Beware the oldie with diarrhoea and abdo pain. It may just be gastro but most oldies have had gastro a few times in their life and usually wouldn't bother coming to hospital.Diarrhoea + abdo pain may be ischaemic colitis = ischaemic gut = mesenteric ischaemia. I got caught out years ago with a 70 year old with mild epigastric pain and diarrhoea: dead a few days later. Classic cases look like they are on deaths door (cos they are), are purple at the edges (shut down +++), very sore with a soft belly. "Abdominal pain out of proportion to abdominal signs." Milder cases can look well. If in doubt do a venous blood gas and lactate (though normal results doesn't rule out mesenteric ischaemia) Do amylase, LFTs. Add a troponin if they are really sick - they often have non-STEMIs as well, presumably from catecholamine release +++ Analgese and rehydrate. Get a big person to eyeball them sooner rather than later. In Australasia ischaemic gut gets treated with analgesics, aspirin and a heparin. (In the States they sometimes get embolectomies, angioplasties etc) Peritonism = bad. Peritonism and/or severe pain: If they are "young old" they might get a laparotomy +/- bowel resection. If they are "old old" they may just receive palliative care. Surgeons decide. All suspected cases should be referred to the surgeons. First seizuresECG in all first time seizures. Non perfusing arrhythmias may seizures due to cerebral anoxia So look for
Advise them against driving, swimming, bathing climbing ladders, working at heights for one year. Make sure you document that you have given this advice. There is no consensus regarding when to do CTs or MRIs on first time seizures. There is a very low pick up rate but it is generally agreed to CT to exclude intracranial nasties. If neuro exam is normal most first time idiopathic seizures can have an outpatient CT brain with contrast and physician (or neurology, if you are in a big centre) outpatient follow-up Pubic rami #s can be quite subtle. Any ? NOF in which you can't see a #d NOF follow all the curves of the pelvis ("the rings") and look for subtle cortical breaks.Here is one that was missed a few nights ago. The photo is not great quality but you will get the idea. Click on image to enlarge.  This prisoner "fell down a step" The XRay shows an abnormality that we will have all seen once or twice and will have forgotten about - and is easily missed. The joint space around the "mortice" - the talus should be equal on all sides. In this patient the talus has moved laterally relative to the tibia - there is "talar shift" or diastasis (separation) which means the syndesmosis (the ligaments holding the tib and fib together) has ruptured. This needs a diastasis screw to hold it together - speak to your friendly orthopod.  Respiratory rate for intubated patient with metabolic acidosis Should be approximately the same as their preintubation respiratory rate to maintain respiratory compensation |
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