Volume 02

Episodes:

026 - 050

Case Synopsis:

82yo male presents with 48 hr with nausea vomiting and diarrhea – thought it was from eating bad eggs
☙ Vital signs normal
☙ Non-specific subjective tenderness all over abdomen – initially treated as food poisoning

Treatment: 
☙ Ondansetron IM
☙ NPO 30 min
☙ trial of ORT 

Case Continued:
☙ This patient stated nausea/vomiting subsided but was still complaining of abdominal pain (4/10).
☙ Normally pain decreases or completely resolves with treatment.

Repeat Exam:
☙ Abdominal assessment found pain to be slightly more localized to epigastric region.  Non-peritoneal
☙ Might consider ASA or PPI (pantoprazole) & discharge – but NOT the best approach! 

Second line of Treatment / Tests:
☙ acetaminophen 1g PO  (possible contraindication to NSAIDs with ?peptic ulcer disease on DDx) 
☙ Comprehensive bedside ultrasound: AAA, FAST, signs of pancreatitis – all negative
☙ Blood work: blood count, Electrolytes, Kidney Function, Liver Function, Lipase, VBG and Lactate

Case Continued:
☙ Pain increases over next 30min so hydromorphone 1-2g PO given to decrease pain to 2/10
☙ Labs return with nothing determinant: 
     WBC – 10.9 (normal 4-11)
     GFR – 48 (baseline unknown) 
     Liver function – normal
     Pancreas – normal
     VBG – normal
     Lactate – 3.4 (normal 2.2) 

Differential Diagnosis: 
? Dehydration from n/v and query possible acute kidney injury
? Partial ileus
Increased pain – potential other cause

Considering CT scan:
☙ Discussion with patient re risk/benefit of getting a CT Scan at this point (nearest CT scanner is 3 hours away for total 6+ hour transportation.)
☙ Not clinically necessary for urgent CT, so came up with plan to admit patient for observation. 

Proceed with Admission / Observation:
☙ Pt NPO and given IV due to possible acute kidney injury
☙ Repeat labs in morning
☙ Hydromorphone for pain over night

Morning assessment:
Over night took: 2nd dose ondansetron, 4mg hydromorphone
☙ Slept well
☙ But Coffee ground emesis just prior to rounds
     ☙ patient believed it to be undigested blueberries from previous day.
     ☙ Sample taken and on fecal occult blood card – NOT blueberries
☙ Discuss concern with patient about digested blood and more convincing indication for CT scan.
     ☙ Night sweats over last month and weight loss over last month.
     ☙  No peritonitis
     ☙ Considering subacute ischemic bowel

Patient agreed to transport to get CT scan and found to have ischemic bowel and received urgent general surgery consultation.


Discussion (CT Timing in Remote Community):
☙ Would CT the night before be wrong? No. (Many docs would have done it, especially if CT was readily available.)
☙ But might not be right choice either:
     ☙ Early pretest probability of a surgical pathology with normal vitals and labs was very low:
          ☙ overall prevalence for acute mesenteric ischemia is 0.1% (1/1000) of hospital admissions (1) 
          ☙ Risk of cancer from CT Abdo/Pelvis in 82y/o male =  1/3405 (2) 
          ☙ Plus have to consider:
               ☙ Transport risk;
               ☙ patient's increased stress from current ordeal (delirium risk) etc.  
☙ no clear "best choice" under this sort of risk/benefit analysis