🚀 go-pugleaf

I've broken this post down into two parts, the first with the
additional questions asked, and this one with the differential
diagnosis list. Otherwise it was just too long.

 Incidently, the Student Nurses and the 'Medics are both doing well,
with one of each recognizing different parts of the problem. 


> 4.  It's the kind of call that makes us glad that diagnosis is not my 
>    responsibility. Guesses include:
>         -  Mastitis?
>         -  Retained placenta?
>         -  Necrotic stillborn retained in uterus
>       -  ? amniotic embolus, but it sure seems late.
>         -  Uterine hemorrhage or infection?
>         -  Post partum cholecystitis?
>         -  Hep? 
>         -  Hypo-Hyperglycemia
 
In a later post, the same couple who provided that extensive list
(yes, you may work as a team!) said:

> -  The following from our original list have been ruled out or just
>discarded because we don't think there's much clinical evidence to support them  
>(Yeah, we're teamin' up on you, but this case deserves it).

That's ok, medicine is an art and a team sport.

>         Omit the following:
>         -  mastitis - not consistent with pt. c/o
>         -  hypo/hyperglycemia - ruled out
>         -  retained placenta - ruled out
>         -  retained products of conception - ruled out
>         -  amniotic embolus -  Nope, don't think so.  
>         -  Uterine hemorrhage - Nope, ssx don't support bleeding in the abd.
 
> -  Leaving behind:
>         -  cholecystitis
>         -  hep
 
> O.K.  Shiloh and I both believe the entire post partum thing is a distractor 
>(and a very clever one at that.  Sucker the paramedics with something they don't see every day....)     

Which left one of two even close, and incidently, the post partum
thing is not a sucker punch, as I have seen a case post partum like
this.

Another 'Medic listed the diagnosis as:
>       First thing that comes to mind is her diaphragm...tear or hernia.  

which was close, but no cigar- there are at least four other things
that should be higher on the list.

The medic responded to the information with:
>       Ok, how about---ruptured uterus causing peritonitis
>                 apendicitis? although the pain is mostly RUQ?
                 >>

one of two getting warmer. (ruptured uteri would show up in the first
hours after delivery with continued severe abdominal pain and
bleeding. They are life threatening and often result in emergency
laparotomy if not emergency csection.)

but that is still not all of the problem!

One of our Canadian readers took a swing:
>        Dx - Rh incompatability - if this is possible - need blood type 
>(maternal,  paternal), Was Rhogam administered?
Mother A pos, infant AB pos (father's blood type not needed for Rhogam
determination)

>        Dx - Liver damage - RBC's have gone interstital and 
>have to sit in areas  with space - ie the orbits., hepatitis

 right area, wrong tree.

From a Student Nurse:
>       My guess would be HELLP syndrome, although I always 
>get confused on which side of the body the liver is on, right or left (great, huh?) =)
 
someone is getting warmer......

but that is not the only problem......

Some one else volunteered:

>Question 4: (for advanced credit...) What is your differential list of
>problems (diagnosis list) at this time.
>? Diaphrammatic hernia.
>? Thoracic aneurysm.
>? Appendicitis possibly ruptured.
>? Trauma/physical abuse.

one of four are involved.

and some one else added:
> add: pulmonary embolus (even though S/S suggest a 
>problem of clotting factors and vascular integrety)  Also: rule out 
>disseminated intravascular coagulation (DIC).  Longshot: CHF secondary 
>to cardiomyopathy?

again, getting closer with one of the three.

re read the additional information in the other post- everyone is
missing one or more facets of the problem.

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