🚀 go-pugleaf

On Fri, 31 Jan 1997 16:47:41 GMT, Krin135@AOL.com (Charles S. Krin, DO
FAAFP) wrote:


>You are called to the apartment of a 25 year old white female who has
>recently delivered a baby without problems. Pregnancy was normal, and
>both mother and child came home in three days. Mother has been breast
>feeding 10 minutes each side every 2 hours since discharge 2 weeks
>ago. You were called by the visiting nurse from the local Health
>Department who was checking on the new mother. The mother is somewhat
>distraught at the time of your arrival.
>
>Mother is complaining about right upper quadrant pain which has
>increased over the last week. She has also noted easy bruising. Her
>appetite is still down and mother has lost about 15 pounds since
>birth. She complains of puffiness in the face today.
>
>Vital signs: B/P 130/86 left, 128/78 right, pulse 100, temp 100.4,
>resp 20 and shallow- she states it hurts to breath.
>
>Primary and secondary assessment are completed, indicating mild facial
>swelling, Pupils are equal round and reactive to light. Eyes track
>well and together. Neck showes no nodes, masses, venous distension or
>nuchal signs.
>
>Lungs are clear with good air movement. Heart sounds are moderately
>hyper dynamic, but regular rate and rythem with a grade II/VI murmur
>heard best at the lower left sternal border.
>
>Abdomen is parous, soft, with reduced muscle tone. There is diffuse
>tenderness most impressively over the right upper quadrant and the
>supra pubic area. OB pad is in place, and shows a scant amount of
>bloody discharge.
>
>Extremities show no clubbing, cyanosis or edema. 
>
>Skin shows no jaundice, but multple small bruises are noted.
>
>Question 1: What other information do you want to get from the mother
>or the visiting nurse?

Has the baby been assessed and are there any similar symptoms?
Is there a partner?
Is the mother on any form of medication? e.g. Aspirin or other
anticoagulant.

>Question 2: How fast do you want to get this patient to the hospital?
Immediate admission.

>Question 3: What would your first treatment be?
Give oxygen via facemask, encourage controlled breathing.
Obtain venous access.

>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.

>Hint: When you hear hoofbeats, look for horses, but occasionally
>zebras will show up.
>
>Please respond by email if you think you have the diagnosis list,
>otherwise feel free to post to the group.
>
>
>Charles S. Krin, DO FAAFP
>Krin135@AOL.com KC5EVN
>"Reckless, Hell! I hit jus' where I was aimin'"
>   "Bubba Shot the Jukebox!" Mark Chestnut, 1995
>

"Smoke me a kipper, I'll be back for breakfast." 
 Ace Rimmer. (RD)

paul.canning@ukonline.co.uk (Paul Canning) wrote:

>On Fri, 31 Jan 1997 16:47:41 GMT, Krin135@AOL.com (Charles S. Krin, DO
>FAAFP) wrote:

inital post snipped
>>Question 1: What other information do you want to get from the mother
>>or the visiting nurse?

>Has the baby been assessed and are there any similar symptoms?
Baby is doing fine, and showing good weight gain.
>Is there a partner?
yes, would you like more information.
>Is the mother on any form of medication? e.g. Aspirin or other
>anticoagulant.
She takes Acetominophen for headaches

>>Question 2: How fast do you want to get this patient to the hospital?
>Immediate admission.
good
>>Question 3: What would your first treatment be?
>Give oxygen via facemask, encourage controlled breathing.
>Obtain venous access.
good
>>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.
only one of four even close. I've had some email responses already,
and have logged my responses with cc:s to myself to keep things
straight.

>"Smoke me a kipper, I'll be back for breakfast." 
> Ace Rimmer. (RD)

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

In article <5ct84c$oe4@news1.iamerica.net>, Krin135@AOL.com says...
>
>(case H&P snipped)
In addition to Dr. Canning's question list:
>
>Question 1: What other information do you want to get from the mother
>or the visiting nurse?

Has paroxysmal nocturnal dyspnea been noted?
Hx of bleeding disorders? (though that surely would have been 
mentioned...)
>
>Question 2: How fast do you want to get this patient to the hospital?
>
Rapid transport

>Question 3: What would your first treatment be?

Oxygen, high flow; venous access (after blood sample) with volume 
expander KVO for now, cardiac monitoring

>Question 4: (for advanced credit...) What is your differential list of
>problems (diagnosis list) at this time.

To Dr Cannings list, 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?

>Hint: When you hear hoofbeats, look for horses, but occasionally
>zebras will show up.

*I'd* be concerned if I showed up on a run like that. Anxiously awaiting 
the dx and remainder of the case study...