🚀 go-pugleaf

In a message dated 97-02-03 11:47:48 EST, Jerry writes:

<< 
(1) How long has the pt's temp been elevated (I'm assuming the temp is
     oral)?  Is there any known pattern of variance?
she felt feverish yesterday, but did not take her temp.

 (2) Is there any obvious reason for the pt's emotional distress
     (the nature of the nurse's visit, response to pain, etc.)?
     How was she when the nurse first arrived?  Any other temporal Hx
*
 
 (2) Is the pt the contact the visiting nurse was sent to interview?
     Or a sexual partner of the contact?
 *
 (3) Is there any pain, erythema, d/c, or cracking around the breasts?
 breast exam indicates normal lactation, with good milk let down

 (4) Is there any prior history of a heart murmur?  Can you describe
     the murmur?
 murmer is holosystolic, soft and "swishy"

 (5) What is the position of the uterine fundus?
 firm and palpable at the pubic line

 (6) Has there been any change in the characteristics of the vaginal
d/c
     other than the previously noted decrease in volume?  
 occasional odor

 (7) Is the liver noticably enlarged?
yes
 
 (8) Is there any temporal relationship between the abd pain and food
     intake, urination, or defecation?
 some increase in nausea with eating only.

 (9) One of the previous answers noted a recent "increase in
urination."
     Is that incr. frequency, output, or both?  Has there been any
     coincident increase in fluid intake?
 appetite is down due to nausea, but she is tolerating fluids well.

 (10) Is there any flank pain of CVA tenderness?
some right flank tenderness
 
 (11) Was there any Hx of PIH?
borderline
 
 (12) If a 12-lead EKG is not available, are there any abnormalities
      (other than rate) noted in MCL2 or MCL3?
 *

 (13) Are there any signs of intestinal obstruction?
* 
 (14) What is the recent food intake?  Does the pt have a hx of
diabetes?
 * and no.
 
(* indicates answers already posted in the newsgroups)

 Some random thoughts:
 
 
 Unless there is an obvious cause for the pt's emotional distress,
 I would consider that in conjunction with the tachycardia might be
 early signs of shock.  I'd administer high flow O2 and make
 note of any changes in pulse rate or mental status.
good
 
 Given the above and the increase in abdominal pain, I'd start a
 large-bore IV NS or LR TKO.
why TKO?
 
 If I remember correctly, the location of the murmur is in the right
 ventricular area.  Assuming recent onset, that would be consistent
 with a pulmonary embolus - although it seems late for embolus from
 the uterus at this point.
try again.
 
 My first assumption is that the increased RUQ pain on inspiration
 is caused by pressure applied by the diaphragm to the liver,
gallblader,
 or possibly the pancreas.  Is it possible it might be referred from
 the diaphragm itself or from a supradiaphragmatic origin (lung
 parenchyma, pleural adhesion)?
 your first thought is close but no cigar for the second.

 The blood glucose seems high given the stated decreased appetite.
 Perhaps this and the increased bruising are evidence of some sort
 of liver pathology.
yes, you are getting warm
 
 Given that the infant is AB+ and the mother is A+, I'd consider the
 possibility of a fetal->maternal transfusion during birth with
 subsequent immune reaction to the B antigen.  I'm not sure how likely
 this would be, though.
 fairly slim this far from delievery.

Another Nursing type took a gander and sent:
In a message dated 97-02-03 17:21:58 EST, you write:

<< 
 I am replying to you alone and not the list simply because I cheated
a bit.  I gave the list to two of my instructors and a few LVN's in my
class....well, here it is...
 
 #1.  find out the color and odor of lochia, assess urinary
elimination patterns
 mild to moderate lochia rubia, with occasional foul odor, increased
frequency with out dysuria.
 #2.  get her there soon
 good
 #3. forgot what they said...sorry
 
 #4.  Probable thrombophlebitis, HELLP, and cholecystitis...possible
UTI and PID
 three of five work well

 Mabye I got close...if nothing else, I spent countless hours thinking
and reading my books to try to figure it out.
 
 Melinda



I definately incourage cooperation: 
"Cooperate and Graduate" (class motto)
 "Medicine (including Nursing) is an Art and a Team sport!"

That's about it for this case.

I'll be posting the rest of the answers tommorrow night.

ck

Charles S. Krin, DO FAAFP
KC5EVN Krin135@AOL.com
"Reckless, Hell! I hit just where I was aimin'"
"Bubba Shot the Jukebox," Mark Chestnut 1995