ERDoc Posted April 23, 2007 Posted April 23, 2007 60y/o female c/o right sided abd pain. It is 0100 and she states the pain woke her up at 2300. When she went to bed at 2000 she was fine. PMH is significant for elevated cholesterol for which she takes vytorin. She is also on ASA and prevacid. No allergies. No h/o surgeries. She states she was dx with pneumonia a week ago and is currently on augmentin. What else do you want to know? What is your differential?
tniuqs Posted April 23, 2007 Posted April 23, 2007 60 y/o Hmm: Ok: lets get the meat first svp. LOC? Am assuming GCS = 15? Soco economic status? Wieght? Primary survey? any dyspnea? VS ? Lung sounds, cough productive? what color? ok: Hyperlipidemia...PMHX therefore ECG, the elderly female is high risk for atypical presentation for MI. Pnemonia?...bug juice.. Did she take with food? Any herbal remidies? has she taken any rx since onset? Was abdo pain onset generalized? then focused to RLQ? PMHX no surgeries. Focused exam....tender abdo? Rebound? N + V? LBM? ps do me a favour there ERdoc....this "yall, meds stuff" can you use genaric names as in Kanukistan we have diff RX trades it sure srews me up...lol. Diff DX: Stuck Fart?
ERDoc Posted April 23, 2007 Author Posted April 23, 2007 Vytorin=ezetimibe and simvastatin Augmentin=amoxicillin and clavulinic acid prevacid=lansoprazole Sorry about the ethnocentrism there. Hope this clears it up. A&OX3, GCS=15, SES is middle class, average American woman. Weight about 200lbs (100 kg) There is no dyspnea, she speaks in full sentences. She does cough on occasion during the interaction. BP 140/86, RR 14, HR 70 SaO2 99% on RA. Cough was productive but it has been getting less since she started the abx. It was green but is now more yellow. Lungs show good air entry with scattered rhonchi. EKG shows NSR with no ST or Twave changes. She takes every dose of the augmentin with food and hasn't had any problems for the past week. No herbal stuff and she has not had any other meds since the pain woke her up. The pain was not generalized. It covers the RUQ and the upper portion of the RLQ. It has not changed location at all. She describes it as an on and off burning sensation. She vomitted once prior to your arrival. Last BM was about 8 hours ago and was normal. On exam the LUQ and LLQ are nontender. The RUQ and upper half of the RLQ are very tender even with light palpation. It is difficult to assess for rebound due to the pt's discomfort. BS are normoactive.
AZCEP Posted April 23, 2007 Posted April 23, 2007 Does anything change the pain? Position/movement/cough? Any surgical history? Diet? Issues urinating/defecating?
Cookie Posted April 23, 2007 Posted April 23, 2007 Questions: What color was the vomit? I believe that could be a pertinent question. Normal stomach contents etc. or bile? Second does the pain radiate at all? Does it hurt to inhale or exhale? Pleurisy comes to mind, or inflamed gall bladder.
becksdad Posted April 24, 2007 Posted April 24, 2007 So far, this is what I see as significant: Recent Hx of pneumonia, which is treated and resolving. Age of patient normal vital signs, no dyspnea completely non-tender left abdomen, sounds as if there is no guarding. pain is localized and severe, even to touch. considering the above, it seems very significant that the pain is described as off and on burning. Any skin changes in the affected area? I gots me an idear......
tniuqs Posted April 24, 2007 Posted April 24, 2007 Er speaking of idears...did we rule out Trauma? Any recent falls? MVC? ???
chaser Posted April 24, 2007 Posted April 24, 2007 gallbladder gerd IBS when did she last eat? (sorry if you mentioned it and I missed it) Temperature?
Bombera Posted April 25, 2007 Posted April 25, 2007 Well, I don't know a lot because I am an EMT student still, but I will throw some thoughts out there and hopefully they won't be too silly. Don't laugh too hard at me. hehehehe I got really curious about this case and I was looking in my book at possible causes of acute abdominal pain. It seems like cholecystitis might fit the signs and symptoms because the onset seemed to be at night so maybe the condition was aggravated by the patient laying in bed and by the fact that she has high colesterol which could mean that she likes to eat fatty foods. I guess what I would like to know is her temperature and the color of her vomit like Cookie and chaser. I would also like to know what her last oral intake was. Anyway, cholecystitis would be my best guess and I am certain no expert.....yet...... Take care!
ERDoc Posted April 25, 2007 Author Posted April 25, 2007 The pain gets worse with any movement, cough and deep breath. No surgical hx. No problems with BMs or urinating. He eats a normal diet. Vomit was greenish in color. Pain does not radiate. No noticable skin changes. No history of trauma. Last meal was at 1800 and she is afebrile.
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