DogLovingPA Posted November 26, 2015 Share Posted November 26, 2015 Young female presents to Urgent Care today with three days of cramping stabbing lower abdominal / pelvic pain that is getting worse. She is one week overdue for her menstrual cycle. Urine pregnancy was positive (a big, fat obvious positive). Vitals wnl, no acute distress with fairly benign exam but given complaint, I sent her to the ER to r/o ectopic. ER does some basic bloodwork (CBC, cmp) and a urine. Their urine hcg is negative and patient is sent home with zofran and bentyl. No ultrasound. This blew my mind. But maybe I'm overreacting? For those of you in the ER if you had a female present with abdominal pain with a reported positive pregnancy test earlier (either home, FP, etc) but your test was negative would you still rule out ectopic? Link to comment Share on other sites More sharing options...
Administrator rev ronin Posted November 26, 2015 Administrator Share Posted November 26, 2015 At the very least, I would order a stat quant, although what do I know... I'm just FP/UC. Link to comment Share on other sites More sharing options...
kargiver Posted November 26, 2015 Share Posted November 26, 2015 Completely agree with Rev Ronin. Urine HCGs, although as reliable as blood HCG --- IF THE TEST IS DONE RIGHT --- in this instance does not inspire any confidence. if you are showing a positive urine pregnancy, this person gets an automatic quant HCG and an ultrasound to R/O ectopic pregnancy. A CBC/CMP is useless in this instance - its the ectopic that is going to kill her. Additionally, I have seen positive HCGs treated with methotrexate that still come back as ectopics because the methotrexate wasn't completely effective. The owness is on the ER provider here to PROVE that there is no ectopic. A negative urine HCG that contradicts your positive test, without any other real testing is a setup for failure. G Link to comment Share on other sites More sharing options...
jen0508 Posted November 27, 2015 Share Posted November 27, 2015 I always do a serum preg in women of child bearing years with vag bleeding or history of + preg test. I've seen several neg Upregs with + serum preg test. Granted these ladies are super early with low betas (5-50) and US shows absolutely nothing (regardless of where the pregnancy is) but gotta get it to CYA Link to comment Share on other sites More sharing options...
db_pavnp Posted November 27, 2015 Share Posted November 27, 2015 (not a provider) I googled this because from inside the lab a serum HCG appears to be a crappy test. I googled "how does a quantitiative hcg rule out ectopic pregnancy" and read my fourth link down: http://www.acep.org/Clinical---Practice-Management/Beta-HCG-of-Little-Value-For-Ectopic-Pregnancy-Dx/ Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted November 27, 2015 Moderator Share Posted November 27, 2015 (not a provider) I googled this because from inside the lab a serum HCG appears to be a crappy test. I googled "how does a quantitiative hcg rule out ectopic pregnancy" and read my fourth link down: http://www.acep.org/Clinical---Practice-Management/Beta-HCG-of-Little-Value-For-Ectopic-Pregnancy-Dx/ The above link is great, and reminds that we're not actually ruling out ectopic, but trying to rule in an intrauterine pregnancy. The algorithm that's at the end of the article is what should be happening in the ER with these pts Link to comment Share on other sites More sharing options...
DogLovingPA Posted November 27, 2015 Author Share Posted November 27, 2015 Thanks for all the input. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted November 27, 2015 Share Posted November 27, 2015 CBC isn't useless if it comes back abnormal. WBC count of 27k with left shoft = something wrong. H/H of 7/22 =something very wrong. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 27, 2015 Moderator Share Posted November 27, 2015 CBC isn't useless if it comes back abnormal. WBC count of 27k with left shoft = something wrong. H/H of 7/22 =something very wrong. agree, but if you are going to stick this pt anyway for labs, a serum quant seems like a no brainer. Link to comment Share on other sites More sharing options...
jen0508 Posted November 28, 2015 Share Posted November 28, 2015 Did you call the ER to tell a provider about the patient before you sent them? Link to comment Share on other sites More sharing options...
jen0508 Posted November 28, 2015 Share Posted November 28, 2015 Pet peeve of mine is when UC sends patients without a courtesy call. Its respectful to call before sending folks so we can get a heads up and what it is you are concerned about. Patients aren't always the best historians :/ Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted November 28, 2015 Moderator Share Posted November 28, 2015 Jen- I agree. I always do this when I send a pt anywhere. Link to comment Share on other sites More sharing options...
DogLovingPA Posted November 28, 2015 Author Share Posted November 28, 2015 Jen0508 - Absolutely, we always call as well as fax a copy of our chart over. Link to comment Share on other sites More sharing options...
DogLovingPA Posted November 28, 2015 Author Share Posted November 28, 2015 We also always try to call before the patient leaves our care.... Just in case the ER can't accept them for some reason (scanner down, certain specialty not available, etc). Link to comment Share on other sites More sharing options...
kargiver Posted November 29, 2015 Share Posted November 29, 2015 You know I love ya, B. But I'm not waiting for a CBC on the way to the OR. Lab test just confirms what I already know... G Link to comment Share on other sites More sharing options...
Febrifuge Posted December 1, 2015 Share Posted December 1, 2015 Pet peeve of mine is when UC sends patients without a courtesy call. Its respectful to call before sending folks so we can get a heads up and what it is you are concerned about. Patients aren't always the best historians :/ Wow, I had gotten the vibe from my local ER that they didn't want me bugging them. Maybe I should revisit that. I do send every patient over with a detailed printout of what we did in the UC, what I'm worried about, and why I'm recommending they head to the ED. I'm assuming even if the patient just shows up and says "here," and shoves it toward the triage nurse, my concerns and intentions will be communicated. I often check ER notes from folks I send over, after a few days. Seems like the system works well enough. But if I should be calling, I'll go back to calling. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted December 1, 2015 Moderator Share Posted December 1, 2015 good idea to call and put in note" pt to be transferred to st elsewhere, report to dr greene who is aware of my concern of r/o appy" Link to comment Share on other sites More sharing options...
sk732 Posted December 1, 2015 Share Posted December 1, 2015 Last place I worked made it mandatory to not only call, but to send a formal consult with the patient...some people thought there were too good for that I guess (I always did incidentally). MM Link to comment Share on other sites More sharing options...
DogLovingPA Posted December 2, 2015 Author Share Posted December 2, 2015 I'm going to humbly take my foot out of my mouth now. So when I checked my patient's chart the next day, I saw a note from the ER for LLQ pain (her presenting complaint to me). This was the only note from the ER in her chart...so.... Yeah that note was 2 months old. I saw her chart again today - on the day I sent her she did get quant serum beta hcg and US. Thought they saw an IUP but couldn't be sure so it looks like she was set up for a repeat US couple days later. But very helpful discussion on ER protocol for such situations and the politics of transferring patients from UC to the ER. Lesson learned - check the date!!! And agree with EMEDPA, I always put in my pt note who I talked to in the ER, time of call nd that I expressed why I was sending the pt. Link to comment Share on other sites More sharing options...
winterallsummer Posted December 3, 2015 Share Posted December 3, 2015 True story - I once had a pt sent from UC to ER for "r/o ectopic". No urine preg done but pt was a few days late. Check Upreg, negative, her abdominal pain had resolved by time she got to ER, pt promptly sent home. No offense to you, sounds like you did the right thing, but the majority of UC turfs I used to get in the ER were flat out ridiculous. Also ectopic is typically not a dx that is missed. Usually these patients are in obvious distress with abnormal VS at the very least. I feel that if I had this pt present to me with normal CBC/CMP/UA, negative U preg, VSS and normal exam, I doubt I would've got the U/S either. Your U Preg likely was a false positive. Now if the pt had a concerning abd/pelvic exam that is another story. But with negative U Preg and benign exam I would be pretty reassured. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted December 4, 2015 Share Posted December 4, 2015 You know I love ya, B. But I'm not waiting for a CBC on the way to the OR. Lab test just confirms what I already know... G Agreed, wouldn't wait, but would still get one. Link to comment Share on other sites More sharing options...
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