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Case Study: Sudden Severe Pain

Disasters Article CSI   (1,545 Views | 15 Replies | 335 Words)

SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

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How Good of an Investigator Are You?

A new case study in which the patient, D.C., a 52-year-old, white, married college professor wakes up to severe and intensifying pain. Though the coronavirus pandemic is sweeping the nation, his pain is so severe his wife drives him to the ER.

Case Study: Sudden Severe Pain
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If you think you know the correct diagnosis for this Case Study (CSI)...

DO NOT POST ANSWER HERE.

Instead, post your answer in the ADMIN HELP DESK.; We don't want to spoil it for others who are late in joining us. In a few days, after I post the diagnosis, the Admins will announce the names of those members who correctly identified the problem. We hope to turn this into a friendly competition with more Case Studies to come. You CAN post questions and post comments below. BUT... Do NOT post your diagnosis guess below.

History of Present Illness:

D. C., a 52-year-old, married, white college professor, woke up to severe and increasing pain in his right flank this morning. He came to the ER in acute distress with pallor, diaphoresis and significant anxiety (over his pain and over having to come to ER during coronavirus pandemic). He was in so much pain, he couldn’t sit still on the bed in the ER but continued to move around, constantly repositioning himself, groaning in pain and grimacing. He even vomited twice from the pain. He was given promethazine hydrochloride IV for nausea by the nurse. Due to his allergy to meperidine he was also given morphine IV for pain.

Okay super sleuths, what are all the possible reasons for right flank pain? As always, imagine you only get 5 questions. With that limit in mind, what information could you ask for that would give you the most information for a diagnosis? What labs do you want? What other diagnostic tests should we run? Ask me some questions!

A few other fun questions to think about:

What is the pathophysiology behind pallor and diaphoresis?

How does promethazine relieve nausea and vomiting?

REMEMBER: DON’T post the ANSWER HERE! Ask questions and I’ll give you more information.

Dr. Kristi Miller, aka Safety Nurse is an Assistant Professor of nursing at USC-Upstate and a Certified Professional in Patient Safety. She is also a mother of four who loves to write so much that she would probably starve if her phone didn’t remind her to take a break. Her work experiences as a hospital nurse make it easy to skip using the bathroom to get in just a few more minutes on the computer. She is obsessed with patient safety. Please read her blog, Safety Rules! on allnurses.com. You can also get free Continuing Education at www.safetyfirstnursing.com. In the guise of Safety Nurse, she is sending a young Haitian woman to nursing school and you can learn more about that adventure: https://www.gofundme.com/rose-goes-to-nursing-school

12 Followers; 60 Articles; 20,047 Profile Views; 376 Posts

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107 Posts; 939 Profile Views

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

Vital Signs?

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

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 60 Articles; 376 Posts; 20,047 Profile Views

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.

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DextersDisciple has 7 years experience as a BSN, RN.

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

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 60 Articles; 376 Posts; 20,047 Profile Views

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!

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southernemtphleb has 5 years experience as a EMT-B and specializes in Urgent care, Specialty.

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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?

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11blade is a RN and specializes in OR.

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ShootingPains.jpg

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 60 Articles; 376 Posts; 20,047 Profile Views

8 minutes ago, 11blade said:

ShootingPains.jpg

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

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NRSKarenRN has 40 years experience as a BSN, RN and specializes in Vents, Telemetry, Home Care, Home infusion.

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

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.

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 60 Articles; 376 Posts; 20,047 Profile Views

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-Hodgkins 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!

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 60 Articles; 376 Posts; 20,047 Profile Views

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 penis?

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 penis. He says, "My urine has been darker the last few days."

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SafetyNurse1968 has 20 years experience as a ADN, BSN, MSN, PhD and specializes in Oncology, Home Health, Patient Safety.

12 Followers; 60 Articles; 376 Posts; 20,047 Profile Views

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.

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