Sudden Need to Deficate

[CytochromeP450]

Here is an interesting call that I hope you all will find intellectually tantilizing

Dispatched to a library for a 60 year old female feeling dizzy.

General Impression:

You arrived to find the patient sitting on the toilet. She is extremely pale and profoundly diaphoretic. She is responding appropriately when you ask her questions but she is very lethargic. You take a quick pulse and it is 80, reasonably strong and regular. Breathing is non-labored.

History of Present Illness:

You start talking to the patient and get a story that goes like this -- she was riding in the car when she experienced a sudden, intense need to deficate. She pulls into the library to use the restroom when she sits down and immediately passes copious amounts of watery diarrhea. She reports that around this time she also began feeling a crampy pain in her abdomen, very sweaty, onset of a headache with blurred vision and like evertyhign was going white. She states that her arms and her legs feel a little numb and weak. Mild shortness of breath, no chest pain.

Exam:

Your physical exam looks like this:

General - 60 year old caucasian female, slightly overweight but otherwise normal habitus and grooming. Skin is extremely pale and profoundly diaphoretic. She only opens her eyes to verbal stimuli, lethargic, but oriented in all respects.

Head - No signs of trauma, PERL, moist mucus membranes, external nose and ears are normal.

Neck - Supple, no JVD, her trachea is midline.

Chest - again atraumatic, breath sounds are clear to auscultation in all fields with no adventitial sounds.

Abd - diffusly tender, no rebound tenderness, no pulsations/masses/distention/ascites

Extremities - + distal circulation with 4+ muscle strength.

Neuro - no focal neurologic deficits

Vital Signs - BP 82/50, HR 76 and regular, RR 16 unlabored

SpO2 93% room air

EKG - shows sinus rhythm at a rate of 76 with no ectopy or ST changes

Blood Glucose - 123mg/dL

History:

History of HTN for which she takes a blood pressure medication and a diuretic; she cannot recall the name of either. When asked about a history of these episodes she reports that she has had aproximately 10 over the past few years and they are always associated with a sudden need to deficate and the simultaneous onset of these symptoms. They ususally resolve spontaneously without intervention but this one is significantly worse and has lasted longer than the others. She has never been evaluated for these before.

What do you think?

[eb1040]

Bowel sounds present in all 4 quadrants? Quality?

[rock_shoes]

BP on the other arm? 12-lead?

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[CytochromeP450]

Bowel sounds are present and of normal frequency and character.

Blood pressure is equal on both arms

12 lead shows a sinus rhythm. PRI is 174ms. QRS duration is 76ms. Normal axis. No ST changes. I'll see if I can upload it as an attachment, but it is really quite unremarkable.

Edited July 26, 2012 by CytochromeP450

[emtdennis]

Air temperature?

Sounds like heat exhaustion, mild virus.

Should reviw with doctor.

[Arctickat]

What's in the toilet bowl?

[DFIB]

Her MAP is 60 which would indicate hypoperfusion. What is she taking to control her BP? When did she lat take her BP meds? How much diuretic has she had today?

Does she present turgor?

Has ever had a copro for ova and paracites?

Mucus in the feces? What color are the feces? Is the smell abnormal?

What has is her per oral intake for the last 24 hrs. and where was the food prepared?

Temperature?

EDIT: Can she stand to check orthostatic pressure changes?

Edited July 26, 2012 by DFIB

[CytochromeP450]

DJ - the air temperature was 76 and sunny, she was sitting in the car prior to onset so I think heat exhaustion was unlikely. The reoccuring nature with sudden resolution makes me shy away from an infectious process but I wouldn't rule it out.

Arctickat - I wish I could say there was something as exciting as THIS in the toilet, but it was really just loose, brown stool. No blood.

DFIB - She is definitely hypoperfused...I just couldn't figure out why. She couldn't give me the specifics of her antihypertensive meds, but she said the first time she experienced an episode like this predated the medications so I figured those weren't the cause. Shes never had a copro antigen test. No mucus in the feces. Brown and loose. Smelled bad...like poop...but nothing unnatural. Her oral intake wasn't anything out of the ordinary, she had some freshly made salsa with veggies from the garden but no one else who ate it was ill. She was normothermic with good turgor. She could stand to take orthostatics, but honestly I don't know why you would -- she is already hypotensive when sitting so its not orthostatic hypotension

[rock_shoes]

How did she respond to a small fluid challenge?

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[DFIB]

I am at a loss. What does she fertilize her garden with?

She might some undiagnosed intestinal condition or an intolerance to certain foods, or a bacterial infection that would cause the lumen of her gut to flood with liquid. If it was quick enough her body wold not have time to compensate (possibly). Not all diarrhea producing bacteria have time to cause fever before they are defecated out.

If we saddle any of these conditions with anti-hypertensive medications and diuretics, could they cause these symptoms?

I am going to dwell on this and think some more while I kick it down the road and see what some of the providers above a my basic level can come up with.