Case Study: Sudden Severe Pain

10 minutes ago, 2Ask said:

Labs: CMP; Liver panel; amylase & lipase; CBC

Vital Signs?

Any urinary symptoms? Any aggravating factors such as fatty foods?

Good questions! More to come next week. No fatty foods- I’ll give you that one now.

54 minutes ago, DextersDisciple said:

A full set of vital signs and PMH please. Also any imaging of KUB like US or Fluoro?

You will definitely get those next week. Thank you!

8 minutes ago, 11blade said:

This made me laugh so hard I got a shooting pain in my side!

Any blood in the urine, difficulty voiding, change in urine output, any diarrhea, pain at tip of member?

Urinalysis results?

Sometimes paleness and sudden excessive sweating/ diaphoresis can be caused by an emotional state like panic due to severe pain.

Promethazine is in a class of medications called phenothiazines. It works inhibiting dopamine, muscarinic and histamine (H1) receptors generally in the vomiting center and in the stomach.

First, an answer to my questions:

What is the pathophysiology behind pallor and diaphoresis?

Pain stimulates the fight or flight response which causes the release of catecholamines. Adrenaline has a variety of effects including enhancing perspiration (or diaphoresis, which prepares the body for the increase in temperature associated with fleeing/fighting), dilation of the pupils (which increases light sensitivity, but reduces acuity), dry mouth (gastric juices and saliva production decreases because blood flow to the digestive system is decreased), enhanced smell and hearing, and a cool, pale skin.

How does promethazine relieve nausea and vomiting?

Promethazine is a phenothiazine (antipsychotic) derivative with very weak dopamine receptor antagonism, that also blocks H1 receptors. It produces clinically useful anti-emetic and sedative effects.

And now on to the case...

Past Medical History:

• Tonsillectomy for chronic earache and sore throat, age 6
• Zenker diverticulum, age 48
• Renal stones: ages 35, 44, 50 (all passed spontaneously)
• IgG immunodeficiency disorder, secondary to Non-Hodgkin's T cell-rich B-cell lymphoma, age 48, treated with 6 monthly sessions of CHOP, currently in remission.

Social History:

Does not smoke or drink, runs 20-30 miles per week. Training for marathon and has increased mileage on his runs. States, “I keep forgetting to bring enough water on my runs.”

Medications:

• Rabeprazole for acid reflux for Zenker diverticulum (ZD)
• Gamma globulin infusions once every 5-6 weeks for immunodeficiency
• Multivitamin daily
• Chewable 500-mg vitamin C tablet daily to boost immune response. Increased to 1000-mg daily since threat of coronavirus has entered the US.

Allergies: Meperidine

Review of Systems: only abnormal values presented

• Skin: Pale, cool, and clammy without lesions or bruises
• HEENT: Difficulty swallowing related to ZD

Vital signs:

• BP 132/84 sitting, RA
• HR 88
• RR 17
• T 98.5oF
• HT 6’
• WT 190 lbs

Laboratory Test Results:

• Na 139 meg/L
• K 4.2 meq/L
• Cl 103
• Mg 2.0 mg/dL
• PO4 2.8 mg/dL
• Ca 10.1 mg/dL
• Uric acid 6.2 mg/dL

I hope there's something in there to help you with your diagnosis - more to come in a few days!

On 4/11/2020 at 4:44 PM, NRSKarenRN said:

Any blood in the urine, difficulty voiding, change in urine output, any diarrhea, pain at tip of member?

Urinalysis results?

Sometimes paleness and sudden excessive sweating/ diaphoresis can be caused by an emotional state like panic due to severe pain.

Promethazine is in a class of medications called phenothiazines. It works inhibiting dopamine, muscarinic and histamine (H1) receptors generally in the vomiting center and in the stomach.

Thanks for answering my questions - I'll get you the UA by the end of the week. No blood in the urine, no difficulty voiding, no diarrhea, no pain at tip of member. He says, "My urine has been darker the last few days."

On 4/11/2020 at 12:40 PM, southernemtphleb said:

Where and what types of foods have you eaten in past 48 hours? Last BM? Is pain localized to R Flank? Colonoscopy/GI records? History of GI problems?

He's eaten his normal diet: oatmeal and yogurt for breakfast, a sandwich for lunch and fish and salad for dinner one night and pizza the other. Last BM was the evening before admission. Pain is localized to R flank. I just posted his medical history - check it out! Thanks so much for participating.

Some of the more common causes of flank pain include:

• a kidney infection
• a kidney abscess
• kidney stones
• dehydration
• a bladder infection
• shingles
• Tietze’s syndrome
• arthritis, especially spinal arthritis
• a spinal fracture
• disc disease
• a pinched nerve in the back
• a muscle spasm

Less common causes of flank pain include:

• kidney disease
• pneumonia
• pancreatitis
• appendicitis
• a blockage in the urinary tract
• an inflammatory bowel disease, such as Crohn’s disease
• a renal infarct, which occurs when a blood clot blocks the blood supply to the kidney
• shingles
• an abdominal aortic aneurysm