medic25 Posted February 21, 2014 Share Posted February 21, 2014 OK, there haven't been many lately, so I wanted to throw out a clinical case for the PA-S's. This is a patient I took care of last year; I want to know what you would like to do for an H&P, along with testing and management. - 58yo female, c/o 3 days of left-sided back and flank pain, along with some dizziness. She is resting on the bed, looking relatively comfortable. -What do you want to know first? Link to comment Share on other sites More sharing options...
fakingpatience Posted February 21, 2014 Share Posted February 21, 2014 Can pre-PA students try? Link to comment Share on other sites More sharing options...
Will352ns Posted February 21, 2014 Share Posted February 21, 2014 V/S and OPQRST Link to comment Share on other sites More sharing options...
Timon Posted February 21, 2014 Share Posted February 21, 2014 Vitals & Hx first First test I'd run is EKG before vitals. And if possible maybe while collecting Hx draw labs: CBC, CMP, CKMB, BNP, HsCRP, Trop I, & Lipase. Link to comment Share on other sites More sharing options...
medic25 Posted February 21, 2014 Author Share Posted February 21, 2014 Can pre-PA students try? Absolutely! Link to comment Share on other sites More sharing options...
medic25 Posted February 21, 2014 Author Share Posted February 21, 2014 T-98.9, P-98, BP- 104/70, RR-18, SpO2- 98% PMH of hyperlipidemia, takes a statin, otherwise negative. 12-lead EKG is unremarkable The patient reports a sudden onset of pain around 3 days earlier while driving in her car. No change with movement, no relief with OTC pain relievers, no radiation beyond the left flank/back/LUQ area. Some discomfort with palpation of the area. She describes the pain as being "moderate", and achy. The bloodwork has been sent and is pending (although I don't believe I ever sent a CRP or BNP) What else? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 21, 2014 Share Posted February 21, 2014 *cough*, What other lab (doesn't always have to be blood)? Link to comment Share on other sites More sharing options...
MedicinePower Posted February 21, 2014 Share Posted February 21, 2014 Chest XR, visualize the area, palpate it. Get a look and feel if things are off. It might be a bruised or cracked rib. Any diminished breath sounds, crackles, rhales, etc? Link to comment Share on other sites More sharing options...
fakingpatience Posted February 21, 2014 Share Posted February 21, 2014 Any PMH? Urinary problems? Can we get a urine sample Link to comment Share on other sites More sharing options...
medic25 Posted February 21, 2014 Author Share Posted February 21, 2014 The only PMH is hyperlipidemia On exam the lungs are clear to auscultation, no rib tenderness is appreciated. There are no signs of bruising noted. The patient has some tenderness to palpation over the left flank/LUQ area. We did not get a chest x-ray on this patient, although it is a very good thought. Urine sample is a great idea; she doesn't have to pee yet, so you start some IV hydration :) Link to comment Share on other sites More sharing options...
wannabePA-S Posted February 21, 2014 Share Posted February 21, 2014 does she have to pee yet? :) any pulsatile mass on abd exam? thinking AAA? Link to comment Share on other sites More sharing options...
MedicinePower Posted February 21, 2014 Share Posted February 21, 2014 Like to get a look with an U/S. Link to comment Share on other sites More sharing options...
UTalum Posted February 21, 2014 Share Posted February 21, 2014 UA to check for hematuria or infection. CT to r/o renal calculus and/or hydronephrosis... but I feel like those are the obvious answers. Saw a similar case a few weeks back, same presentation (flank pain/dizziness), and after doing an abd CT and adding a CTA ended up being an aortic dissection! I'm a prePA and of course was intrigued the by this. Link to comment Share on other sites More sharing options...
Will352ns Posted February 21, 2014 Share Posted February 21, 2014 As long as she has stable V/S, I am happy to wait for the urine and move on from there (prior to performing CT). With IV hydration, it shouldn't take that long. Until then, some orthostatic V/S can be done (prior to tanking her up with NS) while we perform a good ROS....then move on to the advanced Dx testing as indicated..... based off of the completed Hx. Can I assume you will tell us any positives on the ROS, or do you want us to list the questions out? Link to comment Share on other sites More sharing options...
Blue Goose Posted February 22, 2014 Share Posted February 22, 2014 HCG (use blood from IV start)? Can always repeat when urine is available, but were this to be a ruptured ectopic, I'd rather know sooner than later. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
Guest JMPA Posted February 22, 2014 Share Posted February 22, 2014 HCG (use blood from IV start)? Can always repeat when urine is available, but were this to be a ruptured ectopic, I'd rather know sooner than later. Sent from my iPhone using Tapatalk hcg may be useful but a ruptured ectopic in a 58 y/o? thats priceless Link to comment Share on other sites More sharing options...
Blue Goose Posted February 22, 2014 Share Posted February 22, 2014 hcg may be useful but a ruptured ectopic in a 58 y/o? thats priceless Wasn't my first thought either (those were mentioned earlier), but with my limited experience, I figured trying to rule out some life threats wouldn't be bad. Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
medic25 Posted February 22, 2014 Author Share Posted February 22, 2014 ROS is only positive for fatigue and some mild dizziness. Denies dysuria, n/v/d, fever, vaginal bleeding. MrEven: Ultrasound is a good thought, but what specifically are you looking for? I ended up doing a bedside ultrasound that was key in the diagnosis, but what are you evaluating? The patient finally urinated: moderate epithelials, 0-1 RBC's, 0-1 WBC's, negative LE/nitrite, HCG negative Initial labs came back; BMP and LFT's were unremarkable. WBC count of 9.0, H&H of 10/29, platelets of 300. There have been some good suggestions so far; anybody want to generate a differential diagnosis? Link to comment Share on other sites More sharing options...
Timon Posted February 22, 2014 Share Posted February 22, 2014 Possible peptic / duodenal ulcer with some splenic artery involvement? Or hemorrhagic ovarian cyst? Just throwing some darts. Link to comment Share on other sites More sharing options...
BARONEUS Posted February 22, 2014 Share Posted February 22, 2014 What's her stool look like? Link to comment Share on other sites More sharing options...
Moderator ventana Posted February 22, 2014 Moderator Share Posted February 22, 2014 "saw something on US" What could that have been? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted February 22, 2014 Share Posted February 22, 2014 Key question, and not to be oversimplified, what exactly does an ultrasound show us (what TYPE of information can we get from it)? Link to comment Share on other sites More sharing options...
skyblu Posted February 22, 2014 Share Posted February 22, 2014 I want to pipe in and say I think our students are doing a great job with their thought process so far! Link to comment Share on other sites More sharing options...
Febrifuge Posted February 22, 2014 Share Posted February 22, 2014 I want to pipe in and say this sounds like a hella expensive workup so far. ;) It's completely valid to assume that the case is complex, interesting, or obscure, and that's why we're bothering to talk about it; on the other hand, it's tough to overemphasize the importance of a good and COMPLETE history. When we did these cases in my classes, there would be a first phase where everyone could ask one question and the instructor would answer as the patient. Only after everyone had asked all their questions would we proceed to labs and imaging. Sometimes, we would "fast forward" because the right questions had been asked. Just something for the newbies to keep in mind. Spend an extra five minutes in the talking part, and you might save an hour (plus a dose of radiation, plus a $1500 bill) later on. This particular exercise has a different focus, so I'll hush now, but it's good to keep in mind. Link to comment Share on other sites More sharing options...
Will352ns Posted February 22, 2014 Share Posted February 22, 2014 Ummm, I'm missing something. What led you to use the U/S? I understand why we would....but why on this particular patient? A quick review: Left flank pain, dizziness, only PMHx of hyperlipidemia. No trauma. Clean UA w/o blood, neg HCG. Tender to palp over area of pain, but no radiation and does not hurt with movement. It wasn't mentioned, but I am assuming that pt isn't orthostatic and had a normal neuro exam (thinking about the dizziness). No more positives on ROS. U/S was used. Okay, so you were looking for some sort of mass/lesion or looking at vasculature. Kidney/spleen/ovary and vessels leading to are the obvious chioces for the area. What led you to go to the U/S? It isn't really presenting like a torsed ovary or cyst, certainly not kidney stones or pyelo, not really like a m/S strain, and it really doesn't look like a AAA IMO. There are a bunch of other things it could be, but palpable pain and dizziness really doen't give me much to go with. The key is the flank pain + dizziness...but I am really missing something or I'm just being dense. Hint? Link to comment Share on other sites More sharing options...
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