrillation is the underlying rhythm with PJC's at this point. Take care, chbare.

This is very strange? I thought I had commented on your post earlier today, yet my comment is not visible on this thread? Could you explain the meaning of CVC and LFP? I know of a CBC and LP. In addition, what conditions are you looking to rule out/in with these labs? Take care, chbare.

Blood sugar as stated earlier. Vital signs are unchanged. With a diaphragmatic hernia, what findings would you suspect? Would most people with diaphragmatic hernias tolerate the condition for three months? Soonest possible time for evac is 72 hours, and the evac doctor on call is not convinced this guy needs to be emergently extracted and evacuated yet. You can have your labs in about 12-24 hours. What do you want and why? Thus far, all we have are LFT's. If this is all, I can give you the findings. Lets say I throw in another complaint that the patient initially did not tell you. He complains of hand and knee joint pain starting about three months ago with the other symptoms. You have IV access. EDIT: His employment physical 2 years ago was unremarkable. Take care, chbare.

Could be atrial fibrillation; however, I notice an every three complex pattern of significant irregularity. Three complexes are "fairly" regular, followed by an irregular complex. (PJC perhaps?) This does not fit nicely into the irregularly/irregular classification of atrial fibrillation. Perhaps the underlying rhythm is atrial fibrillation, and these additional complexes are confusing the picture; however, I think it is worth considering other problems. Was that ECG taken in a quite, stable environment? Was the patient shivering or moving? Is there anything that could be causing the wavy baseline? Clearly, I cannot identify any well defined P wave. On someone so young, I would want a XII lead, and would want to consider an electrolyte abnormality or perhaps endocarditis given the history of opiate abuse. (Injected opiate abuse?) Was the patient febrile? Were you able to obtain follow up? Take care, chbare.

It has; however, I am answering specific questions at this point. Nope on the sandfly theory. Thus far we have LFT's, and the reasoning is pretty obvious given our abdominal findings. What else would you guys like to know? Take care, chbare.

No so much an isolated mass, as a general enlargement of the liver. Or, so you suspect. Take care, chbare. Primarily diesel. Take care, chbare.

No definitive care at this point. You have to justify calling for an extraction. This means a physician and a medic from the main clinic along with a quick reaction force convoy element to pick up the patient and bring him back to the main clinic. So, you are about as definitive as it gets for now. Do you think this guy can wait? You will have to decide if he is critical and requires emergenct extraction. However, you need to present a good case to the doctor that will be putting her neck on the line by driving out to pick this patient up, if you are looking at an evacuation. It is the middle of the night at brothers house, and nobody answers the phone or email. However, this could be something that runs in the family. Something to consider? It looks like people are leaning toward a liver problem? Clearly, checking liver enzymes may be a good idea. However, you are going to draw blood and have results tomorrow. So, it would be unreasonable to piece meal your labs. We need to decide the essential labs at this point. If LFT's are the only essential labs, I will give them to you; however, is there anything else you want? He has eaten local food and I would not fault you for considering the possibility that he picked up a new friend from such activity. This scenario is not beyond you. Feel free to do some research and develop a list of differentials. Then, we can continue to rule out during this discussion. Please describe why you suspect a hernia? What type of hernia are you considering? Take care, chabre.

It feels like a firm enlarged area just under the rib. You do not note any pulsatile masses or color changes. It is tender to palpate however. He is not sure what his brother has. States his brother has the same signs and symptoms and was being worked up the last time the patient talked with his brother. Take care, chbare.

-Will you even have good results after an hour or more? Does blood taken for an ABG need to be placed in a special container or solution? -Think about the common findings associated with AMS, does this patient appear to be exhibiting the typical signs and symptoms? -He states his brother has had similar problems. -Will 15-30 seconds of listening provide you with an accurate assessment? What are "normal" bowel sounds? -He has been in country for about two years. Take care, chbare.

Take care, chbare. Take care, chbare.

S: "I am weak and tired all the time, now my abdomen hurts." A: NKA M: None P: None L: 4 hours ago E: Generalized weakness and malaise over the past three months with abdominal pain times two days. Primary Survey: NAD Secondary Survey: NAD Ask for specific information. BP: 134/82 P: 90 RRR R: 21 NL SPO2: 95% RA T: 37 Celsius ECG: NSR Lead II without ectopy. Take care, chbare.

You are working by your lonesome in a remote clinic in Afgoochistan. You have access to labs; however, you need to justify your orders because your runner has to drive them into a lab that is at least an hour away via dangerous road. So, when you decide to put his life in danger, you had better convince him of the reason why you want to order or do something. Here goes: You are called to respond to a sick patient who is across the small camp where you are pulling medical support. Take it from here. Take care, chbare.

Nope. With a Mobitz II and 2:1, you still have some "normally" conducted impulses. Therefore, a type II need not have wide complexes. This is especially true with a junctional pacemaker. Take care, chbare.

Absolutely! Take care, chbare.

You are correct, my ECG FU is weak. Technically, an isolated 2:1 block cannot be reliably associated with a Mobitz I or II pathology because you only have one PRI. Some people may call a 2:1 a high grade 2nd degree block. Take care, chbare.