Scenario Saturday – The Nauseous Neighbor

Backstory

A tornado cut a five-mile-long path of destruction through a city of 50,000. You and your neighbors are working together to help each other find and collect personal possessions. A non-profit, disaster response organization brought box lunches and bottled water to the neighborhood about two hours ago.  It’s approximately 2:00 PM, 80 degrees Fahrenheit (27 C), 90% humidity and sunny.

You have been working with your next door neighbor, Sean, since 9 am. He is 42 years old, 5 foot 9 inches tall and weighs approximately 250 lbs. Your neighbor complains that he feels nauseous and his upper back is starting to hurt. You suggest that you both sit down in the shade, take a break and drink some water.

You notice that Sean’s skin is pale and moist. 

While you both rest and drink water, you explain to Sean that you graduated from an Urban and Disaster First Emergency First Aid Course and a big part of the course is deciphering illness signs and symptoms, You tell Sean that you may be able to help if you can ask him some questions.  Sean agrees.

SAMPLE History

You ask Sean SAMPLE History questions.

  • Signs and Symptoms – Nausea and pain in the upper right back near the shoulder.
  • Allergies – Seasonal allergies
  • Medications – Allegra for seasonal allergies. 
  • Past Medical History – Sleep apnea. Uses a CPAP nightly. You ask if what he is feeling now has ever happened before.  Sean says he can’t remember.
  • Last In/Last Out – Box lunch at around 12 noon. Cold cut sandwich, potato chips and the chocolate chip cookie. Sean has been drinking bottled water all day. The bottle he drank at lunch was his fourth bottle of the day. You ate the exact same lunch.
  • Events Leading Up to the Present Crisis – Cleaning up the neighborhood since 9 am and feeling fine until about an hour after eating lunch. After lunch he felt nauseous and he started feeling a sharp, stabbing pain in his upper right back.

Vitals

You ask Sean if you may take his pulse. You explain that just like when we visit the doctor, this is part of understanding why a person is not feeling well.  Sean agrees.  He tells you the pain in his upper right back shoulder is increasing.  Remember, we never tell the patient that we are measuring their respiratory rate

  • Heart Rate: 76
  • Respiratory Rate: 16
  • Skin Presentation: Pale, Cool and Moist
  • Level of Consciousness: A+0x3
  • Time: 2:15 PM

Physical Exam

You explain to Sean that you learned in the first aid class you attended that nausea is sometimes caused by an abdominal organ not functioning properly.  You explain the technique you learned in class about dividing the abdominal area into four quadrants, gently pushing in and quickly releasing pressure in each quadrant. If there is something wrong Sean may feel pain.  You explain that this could help understand if Sean has a serious condition that requires immediate medical attention. You did a great job in explaining your training because Sean agrees to lay on his back and allow you to examine him.

You start with the Left Lower Quadrant, slowly pushing in and quickly releasing pressure. Sean reports no pain. Left Upper Quadrant – no pain. Right Lower Quadrant – no pain.  Right Upper Quadrant – Sean complains of pain when you push in. You push in again on the Right Upper Quadrant and Sean asks you not to push again. It hurts.

Conclusion
What is possibly wrong with Sean?
Let’s evaluate the clues we discovered during our exam.

Skin. The weather is 80 degrees F (27 C), 90% humidity and sunny. Sean has been working since 9 AM.  His skin should be Pink, Warm and Moist.  His skin is presenting Pale, Cool and Moist. Sean is vasoconstricted. This is your first clue that something is wrong.

Last In/Last Out. Sean has been drinking all day, so he is probably not dehydrated. However, he reports that he began to feel nauseous and began feeling a sharp pain in his upper right back near the shoulder. That is your second clue that Sean may have a serious illness.

Physical Exam.  In Wilderness First Aid and Urban and Disaster First Aid we teach that anytime a patient complains of nausea and/or abdominal tenderness, perform a physical exam of the abdominal area.  Divide the abdominal area into four quadrants that are created by drawing a vertical and horizontal line that intersects at the patient’s belly button.  Then gently push into each quadrant and quickly release pressure.  If the patient complains of any pain then the patient needs to seek definitive medical care.

Diagnosis. Using the flow diagrams in Wilderness First Aid Made Easy and Urban and Disaster Emergency First Aid Made Easy, you are led to Page 11,

Abdominal Pain Considerations where you learn that Sean possibly has gallstones and needs to see a medical professional.