EM Case Quiz
Ok, I know I’m not posting as much but I need to wait for something to inspire (or infuriate) me. Here is a case that did:
78 y/o male with HTN and High Cholesterol but no other known cardiac disease presents with generalised weakness over about a 1 hour period. His family said he just said he did not feel well and went to lie down on the sofa. He soon was found to be semi-responsive so they called 911. Medics found him with AMS but rousable and a HR of 140 and an SBP of 90. Fingerstick normal
In the ED his vitals and appearance were very similar. He would rouse and described some vague abdominal discomfort but was more or less semi-conscious. He had a temp of 100.8, was tachy and hypotensive. Lungs clear abdomen mildly distended and slightly tender. Skin pale. EKG showed rapid Afib (pt had no prior history).
CXR normal, WBC 20K, lactate 5.8, Cr 2.0
What is it? I’ll tell you what I thought it was (and what I did for him) and what it turned out to be in the answers.
Thursday, February 14th 2013 at 5:49 am |
? Gut ischemia/ septic with overlying cardiac stress resulting in +/- MI?
Ct abd fluids surg consult?
Thursday, February 14th 2013 at 7:26 am |
Agin leading to mesenteric ischemia from thrown clot
Thursday, February 14th 2013 at 7:46 am |
This is mesenteric ischaemic until proven otherwise. Resuscitate and consider suitability for urgent laparotomy +- CT first if stable enough.
Thursday, February 14th 2013 at 9:23 am |
Bladder obstruction leading to ARF. Low bp from kidneys inability to concentrate urine and low abd pain from a distended bladder. I know it’s probably wrong but I encountered this in a 80+ y/o male with the same presentation about six months ago.
Thursday, February 14th 2013 at 9:25 am |
I take that back. I missed the Cr. the guy I saw had an outrageous BUN/Cr and a GFR of 1. Never-mind. Idk what it is.
Thursday, February 14th 2013 at 2:30 pm |
AAA
Thursday, February 14th 2013 at 2:53 pm |
Badness. Unspecified. (What do you expect, I’m just a chaplain…)
Thursday, February 14th 2013 at 3:39 pm |
My best guess is mesenteric ischemia due to thrombus.
Friday, February 15th 2013 at 7:56 pm |
Could it be his appendix?
Friday, February 15th 2013 at 10:45 pm |
Ruptured AAA diagnosed via US, resuscitate with blood products, to OR.
Saturday, February 16th 2013 at 7:02 am |
Ok. The answer.
I figured it was dead bowel from mesenteric ischemia given the new onset afib. I fluid resuscitated him and was preparing him for CT but he remained hypotensive and I had to start pressors.
The CT scanner was malfunctioning and it was delayed. Eventually he got scanned with a BP of 60 and it showed…..
A leaking AAA. Went to the OR but didn’t make it.
Saturday, February 16th 2013 at 10:38 pm |
Why not do a quick US? See the AAA, you got your diagnosis.