doc_clotaire
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You are evaluating a 72-year-old man brought to the emergency department in an altered mental status. He lives alone, but his neighbors informed paramedics that the patient was complaining of abdominal discomfort earlier in the day. Paramedics noted that there is evidence of vomiting at the bedside at the patient's home. The patient is wearing a wristband identifying him as an insulin-dependent diabetic. His temperature is 38.3 C (101 F), blood pressure is 106/60 mm Hg, pulse is 86/min, and oxygen saturation is 94% on room air. He is moaning in pain and is flexing his hips. His mucous membranes appear dry, and chest auscultation reveals coarse crepitations. Abdominal examination shows a distended, tender abdomen with guarding and hyperactive bowel sounds. His extremities are warm with diminished distal pulses. During the physical examination, particular attention should be given to his
A. chest
B. groin
C. hips
D. neurological status
E. peripheral vasculature
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| farnsworth
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A?
one of the most common presentations of pneumonia in elderly is an altered mental status (hypoxemia, dehydration, low blood pressure, etc). Pneumonia in turn can lead to hyperglycemia (infection!), causing a variety of symptoms (abdominal pain, dehydration etc)
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| yuna
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agree with farnsworth, A. Other possibility is diverticulitis
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| Korotkoff
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I will vote for C. Something is wrong with his abdomen. I don't know whether it is appendicitis or intestinal obstruction.
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| equinoxe
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E? he absolutely needs fluids fast. (hTN, DM, dry membranes, probably hyperglycemic+SBO, alterned mental status, vomitus). the fever may be from sbo?dehydration?dm?...
Edited by equinoxe on 02/15/08 - 02:51 PM
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| Korotkoff
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how did you know it is Small bowel obstruction?
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| equinoxe
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my guess is that vomiting, abdominal guarding+distension+pain, and especially hyperactive bowel sounds... + htn due to vomiting and 3rd space fluid accumulation..
my other guess would have been mesenteric angina, similar picture minus hyperactive bowel sounds...
fluids+surgery ?
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| Korotkoff
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You are right. But it could also be large bowel obstruction. I think the question is asking which finding should draw our attention. This patient is flexing his hip because he is having severe abdominal pain. We know this patient needs fluids. We should rule out acute abdomen first. I have to grab C again.
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| equinoxe
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you are right, it could be large bowel obstruction. the main cc is the abdominal pain. I'd say SBO due to the vomiting, sbo more prone to vomiting than LBO. The PE should focus on the abdomen, but there's no choice for this. B would be nice if there were any mentions of hernia (incarcerated), but since no suggestive hx, Id chose smth related to fluid depletion which needs urgent action
though as I reread the q it sounds really strage ... what exactly do you understand that the q asks for?
Edited by equinoxe on 02/15/08 - 03:23 PM
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| farnsworth
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this could really be anything: ileus, urosepsis, pancreatitis (hips/flank - C), poisoning w/ TCAD/SSRI (D), etc...
for a diagnosis more information is needed.
Personally I would favor the 'bowel obstruction'/ileus theory. Dry mucus membranes indicate a fluid deficit. In contrast to that: the extremities are warm -> sepsis (patient does not meet sepsis criteria at this point!). In a septic patient the 'peripheral vasculature' is not a good indicator of the volume status (if it was, we could refrain from sticking central lines, arterial lines, pulmonary artery catheters, and other fancy stuff into the patient), so I would not go for E.
In the exam I would still make my mark on A: pneumonia (coarse crackles can appear!) w/ fever, altered mental status, abdominal pain, most probably associated w/ hyperglycemia. But again: this is just an educated guess.
Doc_Clotaire: excellent case!
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| Korotkoff
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As I paraphrased the question for myself: Which finding from what you saw should bother you the most?
That is why I picked the flexed hips.
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| farnsworth
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Strategy:
monitoring: pulse oximetry, HR, BP
Oxygen
IV lines (if possible: 2 large bone peripheral IVs, 14G), fluid resuscitation w/ acetated Ringer's (or lactated Ringer's)
pain medication (whatever one prefers, I would go for fentanyl, easy to titrate, fast onset)
-> draw blood (Chem 14, LFT incl PT/INR, PTT, D-Dimers, trop I, CPK, CBC, IL-6/PCT, glucose, LDH, lactate!, Lipase, type/crossmatch for PRBCs), blood cultures
12lead ECG (can be done in the ER, just to rule out myocardial ischemia in a pre-septic patient w/ pre-existing DM)
CXR and AXR
while the CXR and AXR are printed, insert arterial line (ABGs!) and a central line (for measuring the CVP and SvO2, therapeutic goal: SvO2>70%, 'early goal directed therapy' w/ fluids, intropes, RBC (in that order)!)
Foley catheter, U/A, toxicology screen.
if the AXR comes back inconclusive: CT abdomen. A smart radiologist will do this with and without IV contrast agent. Why with IV contrast: modern CT machines have such a good resolution, that you use this as a CT angiogram (mesenteric ischemia!). Do a CT thorax, too. Takes another 30sec (pneumonia? pleural effusions? pulmonary embolism?)
Meanwhile the D-Dimer values should come back: negative -> thrombembolic event excluded.
Increased lactate levels (>2mmol/L): most probably due to mesenteric ischemia. Will the CT angiogram you should already know if this is due to a thrombembolic event or by mesenteric angina due to the relatively low perfusion pressure). Most modern ABG machines give you lactate.
This procedure takes less than 30 min with a good team (including CT, central line, arterial line, CXR, AXR, Foley etc).
So at this point you should have the diagnosis and go either to the OR (ileus, mesenteric ischemia) or got the ICU (pneumonia, DM, pancreatitis...)
You still haven't ruled out endocarditis, which could also cause fever and thrombembolic events (the blood cultures will take a couple of days to give a valid result, if ever!). But this is an improbable diagnosis and could be easily ruled out with an TEE...
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| equinoxe
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more info needed. 
A rephrase "what would you (re)examine for more info" would lead to ... A to look for pneumonia?, B to look for hernia?, C to look for fractures/arthritis?, D to look for delirium?, E to look for shock/pulse/bp
I wouldn't chose C or D. I'd bet on E since it excludes an emergency.
nice one. step 3? 
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| Korotkoff
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I won't bet on any of those but I think the answer is C.
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| doc_clotaire
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Waooooooooo .........It s getting hot in here I like that !
This generation is pretty clever man ( I am old school here ) but I am sorry fellows , none of you got the right answer and explanation 
Please try again !
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| Korotkoff
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I gave up!
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| farnsworth
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C'mon Korotkoff, don't give up.
But the clinical situation is so ambigous, could even be meningitis (D)...
Or just 'simple' hyperglycemia (insulin resistance, decreased resorption from injection site).
I am really looking forward to seeing more input.
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| equinoxe
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distension+guarding+hyperactive bowel sounds+started this morning+vomiting+dehydrated: obstruction. if it's not E, then B: check for incarcerated hernias, 2nd mcc obstruction. crackles+fever can be from vomitus aspiration+living alone. DM not sure what it means except maybe aggravated.
B?
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| farnsworth
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If it is bowel obstruction and the patient aspirated, than it would be (A) again. The obstruction can be fixed surgically, but the patient is prone to developing an aspiration pneumonitis, which can turn into a full-blown ARDS (mortality somewhere between 40 and 50%! Especially with co-existing diseases like DM....)
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| equinoxe
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damn - is ck that vague?
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| farnsworth
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no CK is not that vague (passed that), I hope Step 3 is not that vague.
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| Korotkoff
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doc_clotaire must be kidding. At least one of us will get the answer right. I couldn't think of how D would be the answer.
That is why I quit.
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| sandra
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guys..this man is dehydrated due to vomitting ( intestinal obstruction)...anyways, whatever the reason, he is clearly dehydrated. he is a type 2 diabetic...most important thing which should strike u....
HYPEROSMOLAR COMA!
so D
am i right doc?
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| sandra
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guys..this man is dehydrated due to vomitting ( intestinal obstruction)...anyways, whatever the reason, he is clearly dehydrated. he is a type 2 diabetic...most important thing which should strike u....
HYPEROSMOLAR COMA!
so D
am i right doc?
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| RX 135
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can it be poisoning...old man livin alone food poisonin,drug,medication,...d
can explain fever ,colic,diminshed pulse,vomiting,
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