Case #58 "Sticky Bun Plus One"
by Charlene Babcock Irvin, MD

The nurse calls you to triage to check out a 32 y/o female who arrives with chief complaint of passing out. The nurse tells you she passed out at work, but the nurse is concerned as she is hypotensive and clammy. She tells you her friend drove her to the hospital to get checked out, at the insistence of her boss. She did not want to come to the hospital, as she felt fine.

As the nurse repeats the blood pressure at your request, the patient tells you she has the stomach flu. Her husband had it yesterday, and today she woke up with some nausea and had one episode of diarrhea. Then she felt better, ate breakfast, and went to work. No vomiting, nausea has resolved, and she has no complaints at this time except she admits to feeling a little weak. She was helping her co-worker move some boxes of paper, and suddenly felt weak and passed out. She thinks she was only out a few seconds. She denies any abdominal pain, and only had one episode of diarrhea today.

The repeat blood pressure is 80 by palpation, with a heart rate of 125. The nurse wants to know where you want to send her (i.e. to the critical care area, or the general medical area).

Although she is conscious and doesn’t appear toxic, her hands are cool and clammy, and you believe she really is hypotensive. You elect to start her in the critical care area.

While walking with her while she is in the wheelchair, you also find out more history.

PMH: Anemia (she is on iron, and her doctors believe it is related to heavy periods).

G3P3, ‘no chance’ she is pregnant (when asked why, she notes she had a tubal ligation after her last baby about one year ago). No other surgeries. Last period was 4-5 weeks ago.

SH: She denies any drug or alcohol abuse. She has been exposed to her husband who had vomiting and diarrhea yesterday.

FH: Negative

Physical Exam:
VS: Blood pressure = 80 by palpation, HR=125, RR=20, Temp (oral)=98.4

PE: WDWN female, smiling, in no acute distress.

HEENT: Unremarkable except palor to conjunctiva and tongue

Heart: Tachycardic, no murmurs

Lungs: Clear

Abdomen: Soft, mild tenderness to deep palpation (1/4) diffusely.

Rectal: Guiac negative Pelvic: Normal non-tender uterus. Mild adenexa tenderness bilaterally to deep palpation. No masses. Mild cervical motion tenderness.

EXT: No rashes, unremarkable except decreased capillary refill (4 sec) noted distally.

Neurologically: Unremarkable

1. What are the six things you need to order, and which blood test is most important (therapeutic, not diagnostic)?

2. What stage of shock is she in?

3 What can you do that will tell you in less than 60 seconds if you are facing a surgical emergency?

4 How is the Beta-HCG helpful in ectopic pregnancies?
 

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