Once again another great case by Drs. Teresa Wu and Brady Pregerson in EP Monthly. Whenever I read their cases, I can actually imagine myself going through the case too. This is especially true for this one, as it is a prime example of how ultrasound can get you the diagnosis immediately, and how ultrasound can be utilized in the elderly and demented nursing home patients who get sent to the emergency department for “she just doesn’t seem normal” or, in this case, “abdominal distension”. Trust me, both can actually end up with the same diagnosis. It’s also a great entry as it speaks of a procedure that all emergency physicians should know how to do – it is too easy!
The case: “72-year-old male brought in by his nursing home aide for abdominal distension. He has a history of dementia and is primarily bedridden at baseline. The patient cannot give any reliable history, but on physical exam, his otherwise thin abdomen shows obvious signs of suprapubic distension. Your intern recaps his vital signs, which include tachycardia at 120 bpm, a blood pressure of 190/86 mmHg, a respiratory rate of 20/min, and a normal temperature and O2 saturation.”…. So, the differential diagnosis? Well, you should always think of the most emergent first, like an abdominal aortic aneurysm, which can also be diagnosed by ultrasound immediately – as discussed in a prior post of another elderly patient with altered mental status. (To see more sonocase posts in evaluating the altered patient, go here). Other badness? perforated bowel, volvulus, mesenteric ischemia, hemorrhage…. Oh, the list keeps going on and on when you have an elderly patient, a demented patient, a nursing home patient – or, in this case, it was all of the above!
Whenever I am evaluating the elderly patient with abdominal complaints, I think bedside ultrasound immediately (of course, with a very low threshold for CT scan since they can have anything happen! – and let’s be honest, they aren’t the ones we think about when we talk of the radiation risks… But, healthcare bill/cost? That’s a whole other conversation…). After as best of a history and physical exam that I can get (it can be challenging when they are demented and no caregiver at the bedside! Calling the nursing home is always done but usually they are too sick or the person on the other end of the line gives limited information), I bring my ultrasound machine and explore their abdomen: FAST (which also gives you a good look at the kidneys for hydronephrosis), Aorta, Gallbladder, Bladder, Bowel, +/- Pelvic/Testicular (depending on exam). Doing that may give you the answer, as in the case highlighted above…. to find out what they found and what happened to that patient, read on here. Trust me, you’ll love it.