tompat
Forum Elite
Topics: 36
Posts: 312
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my guess is some sort of intestinal obstruction and then release of toxins or bacteria in blood stream. here diabetic keto-acidosis might cause warm shock. it may further deteriorate to hyperosmotic coma. q ask us what u wud moniter next. it shud be neurological status.
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| tompat
Forum Elite
Topics: 36
Posts: 312
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ok, this one is asking us to nail the cause of his condition. initiating factor cud be incarcerated hernia so we have to pay attention to groin.
he never had complains of cough or high fever before this so pneumonia can not be the initiating factor. crackels can be seen in shock lung.
as he was having pain in abdomen incarcerated hernia suits better here, add to that the vomiting and hyper active bowel sounds.
toxemia causes warm shock.
altered mental status does not give any information as in can be seen in toxic shock or hyper osmosis due to DM.
so particular attention shud be given to groin.
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| equinoxe
Topics: 15
Posts: 77
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doc - I am looooooking forward for a long explication, references, suggestions...
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| docnikki
Forum Guru
Topics: 93
Posts: 680
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abd tender and hyperacrtive bowel sounds...and SEVERE abd pain..leading to vomiting and aspiration...
and the quest asks During physical exam particular attention should be given to..."
it seems they are asking in a way the cause of these symptoms... from where they originated
I feel the incarcerated hernia is the most likely. cause and hence particular attention should be given to the groin..and its imp to deal with the cause...to relieve the symptoms...if the hernia is not adressed early the old man will decompensate...so I guess its groin.
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| mildus
Forum Guru
Topics: 19
Posts: 614
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really an interesting case, I don't have anything to add, it seems to me like ileus, there are also some features of diabetic ketoacidosis (it can go with pseudo- acute abdomen, but dehydration is more with diabetic hyperosmolar state), features of pneumonia (fever, crackles, but crackles can also appear in ARDS), altered mental state in elderly is not specific. Maybe the groin should be inspected first, as all ileus cases PE starts with searching for hernia
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| doc_clotaire
Forum Guru
Topics: 159
Posts: 1,245
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Here is the answe to that SUCKER .... It s from Kaplan Q bank step 3
Enjoy fellows ! 
Explanation:
The correct answer is B. Hernial sites must be examined to complete any acute abdomen evaluation. Incarcerated or strangulated hernias in an elderly patient can cause acute abdomen, dehydration, and altered mental status. Failure to diagnose an incarcerated hernia at an early stage can lead to strangulation.
An incarcerated hernia causing bowel obstruction leads to nausea and vomiting and may result in aspiration to lungs. Coarse crepitations on auscultation (choice A) may be the result of aspiration and to prevent further aspiration, it is important to diagnose and treat the incarcerated hernia.
Hip fractures are common in the elderly. This patient's lower extremity is in an abducted position and shortened. Flexed hips might be due to an incarcerated hernia in this patient (choice C).
Altered mental status in an elderly patient might be due to widely spread reasons including metabolic (diabetes, dehydration), respiratory (pneumonia), neurological (intracranial bleeding), abdominal, or due to ischemia from lower extremities in advanced stages. In this patient with abdominal signs, while his neurologic status (choice D) and peripheral vasculature (choice E) may be abnormal, with his symptoms and physical findings, an incarcerated hernia needs to be ruled out, and therefore particular attention should be given to his groin.
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| RX 135
Forum Elite
Topics: 21
Posts: 509
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 ...thanks doc...
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:-( :-( :-(...
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| shakespeare
Forum Newbie
Topics: 4
Posts: 15
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please don't post qs for step 3 here, it's frustrating.
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Herz und Mund und Tat und Leben
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| elixir
Forum Newbie
Topics: 1
Posts: 10
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wow,that was a toughie. u had me thinking it was DKA with severe abdominal pain and that neurological status(D) should've been checked for impending coma
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| sherry39
Forum Junior
Topics: 3
Posts: 105
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ddddddddddd...coz dehydration is putting him to a risk of DKA...coz acidosis superimposed on other enha n cause deathnces danger
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| sherry39
Forum Junior
Topics: 3
Posts: 105
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ddddddddddd...coz dehydration is putting him to a risk of DKA...coz acidosis superimposed on other enha n cause deathnces danger
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| Miradautas Vras
Forum Senior
Topics: 8
Posts: 154
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Step 3
the horror...the horror..
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Man who fights too long against the dragons becomes a dragon himself.
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| gray10
Forum Newbie
Topics: 0
Posts: 1
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Hi, have been following discussion.
Just a question from NBME.
Is it mandatory here in the USA for a person
who dies in ED after RESUS to have a autopsy.
Can the family refuse.?
Thanks
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| WaqasQureshi
Forum Junior
Topics: 3
Posts: 116
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I dunno why am I gettin it as STRANGULATED HERNIA
examine GROIN
B
I would have gone for neurological status too but that wont change the maangement
whats the answer dr
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| Jcala
Forum Junior
Topics: 10
Posts: 44
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B
Abdominal distension + Increased bowel sounds + dehydration.. could be strangulated hernia.
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