EM Forum Case #115 "I Have Pain
Every Day!"
by Charlene Babcock Irvin, MD, FACEP
“I have pain every day,” was the chief
complaint translated into English.
She was a 38 y/o farm worker who presented
to our remote clinic at a village in South
America during a medical mission trip.
A Lutheran Church in Utica
Michigan sponsored the mission
trip. We brought our own
medications and a pharmacist
with us. We also had medical
technologists (who could do
CBC’s, UCG’s, Glucose, stool for
Ova or parasite, Urine analysis,
and HBG analysis). There was
also a dental arm (who mostly
pulled teeth) and a free
eyeglass arm that tested and
then gave away used eyeglasses
(I personally thought this had
the biggest impact).
This particular patient
complained of chronic joint pain
for some time (it took a long
time to understand it was joint
pain and not total body pain; a
challenge with translation). She
also noted she felt very tired,
and had a sore on her leg, which
wouldn’t heal. She had been
putting hydrocortisone cream on
it, but it never goes away. She
has to walk several miles from
her home to the farm where she
cooks, and she often has to stop
because she gets tired and short
of breath. It has been getting
worse, and she becomes tearful
when she describes how she
feels. She continues to get
worse and she doesn’t know what
she can do.
PMH: No
hospitalizations, delivered one
child at home.
SH: No
smoking and lives with her
mother and her son.
Meds:
Ibuprofen prescribed by the
village doctor, which didn’t
help. Also 2 tubes of
hydrocortisone cream, with
little improvement in the leg
sore.
PE: Vital signs:
BP=148/88 HR=110 RR=20, Temp-98,
Sat =98
She appeared
comfortable in no acute
distress.
HEENT: Normal
except some oral ulcers were
noted on the buccal mucosa in
the mouth. These were
non-tender.
Neck: Supple
Heart: RRR with very distant
heart sounds, no murmurs
Lungs: Clear
Abd: Soft
non-tender, scaphoid
Ext:
Large (6 x 5 ulcer on the left
pretibial area of the leg. Per
the translator, has been there
for 8 months, and gets better
with some creams (but never goes
away), but then gets worse when
the creams are stopped. She also
has pain and swelling to
multiple joints.
Neurologic: Normal except she
does appear depressed and is
tearful at times. No suicidal
ideation.
We bring a
Sonosite (donated for the
duration of the trip by
Sonosite) with us.
As
part of the trip, I was teaching
the 2 foreign medical students
how to use the ultrasound and
perform a ‘FAST’ exam. The
student (Tamires) is seen in
this picture with this patient.
Charlene Irvin, MD and Tamires Richards de Andrade
Look at the image of the heart on the screen
.
Her HBG’s came
back at 6.8 gm, WBC = 3.5 K and
her urinalysis had RBC casts and
elevated protein on dip stick.
Specific gravity on urine was
1.030 (high).
Questions:
1. What do you think she
might have (think serositis,
anemia, leukopenia, arthritis,
oral ulcers, and some sort of
skin manifestation)?
2.
What are the echocardiographic
findings for Tamponade?
3. What is highly suggestive on
EKG for a pericardial effusion?
4. When should you aspirate
a pericardial effusion??
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