so here we go guys.... (edited to change RR from 16 to 24)
#1: This is a REALLY busy, information dense post.... read and read again
#2: and please remember, this is a "suspend your disbelief" type scenario for teaching purposes.... yeah in real life, we'd get Os, IVs, monitors, and load and go w/ ongoing tx as dictated by time, etc....and you might not have anything but a BG.... we're trying to emphasize solid basic stuff that you may see again either on a cert exam or the exam of real life, hence the "20 questions" routine....
Clarification on injuries:
it was a tib/fib fx, approx 1 month ago and the cast was on the right leg.
spine was transverse processes(sp?) at L2-4
Fentanyl patches off.
LP12 (or machine o’ choice) on w/ leads and pads.
Temp: slightly cold ....95F /35 C
Foley in unless someone says no. 30mL slightly concentrated, dark yellow nonodorous urine out.
Vicodin – he takes 10/325 q 4-6 hrs. states he has taken 2 today per scrip for both chronic and post op pain. Denies current herbals, OTCs, or recreational. Aside from slight global weakness and predictive course of preexisting injury Appears Neuro Intact. Pupils: PERRLA GCS 15 MMSE: WNL somewhat less than excellent historian.
What was the significance of being told no JVD? Please discuss how this test should be done. In other words, almost everyone can display JVD under the “right” conditions. What increases your index of suspicion to pathology?
What was the significance of being told no pedal edema?
What was the significance of being told you had equal, bilateral BPs?
You have equal, somewhat erratic distal pulses (40-50bpm) X 4. Central pulses (brachial and fem x2) present. rate and regularity as per distal. What does this tell you with regards to hemodynamics?
Given that pt denies other OTCs and you don't have access to LFTs, etc, how would you rule in/out APAP OD on the basis of physical assessment/info given thus far?
Negative Trousseau’s. If you don’t know what this test is, please read on..... Trousseau's is a way of getting a feel for serum Ca++ levels in the field w/out labs... gotta have Ca++ for coordinated muscular contraction....use a bp cuff obliterate pulse downstream of brachial artery 2-3 minutes... spasming (sp?) is + for hypocalcemia http://www.turner-wh...r00_hypocal.pdf
(ANOTHER hat tip to Wes for introducing a great teaching point!)
You may have both an EJ an IO. Some one please take point, verbalize contraindications for each and state where you are placing them.
EJ whizzes: if needed, what can we do to get the EJ to “pop out and say hello” in a profoundly dehydrated pt? (you guys have no trouble visualizing and cannulating in this guy, but what if?)
Please calculate Anion Gap and discuss Anion Gap and Base Excess and their relationship to what has been presented thus far.
If the magic lab fairy was going to bless you with one more #, what would you pick and why? Do you actually need this # or can you safely treat empirically?
Bonus Points: discuss the oxyhemoglobin dissociation curve in light of the current labs, etc. right or left shift?
Now that you have labs, what is the consensus on MIVF, medications and your rationale?
Run through the labs and hx to date....thoughts?
As for second set of vitals, : BP 110/60 palpable HR of 40 (monitor varies but tachycardic) RR 24 SPo2 97
iSTAT Labs: Coags slightly elevated but WNL Cardiac Enzymes slightly elevated but WNL CHEM8+ 03M88-01
Sodium (Na) 138
Chloride (Cl) 95
Ionized Calcium (iCa) 1.16 mmol/L
Glucose (Glu) 170
Urea Nitrogen (BUN)/Urea slightly elevated but WNL
Creatinine (Crea) slightly elevated but WNL
Hematocrit (Hct) 45 (extra extra bonus points: is the "true" H&H [and BUN/Crea or other labs for that matter] higher or lower and why?)
Hemoglobin* (Hgb) 14.4i-STAT CG4+ 07G02-01 (venous #s)
I think we got everything....it was my turn to update, so any screw-ups or inadvertent omissions are on me.... post or send send a pm and i will clarify/correct asap....