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 abdominal pain  



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Author3 Posts
  #1

55 yo male

History:

heavy smoker (20 cigs/day for 20 yrs),
chronic stable angina,
NIDDM

Come to you with moderate abdominal pain of recent onset, severe dizziness and shortness of breath and blood in the stools.

Physical:

the pt. is very agitated.
BP = 95/65 supine, 70/50 orthostatism
HR = 180
RR = 30
systolic murmur best heard at the apex
distended neck veins
bilateral lung rales
generalized palor; cool extremities
diffuse abdominal tenderness, voluntary guarding, mildly distended abdomen
DRE: blood-streaked stools

Lab:

pH = 7.12,
SaO2 = 88%
ECG: supradenivelated ST segment in precordial leads, irregular rhythm
CXR: enlarged heart silhouette, blunted costovertebral angles, bilateral upper lobe infiltrates

The next logical investigation is 8) :

The most probable dx is grin : (be very careful)




  #2

The patient is a NIDDM - so he had a silent myocardial infarction (probably anterior) some hour before, then he developed atrial fibrillation or an intraventricular thrombus - the trombus embolised into a mesenteric artery producing a intestinal infarction (thus the blood in his stool)

The next investigation (this is always my weak point :roll: ) - probably some cardiac enzymes to confirm the AMI and/or abdominal XR


  #3

WELL DONE Deea!!!!!!!!!!!!!!
CONGRATULATIONS !!!!!!!!!!!!!!!!!!

Yes, the pt has MI and intestinal ischemia, probably secondary to chronic AF

There is still one aspect you did not notice - the patient is in shock - so the pt. has cardiogenic shock

The next investigation is ECHO - to see the ejection fraction
Also try to get the cardiac enzymes. Although not very useful right now.

Then ask an angigraphy = gold standard dx for ischemia

Treatment: O2, Morphine (also for pulmonary edema - present in this pt.), vasopressor drugs / Digoxin, depending on what you fing on ECHO
Ganz catheter - monitor fluid status





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