RehabEdge Physical Therapy Forum

Forums  Register  Login  Forgot Login?
  My Profile 
My Subscription
  My Forums 
Search
  FAQ  Log Out
Follow @RehabEdge

Feb case 2

 
Logged in as: Guest
Users viewing this topic: none
  Printable Version
All Forums >> [RehabEdge Forum] >> Medical Complexity >> Feb case 2 Page: [1]
Login
Message << Older Topic   Newer Topic >>
Feb case 2 - February 24, 2008 1:12:34 AM   
Dr.Wagner


Posts: 1242
Joined: January 25, 2003
From: Indianapolis
Status: offline
You are currently working with a patient you have have been seeing post TKR in a rehab facility (ECF).  He has been progressing well and you will be able to discharge him soon.  During a rehab session he complains of middle back pain in addition to his post operative pain.  You find out that he did fall this morning while attempting to transfer from his bed to a chair.  His pain is deep in the back and "aching" it is non radiating.  He tells you it is bad enough to vomit. You are able to order an xray.

Here are the films.
Would you like any additional information?





Attachment (1)

< Message edited by Dr.Wagner -- February 24, 2008 1:17:22 AM >


_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum
Post #: 1
RE: Feb case 2 - February 24, 2008 1:13:17 AM   
Dr.Wagner


Posts: 1242
Joined: January 25, 2003
From: Indianapolis
Status: offline
2





Attachment (1)

_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to Dr.Wagner)
Post #: 2
RE: Feb case 2 - February 24, 2008 1:13:48 AM   
Dr.Wagner


Posts: 1242
Joined: January 25, 2003
From: Indianapolis
Status: offline
3





Attachment (1)

_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to Dr.Wagner)
Post #: 3
RE: Feb case 2 - February 24, 2008 5:22:18 AM   
Sebastian Asselbergs

 

Posts: 2293
Joined: September 30, 1999
From: Barrie, Canada
Status: offline
How/why did he fall? How are the breath sounds? And how are the bowels and bowelsounds...
For starters...

(Thanks Wags - for these)

_____________________________

Mundi vult decipi

(in reply to Dr.Wagner)
Post #: 4
RE: Feb case 2 - February 24, 2008 7:43:38 AM   
T_Thom

 

Posts: 63
Joined: December 26, 2007
Status: offline
(Did you read this weeks Medscape/eMedicine case, Sebastian? )

< Message edited by T_Thom -- February 24, 2008 7:46:46 AM >

(in reply to Sebastian Asselbergs)
Post #: 5
RE: Feb case 2 - February 24, 2008 2:52:37 PM   
Sebastian Asselbergs

 

Posts: 2293
Joined: September 30, 1999
From: Barrie, Canada
Status: offline
nope....

_____________________________

Mundi vult decipi

(in reply to T_Thom)
Post #: 6
RE: Feb case 2 - February 24, 2008 7:59:47 PM   
kamryn


Posts: 27
Joined: February 23, 2008
Status: offline
In addition to the above:
1. did the pain come on immediately following the fall?
2. any current SOB or difficulty breathing?
3. is there a lateral view of the t-spine? 
4. past medical history and current meds?

(in reply to Sebastian Asselbergs)
Post #: 7
RE: Feb case 2 - February 25, 2008 12:25:53 AM   
bonez

 

Posts: 701
Joined: August 29, 2007
Status: offline
There appears to be significant air below the diaphram. additionally the cardiac shadow appears deviated to the right along with the trachea. I assume that he percusses like a drum and has difficulty to lay and breathe.
Did he break a rib falling which has accounted for the air distortation esp below the diaphram? There is a significant amount of air in the bowel too.

(in reply to Dr.Wagner)
Post #: 8
RE: Feb case 2 - February 25, 2008 3:32:15 AM   
Dr.Wagner


Posts: 1242
Joined: January 25, 2003
From: Indianapolis
Status: offline
Difficulty breathing; pain with each breath. 
Very little injury or pain at the time of the fall.
Abdomen is soft, non distended, but painful to palpate.
Breath sounds are equal bilat
abdominal sounds are overactive.
Past medical history is 1. Depression, 2. Hypertension, 3. NIDDM, 4. Reflux
Meds: Zoloft, diovan, atenolol, glucophage, pepcid, alprazolam, ibuprofen, vicodin


_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to bonez)
Post #: 9
RE: Feb case 2 - February 25, 2008 4:43:20 AM   
jlharris


Posts: 486
Joined: April 13, 2006
From: Oregon
Status: offline
The above chest xray doesn't seem to fit with the rest of the clinical presentation as well as the other xrays provided.  It seems to be a tension pnuemo especially what appears to be a chest tube in the upper left chest and no free air below the diaphram as seen on the abdominal films.

With this amount of free air under the diaphram, I hope the pt has been sent to the OR to repair what is most likely a small bowel (or other hollow viscus) injury.  It is common to see this with chance fx's of the Tx and Lx spine.  With his scenario of back pain and recent fall, this would be first (with xray) on my DDX.

Also, if pt has been taking a large amount of NSAID's (or hx of ulcer disease) this could lead to a ulcer perforation of the bowel.

One could also see a psuedo obstruction d/t narcotics which, left untreated, could proceed to perforation of the right colon. 

_____________________________

Jason L. Harris, PT, DPT
My PT Blog

(in reply to Dr.Wagner)
Post #: 10
RE: Feb case 2 - February 25, 2008 6:49:57 PM   
Dr.Wagner


Posts: 1242
Joined: January 25, 2003
From: Indianapolis
Status: offline
HAHAHA!

Yes, I have put together multiple films and accidentally included one with a chest tube.

This patient had a ulcer (GERD history) and developed a perforation with NSAID usage.

Sometimes when I do not have the films myself, I put them together (hence the Medscape images).


Perforation of peptic or duodenal ulcers are acute surgical conditions which have rates of mortality that increase with time from onset. 
The fall was incidental.


_____________________________

Dr. Wagner DO
Moderator of Medical Complexity Forum

(in reply to jlharris)
Post #: 11
RE: Feb case 2 - February 25, 2008 8:47:13 PM   
jma

 

Posts: 2638
Joined: August 25, 2000
From: NY
Status: offline
That was definitely a good case. Long term NSAIDS do their damage in the long run. Unfortunate.

(in reply to Dr.Wagner)
Post #: 12
RE: Feb case 2 - February 26, 2008 12:31:09 AM   
jlharris


Posts: 486
Joined: April 13, 2006
From: Oregon
Status: offline
BTW, I have to admit that I cheated in my answer.  My wife is a general surgeon and she pointed out the chest tube and Chance fx (which until that point I'd never heard of).  I did come up with the perforated bowel d/t NSAIDS myself (where else would free air come from).  Thanks Doc.

_____________________________

Jason L. Harris, PT, DPT
My PT Blog

(in reply to jma)
Post #: 13
Page:   [1]
All Forums >> [RehabEdge Forum] >> Medical Complexity >> Feb case 2 Page: [1]
Jump to:





New Messages No New Messages
Hot Topic w/ New Messages Hot Topic w/o New Messages
Locked w/ New Messages Locked w/o New Messages
 Post New Thread
 Reply to Message
 Post New Poll
 Submit Vote
 Delete My Own Post
 Delete My Own Thread
 Rate Posts



Google Custom Search
Forum Software © ASPPlayground.NET Advanced Edition 2.5.5 Unicode

0.125