The evaluation of elderly with intra abdominal pathology on the emergency department (ED) is a challenging one, since they tend to have a very vague presentation. It is not unusual that the abdominal complains are fully at the background. The difficult evaluation and the high mortality rate makes this a very high risk group on the ED. For this reason it is very important for ED doctor to know the differential diagnosis and how to differentiate between them.
A 83 year old woman with parkinson’s disease was referred at night by her family doctor with dyspnoea and elevated temperature. She was believed to have a urosepsis. No abdominal pain was noted.
On presentation on the ED she clearly was short of breath, weak and she had an altered mental state. According to her son she was in fairly good condition the day before.
Her vital sings showed a heart rate of 120 beats/minute, respiratory rate of 30 breath/min, blood pressure of 90/60 mmHg and rectal temperature of 38.6°C. Her pulse oximetry was 95% with 5L oxygen via an oxygen mask. On physical exam she had a bulby, tender, hypertympanic, painful abdomen, without bowel sounds. On the outside was no herniation palpable.
The laboratory data obtained at admission showed low leucocytes with elevation of the CRP, lactate, lactate dehydrogenases, pancreas amylase and kidney functions. The arterial blood gas showed an respiratory fully compensated metabolic acidosis and there were leucocytes in the urine.
Since she was clearly in shock extensive infusion and antibiotics were started. The chest X-ray showed no new pathology, after which a CT of the abdomen was performed. This showed a very strongly dilated stomach with dilation of the small bowels filled with fluid, without free air. In the right lower abdomen a part of the small bowel was strangulated between the m. pectineus (1 in picture) and the m. obturatorius externus (2 in picture). Patient got an gavage and a operation was performed that same night under the diagnosis “incarcerated obturator hernia”.
During the operation a hernia sac was seen through the fossa obturatorium. This sac was mobilized and the herniation was reduced with loose sutures.
Postoperative the patient shortly went to the Intensive Care, but the postoperative process was without complications.
Currently she has left the hospital in good health.
This will be the last GMEP Fun Friday. We had a meeting last week with all webmasters and desided that things are gonna change on EMDutch. Just look at the new layout with the headers. One thing we all decided on was that we will put more real-life cases on the website (like “Blood on the floor and 5 places more”) and GMEP Fun friday will be out! So here is the (last) answer of last week: A patient who only shows cotton wool spots on fundoscopic exam next to several painless pigmented lesions on his cheeks and forehead probably has……AIDS!!!
That’s it folks! Keep following the new and improved EMDutch site!
Hello everybody, today we have a very interesting case for you (that was send to me by one of my great collegeaus and friends working in the Netherlands!) Sadly the forensic pathologist had to give the diagnosis, which is always a bad sign.
An 80-year old man came to the ED during a nightshift, after falling a few steps from the stairs. He was complaining of neck and back pain, pain in his left elbow and in his right wrist. It was uncertain if he had fallen on his head, but he had no loss of consciousness. Because he used marcoumar a CT-scan of brain was ordered which showed no traumatic brain injury. The CT-scan of neck, thorax and abdomen showed 2 vertebral fracture from C4 and T2 and 3 ribfractures (#1, 2, 7) on the right side with no pneumo-/hematothorax or vascular injury. In the thorax or abdomen no free fluid was found. In the extremities there was also afracture of the left elbow.
Welcome back to EMDutch and GMEP Friday! At first I have to apologies for 2 things. 1.) Still no post about PE…I know, but I have to work 6 days this week + 1 day with the kids, so the post had to waith. 2.) Their were 2 correct answers in the question from last week, which was: What does alcoholic ketoacidosis have in common with diabetic ketoacidosis? The correct answers were a Kussmaul respiration, but also a low serum insulin level. This means that 13/14 were correct! Great job!
Now the case + question for this week. First the case. (First take a look and the picture and see if you know what is wrong!)
The answer of last week was A: a pneumomediastinum does NOT always need a chest drain! 13/17 were correct!
Hope to see you next week! In the meantime the post “PE not as deadly as we think” is coming. It takes some more time since I am going to post it in a PPT which you all can en may use in your own hospital or for whatever reason you want.
HAVE A GREAT WEEKEND!
P.s. tell all your collegeaus about GMEP.org! Help build the greatest database out there!
Video night Essentials 2012June 5, 2013 at 19:00 – 23:00Amsterdam, at my homeIk ga aan mijn Essentials Of EM Digital Package 2012 beginnen. Vier congresdagen online te bekijken wanneer het uitkomt. Woensdag 5 juni zal ik beginnen met dag 1, en daaruit de meest interessante voordrachten k iezen om savonds te bekijken onder het genot van een hapje en een drankje.\