PA student Case Study

[GetMeOuttaThisMess]

Will352ns, you brought up something that you've learned previously (O->T).  Where is the "O" in this scenario?  For those that aren't familiar with this EMS hx. component, "O" is for symptom onset, and the circumstances surrounding same (not the "T", which is actual duration of symptoms, or "time").  No one has asked.  Might it be relevant in that while it may not give you your diagnosis it might help to exclude some choices?

 

"R" could come in handy as well.

[fakingpatience]

Will352ns, you brought up something that you've learned previously (O->T). Where is the "O" in this scenario? For those that aren't familiar with this EMS hx. component, "O" is for symptom onset, and the circumstances surrounding same (not the "T", which is actual duration of symptoms, or "time"). No one has asked. Might it be relevant in that while it may not give you your diagnosis it might help to exclude some choices?

 

"R" could come in handy as well.

 

 

They were asked and answered... He said sudden onset while driving a few days ago, no radiation beyond l flank and ulq

 

 

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[GetMeOuttaThisMess]

^^ you are correct and I apologize for missing that later post.

[Will352ns]

Yes, the first thing I asked for was OPQRST and any positives on ROS.  I understand the importance of a complete history.  I just can't help to think I am missing something obvious....if the the above was answered and nothing was left out....what was the deciding factor to go straight to U/S?  Again, I can understand if he was kind of shotgunning it, but it doesn't seem like he was.

[Timon]

Recapping what we know:

 

58yo female, c/o 3 days of left-sided back and flank pain, along with some dizziness. She is resting on the bed, looking relatively comfortable.

 

The patient reports a sudden onset of pain around 3 days earlier while driving in her car. No change with movement, no relief with OTC pain relievers, no radiation beyond the left flank/back/LUQ area. Some discomfort with palpation of the area. She describes the pain as being "moderate", and achy.

 

The only PMH is hyperlipidemia and takes a statin.

 

ROS is only positive for fatigue and some mild dizziness. Denies dysuria, n/v/d, fever, vaginal bleeding

 

On exam the lungs are clear to auscultation, no rib tenderness is appreciated. There are no signs of bruising noted. The patient has some tenderness to palpation over the left flank/LUQ area. We did not get a chest x-ray on this patient, although it is a very good thought.

 

T-98.9, P-98, BP- 104/70, RR-18, SpO2- 98%

12-lead EKG is unremarkable

U/A: moderate epithelials, 0-1 RBC's, 0-1 WBC's, negative LE/nitrite, HCG negative

BMP and LFT's were unremarkable.

WBC count of 9.0, H&H of 10/29, platelets of 300.

 

 

 

In my initial differential diagnosis I'm thinking MI, Angina, peptic ulcer, ovarian cysts, uterine fibroids, tuboovarian abscesses, endometriosis, herpes zoster, later stage chlamydia, pyelonephritis, kidney stone, pancreatitis, lupus, hiatal hernia, Barret's esophagus, colic, diverticulitis, bowel obstruction, spleen rupture, diabetic ketoacidosis, purpura, porphyria, or maybe some type of tumor (pancreatic / renal / bowel / intestinal / splenic / pancreatic / ovarian).

 

I think you jump to ultrasound in this case because you want a quick look at the organs (kidney) in the area with minimal radiation to the patient. I would guess that the next step after the ultrasound would be abdominal CT w/ & w/o contrast but my red flag is someone who is post menopausal that's anemic complaining of pain where mostly organs exist with moderate epithelial cells in UA (thinking kidney and some type of inflammation).

 

I'd probably do another clean catch UA to rule out a contaminated specimen. If moderate epithelial cells again I'm thinking kidney or some type of inflammation.

[medic25]

Great summary so far guys; you're hitting pretty much everything to consider in a differential diagnosis.

 

As I said, in this particular patient we elected to perform a bedside ultrasound while waiting for a CT scan.  The initial intent was to scan the kidneys to evaluate for hydronephrosis.  Given the sudden onset of pain and the location, kidney stone was fairly high on the differential.  The ultrasound of the left kidney showed an image similar to the attached picture.  What are we seeing, and what do you want to do next?

 

 

 

 

 

 

 

 

[Timon]

I think I'm going to bow out at this point lol. Only half way into didactic and I think I'm in over my head at this point. If I had to guess it looks like a hemorrhagic cyst with fluid in the morisons pouch but I don't know. My exposure to ultrasound imaging is very minimal as well as to kidney pathologies. Definitely looking forward to what others have to say.

[True Anomaly]

Oh oh!! *raises hand*

[True Anomaly]

Wasn't my first thought either (those were mentioned earlier), but with my limited experience, I figured trying to rule out some life threats wouldn't be bad.

 

 

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As an aside to this case....a few years ago I had a 57 y/o female with a similar pain to that described above.  In our ED patients are generally asked for urine during the triage process, and for some reason the tech did a urine HCG test which came back positive.  He did it again...again, it was positive.  Once she got back to the room I got another sample, tested it myself and it was positive as well.  No periods in 10 years.  One thing lead to another, and she had a large pancreatic mass with mets everywhere in her abdomen- of course, she didn't know any of this.  When I asked the tech why he did the urine HCG on a 57 y/o, he actually said he didn't know.  

[BARONEUS]

Oh boy, an ultrasound. I might as well be looking at a snowed-screen TV. Official diagnosis: a circle inside of another circle syndrome.

 

And on an unrelated note, I'm supposed to be in practice in 10 months. Believe me, no one is as scared for your family members as I am.

[True Anomaly]

Oh boy, an ultrasound. I might as well be looking at a snowed-screen TV. Official diagnosis: a circle inside of another circle syndrome. And on an unrelated note, I'm supposed to be in practice in 10 months. Believe me, no one is as scared for your family members as I am.

 

As a hint, look up images of "Abdominal FAST" and what it describes

[Will352ns]

Honest, didn't look it up....there is blood/fluid around the kidney.  I was trained to do FAST exams in the military, that said, I do not claim to be an expert.  Beyond that I can't tell you much.....I could be completly wrong. 

 

It also looks like th kidney itself is a bit swollen?  The pelvis looks big to me....or am I looking at phantoms?

 

Okay, the fact you said that you did this while waiting for CT clears my confusion.  I was thinking you did the U/S only that was it and you had a definiative Dx.  I couldn't think of anything that you do that for this type of presentation....CT is usually the diagnostic tool of choice for unexplained ABD pain...or flank in this case. 

 

So, atraumatic left kideny with blood/fluid around it.  Why?

[GetMeOuttaThisMess]

Surprised that no one ever brought up the spleen with the concurrent low H/H and statin therapy (hemolytic anemia with secondary splenomegaly).  It's those darn statins again.  They're everywhere!

 

The point I was trying to make with regard to what the sono shows is not necessarily the specific diagnosis, but levels of density (solid, cystic, fluid, or....air).  If she had perf'd an ulcer for example you might find free air, and if the air is on the left where might she have referred pain to?  Left shoulder from diaphragmatic/phrenic nerve irritation (this is why I asked about the O-T hx. that I had missed, which I later went back and saw after dosing my Geritol).  This in turn would potentially give you your diagnosis, or significantly fine tune your differential.  No one....as I recall, and yes, I'm due for another Geritol dosing at present....asked about specific PE findings ("tenderness" was volunteered, and pertinent negative findings were provided, but nothing more was asked).  So would there have been splenomegaly found on exam?  Guarding?  She's lying comfortably but you approach her to palpate and she may have tried to cold-cock you.

 

Just an observation and not specifically directed toward any particular group or individual here, but I noticed during this past summer that EMS students who were running through case scenarios were very quick to "diagnose" and start a treatment without taking the time to get an adequate history.  As a result, diagnoses, and subsequent treatments, were incorrect.  The history is where you're going to get the majority of your information as most already know.  I'm going to go out on a limb and say that medic25 sono'd looking to find hydronephrosis due to ureteral obstruction as a result of a stone and was surprised to find what was found (please correct me if I'm wrong).  Why CT (radiate) if you can find your answer with a faster, cheaper, safer modality?  Same with appy's potentially.

[Will352ns]

Until just now, if you were to tell me that the pt had a low H&H, I would have said....no she doesn't.  Looking back...yes she does indeed.  I think I may need some Geritol as well.  Completely missed that.

 

I guess I have the reason for the dizziness that I couldn't figure out.

 

You mention the merits of going to CT and I understand what you are saying, but when wouldn't you in an ER setting?  I've never seen a positive FAST not further scanned...unless they went straight to the OR.  For that matter, if the PE is enough to worry but the FAST is negative, PT is going to CT anyhow.  FAST scans are good tools to point you in the right direction, but don't tend to be the definitive testing.  Or am I way off?

[JP86]

As an aside to this case....a few years ago I had a 57 y/o female with a similar pain to that described above.  In our ED patients are generally asked for urine during the triage process, and for some reason the tech did a urine HCG test which came back positive.  He did it again...again, it was positive.  Once she got back to the room I got another sample, tested it myself and it was positive as well.  No periods in 10 years.  One thing lead to another, and she had a large pancreatic mass with mets everywhere in her abdomen- of course, she didn't know any of this.  When I asked the tech why he did the urine HCG on a 57 y/o, he actually said he didn't know.  

 

I also accidentally ordered a quantitative hCG (I have been doing more quantitative hCGs lately as I had a qualitative one come back negative recently, fortunately had high suspicion, then ordered the quant and it came back positive. Would have missed ectopic if I had payed attention to the initial false neg test!) on a 61 year old on a busy shift when I was putting in basic labs on patients that it was going to be a few minutes to see and it came back positive. She ended up having a mass on her ovary with mets if I remember right. It can be a marker for tumors in older patients. Just wanted to compound on your post and experience for others to see!

[medic25]

Honest, didn't look it up....there is blood/fluid around the kidney.  I was trained to do FAST exams in the military, that said, I do not claim to be an expert.  Beyond that I can't tell you much.....I could be completly wrong. 

 

So, atraumatic left kideny with blood/fluid around it.  Why?

 

We have a winner!  The bedside ultrasound for hydronephrosis turned into a positive FAST, with blood in the perisplenic region.  The crit of 29 was also significantly lower than the last CBC on file.  We got her to CT ASAP and she had a significant splenic rupture (it's been a while, but I think she was a grade III).  She was admitted to surgery and embolized by IR, and ultimately did fine.  After an inpatient workup (r/o ID, neoplasm, etc), it was determined to have been an idiopathic splenic rupture.  Certainly much more unlikely than the trauma-related splenic injury, but one more thing to consider with LUQ pain.  Here is a case review on the topic:

 

http://www.ncbi.nlm.nih.gov/pubmed/19787754