Pavehawk Posted March 26, 2012 Posted March 26, 2012 There is a huge differential on any woman who is old enough to have children (on the young ones too but some stuff can be safely ruled out). I don't know much about NZ prehospital care but in the USA what exactly is going on with the gal is not really a field medics job. Even an MD in the field without labs, ultrasound, X-ray, and limited in the scope of their exam, i.e. no pelvic/bimanual exam is going to go... hmmm. febrile, hypercapnic, dysuria.... could be this, or that, or whatever.... So in the USA we would transport to her hospital of choice where she would be worked up, figured out, and treated. If the doc/nurse/whatever asked what we thought was wrong the answer is going to be along the lines of what 1C gave as a hand off. Does she have an ectopic?? She denies...but patients have been known to lie, does she have a hot appy?? who knows, UTI?? who knows... thats what the hospital does NOT what the medics in the field do. Recognizing that the gal is sick and needs to be seen is the gold standard along with symptomatic treatment PRN. Once she hits the ED then the work up will point us to where we need to be. In your system you may do things differently so please rather then spank "us" for not trying to over think a patient*, tell how you guys would "pin point" her pathology in the field in the back of your ambulance. * Please don't take this as being anti-knowledge for EMS people but we have to recognize that difinitive differential diagnosis of complex medical problems is the job for the ED/Clinic etc. Having a good knowledge base is great and EMS eduction in the USA is lacking in many ways but I would rather have a medic in the field that says... "I don't know wtf is going on here, but this gal needs to go to the hospital." then one who says "Ooh damn this gal has hysterosalpigingiooophoritis and needs to see her PMD on Monday.." and be wrong! Cheer! Pave 1
craig Posted March 26, 2012 Posted March 26, 2012 Six hours ago, big, well developed and smells like shit definately from New Zealand then.................
Kiwiology Posted March 26, 2012 Author Posted March 26, 2012 (edited) definately from New Zealand then................. I reckon we come off the southern coast of NSW, you can practically bloody see it; so that begs the question if we're a little bit of shit we must have broken off a bigger bit of shit (i.e. you) mwahahah There is a huge differential on any woman who is old enough to have children (on the young ones too but some stuff can be safely ruled out). I don't know much about NZ prehospital care but in the USA what exactly is going on with the gal is not really a field medics job. The location is not important Even an MD in the field without labs, ultrasound, X-ray, and limited in the scope of their exam, i.e. no pelvic/bimanual exam is going to go... hmmm. febrile, hypercapnic, dysuria.... could be this, or that, or whatever.... A common misconception. Based solely on knowledge of physiology and pathology with no access to lab tests or diagnostic imaging there are several huge clues in the information I have provided that should be screaming "really big problem". A Consultant Physician once told me that biochemistries and images help to augment what is found during the physical exam but are not an examination technique in and of themselves. Does she have an ectopic?? She denies...but patients have been known to lie, does she have a hot appy?? who knows, UTI?? who knows... thats what the hospital does NOT what the medics in the field do. Recognizing that the gal is sick and needs to be seen is the gold standard along with symptomatic treatment PRN. I don't know, could she have an ectopic pregnancy? what would cause you to suspect that? (as an aside, I'm really dumb and cannot remember basic facts I learnt 20 minutes ago if my life depended upon it but for some strange reason one thing burned forever into my head are the risk factors for ectopic pregnancy; I can recite them off the top of my head cold and I have no idea why; it is truly bizarre) Once she hits the ED then the work up will point us to where we need to be. In your system you may do things differently so please rather then spank "us" for not trying to over think a patient*, tell how you guys would "pin point" her pathology in the field in the back of your ambulance. I'm not really into spanking, maybe a little, no whips or chains though y'know that's just creepy Nobody is expecting you to know exactly what is wrong with this person but bloody hell mate, these scenarios are clinical cases or situations we think interesting enough or out-of-left-field enough to post up and generate some discussion or ideas or debate; you know to get people thinking maybe a bit out of the box or something a bit different. This is not about an exacting diagnosis; you know these things never really are; how sick is this patient? how time critical is she? she has by all accounts "a sore tummy and fever" so do you take her to big surgical hospital or small hospital with no surgical capability and why? There are several huge red flags in the physical exam and trended obs provided that should be setting off the "time sensitive extremely sick person" flags but could just as easily be explained away to the satisfaction of the crew. None of the red flags are very advanced honestly. I'm not trying to put myself up on a pedestal as posting shit up that requires some bloody massively advanced knowledge of biomedical science (because I sure a hell don't have it ... oxidative phosporowhat? bloody Devil talk that is right there!) but you know patients who present subtly unwell but in fact have a time critical problem that will kill them in 24 to 48 hours are not extremely common; I can think of only two or three problems that can take a healthy young person such as this and turn them stone cold dead inside a short time span. Perhaps you yourself ran across such a patient; but all you did was take them to the hospital so it's not even important Why even post a reply to this if you're not interested in having a go because "it's not my job to know I only take them to the hospital" doesn't help; in fact all it does is exemplify what Skip Kirkwood and I were recently discussing. I could go on and on and have a massive bloody deconstructive rant but then I'd just look like that Semmelweis bloke and knowing my luck I'd probably end up like he did. Excuse me, I have to go wash my hands now. Bloody hell forget I ever posted the damn thing. Edited March 26, 2012 by Kiwiology
Vorenus Posted March 26, 2012 Posted March 26, 2012 Hm... it`s really a lot of text up there so I just had a quick go over it. Just something I think has not been covered yet: Is she still equipped with her appendix and what does it feels like (and pain score) when you touch the McBurney point?
Kiwiology Posted March 26, 2012 Author Posted March 26, 2012 (edited) Just something I think has not been covered yet: Is she still equipped with her appendix and what does it feels like (and pain score) when you touch the McBurney point? Good thinking mate, I suppose you could say there is non-specific pain upon palpation of McBurney's point And it was covered that she no longer has her appendix; a key factor to rule out before calling the Surgical House Officer or Reg to admit her (yes, it happens) You would think when the House Officer is on a surgical service it turns them into the House Surgeon but it does not ... Edited March 26, 2012 by Kiwiology
Vorenus Posted March 26, 2012 Posted March 26, 2012 Muscular defense when palpating? Since the title is Travelling Soldier, where has she been in the last time? (or this is only a hint at the Dixie Chicks ).
Kiwiology Posted March 27, 2012 Author Posted March 27, 2012 Yes there is some muscular rigidity when palpating her lower tummy
Just Plain Ruff Posted March 27, 2012 Posted March 27, 2012 could we be talking a twisted ovary? could we be talking a issue with her uterus? What about a fallopian pregnancy? I mean she could have been date raped and thus not remembered it.
Kiwiology Posted March 27, 2012 Author Posted March 27, 2012 could we be talking a twisted ovary? no could we be talking a issue with her uterus? What about a fallopian pregnancy? it is a gynae problem but it's not a uterine problem or ectopic pregnancy I mean she could have been date raped and thus not remembered it. Kettymainz for teh win it makes my dates so much more complaint! You have a female crew partner, she takes a squiz down below and reports the perivaginal area is also very red and warm to touch and smells bad The patient once again forcefully denies being pregnant Without being really obvious and giving it away here's another clue; when you percuss the abdomen it is resonant however distal to the umbilicus it is hyper resonant; when you have the patient turn towards one side at about 45° angle the area of hyper resonance shifts What do hyper resonant areas indicate and what could it mean if it shifts?
Chief1C Posted March 27, 2012 Posted March 27, 2012 does she have a hot appy Appendicitis never even crossed my mind, as the history noted: Prior medical history of unremarkable, appendectomy at 10 years Of course, she could be lying about that too. Maybe a skin infection, hot/tender/red, fever, vomiting, but no GI upset to the lower end. Which is why I thought an abscess; or cellulitis - which can occur anywhere on the skin. And you could be getting there at the start, the fever could spike with worsening symptoms. Monitor the vitals, make a detailed and anal outline of the history and exam of the current condition; treat symptoms. That's basically what you're gonna get in the ambo. Diagnose it, yeah, prolly not.
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