RetNavyPAC Posted April 8, 2014 Share Posted April 8, 2014 This (eventual) pearl is for all the newer EM PAs (and it's a nice reminder to those of us who have been around a bit longer) I reviewed a case at Peer Review this morning that was a classic instance of ignoring the dictum of "If it doesn't fit, you must admit" (or at least STOP and think again before you discharge). With thanks to Eric/EMEDPA for the 'Cochran-ism' The following narratvie/info is 'distilled' from the actual chart CC: 74yo woman with ~24 hrs of progressively worsening belly pain HPI: "Achy" 10/10 pain, mostly in RUQs/epigastrium without radiation. Aggravated by eating/drinking early on. Now assoc with nausea & several episodes of vomiting. ROS: No chest pain or SOB. No fever/chills. No irritative voiding symptoms PMHx: well-controlled HTN PSHx: C-sexn 40-some yrs ago Soc: non-smoker, non-drinker VS: P-71 R-18 BP-110/62 T-98.7 100% sats RA Exam: Mildly TTP all over, but mostly tender in RUQ/epigastrium DDx: cholecystitis, gastritis, pancreatitis Treatment: 4mg IV Zofran & 2mg morphine Labs: CBC showed mild leukocytosis (13.9) with ANC 12.3 (our labs ULN is 7.7). CMP unremarkable. Lipase 38. Imaging: RUQ U/S. Rad read as "No sonographic evidence of cholelithiasis or acute cholcystitis" MDM: ". . .unsure of etiology of abd pain. Workup negative for pancreatitis, cholecystitis, acute hepatitis. . . US reveals no acute abnormality. L:abs unremarkable. Sx improved with morphine and Zofran. Discharge to Home" Lets get some observations, commentary and what anyone would have done differently than this physician (if anything), before I reveal "the rest of the story" Link to comment Share on other sites More sharing options...
bradtPA Posted April 8, 2014 Share Posted April 8, 2014 Would personally have liked to see a Abd/pelvis CT. I would add diverticulitis to my ddx, and consider a HIDA scan if CT is neg. white count is worrisome in a older belly pain patient. Of course, my bias is family med, not emergency. I like to know the problem before they go home, where lots of ED folks make sure it's not critical, then send it to me to diagnose. Link to comment Share on other sites More sharing options...
akdEM Posted April 8, 2014 Share Posted April 8, 2014 I'll second the abd/pelvic CT. That was my thought, too. Her age and 10/10 belly pain would make me nervous. Link to comment Share on other sites More sharing options...
primadonna22274 Posted April 8, 2014 Share Posted April 8, 2014 That differential is FAR too narrow for epigastric/RUQ pain in an elderly lady. Always consider every system in the neighborhood--and there's a whole lot of neighbors!! Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 8, 2014 Share Posted April 8, 2014 Pregnancy test! Someone had to say it (kidding). Consider mesenteric ischemia/infarct. Before killing her off with a boatload of radiation how about an old school upright KUB to look for ileus/SBO/free air. Look for fatal concerns first (don't forget the ticker even with belly pain). Link to comment Share on other sites More sharing options...
primadonna22274 Posted April 8, 2014 Share Posted April 8, 2014 Considering this was brought up at M&M, I'm guessing she did not do well. I couldn't be compelled to send this lady home. Admission and further workup necessary. Agree with mesenteric ischemia, SBO, ACS. Also r/o RLL pneumonia, pyelonephritis, renal capsular bleed, leaking aortic aneurysm, renal infarct, peptic or duodenal ulcer or worse (perf), colitis, possibly even thoracic vertebral osteomyelitis...probably a few zebras I haven't thought of too. In other words, the Ddx and workup for this woman was woefully inadequate. Link to comment Share on other sites More sharing options...
Febrifuge Posted April 8, 2014 Share Posted April 8, 2014 Yeah, from Urgent Care, I send her to the ED. In the ED, I widen out that DDx quite a bit. Just because I have a couple of labs that don't scare me doesn't mean it's magically nothing (and anyway a WBC of 13.9 means more to me in a 74 yo woman than a 54 yo one). Almost everything gets better with Zofran and morphine, so that isn't impressing me either. I would admit her for overnight observation and serial labs and exams, at least. And that's not to mention all the many tests that have not been done at this point (which I won't list, because everyone above me has great ideas already). Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 9, 2014 Moderator Share Posted April 9, 2014 before i read the replys 10/10 in an elderly is concerning RUQ Any shoulder pain? No mention of Pancrease on US - need to get CT Need to make sure no pneumo, no pleural effusion, no lung pathology - diaphragm is mighty sensitive looking for other ABD issues - obstruction, colic artery occlusion, divertic on right side Gastric issues - DU/gastric ulcer with perf - unlikely with normal H:H HNP or pinched nerve (although unlikely) GB - ballcocking valve stone? - did they see a stone? Renal colic - stone gulp - AAA Renal artery thrombosis/infarction Great imposer - Shingles - rash? out there - compression fx, radic pain from back Next step - Abd Pel CT with and Without contrast - need to do non-contrast to r/o renal stone, then with for better pictures - with oral contrast. Before admitting I would get this and talk directly to the Rad. also nice to see if there is a frequent flyer hx - if not the red flag is blowing in the breeze - little old ladies don't make stuff up This is where the medicare denying admission status for work up is HORRIBLE - they are discharging home bound patients for outpatient work ups...... makes no sense.... system stinks Link to comment Share on other sites More sharing options...
Guest JMPA Posted April 9, 2014 Share Posted April 9, 2014 you need to r/o appendicitis which can present with RUQ/epigastric pain depending on the position of the appendix. Hx needs to be more thorough. remember 85% of your diagnosis, especially abd pain is in the hx Link to comment Share on other sites More sharing options...
primadonna22274 Posted April 9, 2014 Share Posted April 9, 2014 Great list V...we agree. One interesting thing: the ultra-sensitive high-resolution CT scanners have made contrast (PO or IV) unnecessary in most average and obese folks. It's only the very thin who may still need contrast to improve imaging of vascular and hollow viscus structures. This is pretty amazing to me (I just finished a month of academic EM...kinda cool to learn all the newest and greatest). Caution: talk with your radiologists to know whether their equipment is adequate for non-contrast CTs. Link to comment Share on other sites More sharing options...
Guest JMPA Posted April 9, 2014 Share Posted April 9, 2014 ps everything improves with morphine and zofran Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 9, 2014 Moderator Share Posted April 9, 2014 One interesting thing: the ultra-sensitive high-resolution CT scanners have made contrast (PO or IV) unnecessary in most average and obese folks. It's only the very thin who may still need contrast to improve imaging of vascular and hollow viscus structures. This is pretty amazing to me (I just finished a month of academic EM...kinda cool to learn all the newest and greatest). Caution: talk with your radiologists to know whether their equipment is adequate for non-contrast CTs. oh my kidneys love that! ALARA rules! That might protect the CT makers from loosing their entire product line to high speed MRI...... Link to comment Share on other sites More sharing options...
primadonna22274 Posted April 9, 2014 Share Posted April 9, 2014 It might :) I've been meaning to do a radiology lit search to verify what my attending said, but haven't got up the energy to open the laptop lol Link to comment Share on other sites More sharing options...
medic25 Posted April 9, 2014 Share Posted April 9, 2014 Great list V...we agree. One interesting thing: the ultra-sensitive high-resolution CT scanners have made contrast (PO or IV) unnecessary in most average and obese folks. It's only the very thin who may still need contrast to improve imaging of vascular and hollow viscus structures. This is pretty amazing to me (I just finished a month of academic EM...kinda cool to learn all the newest and greatest). Caution: talk with your radiologists to know whether their equipment is adequate for non-contrast CTs. After years of requests, we finally convinced our radiologists last month to stop requiring PO contrast; it has made a huge difference in ED length of stay, and the staff love it. Great advice about knowing the limitations of your radiology equipment. my free-standing ED still has a 16-slice CT, while our main hospital has 64-slice or higher. The 16-slice doesn't give adequate images for a CTA of the brain, so we know for those patients they need to be transferred out. Link to comment Share on other sites More sharing options...
PACdan Posted April 9, 2014 Share Posted April 9, 2014 After years of requests, we finally convinced our radiologists last month to stop requiring PO contrast; it has made a huge difference in ED length of stay, and the staff love it. Great advice about knowing the limitations of your radiology equipment. my free-standing ED still has a 16-slice CT, while our main hospital has 64-slice or higher. The 16-slice doesn't give adequate images for a CTA of the brain, so we know for those patients they need to be transferred out. Ugh. Those 256-slice scanners. Beautiful 3D reconstruction and almost a full order of magnitude less ionizing radiation exposure compared to previous machines. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted April 9, 2014 Moderator Share Posted April 9, 2014 Agree with all of the above, but I'd also add in an EKG at the very least, and likely cardiac enzymes Link to comment Share on other sites More sharing options...
primadonna22274 Posted April 9, 2014 Share Posted April 9, 2014 Agree wholeheartedly ^^^^ Link to comment Share on other sites More sharing options...
Moderator ventana Posted April 9, 2014 Moderator Share Posted April 9, 2014 Agree with all of the above, but I'd also add in an EKG at the very least, and likely cardiac enzymes yikes - didn't catch that was not done already - yeah that is one of the basics...... Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 9, 2014 Share Posted April 9, 2014 That's why I had mentioned "ticker" in my original posting. Cardiac etiology doesn't fit the full picture (diffuse tenderness in abdomen, food correlation) but whose to say there is only one etiology for symptoms? I'd still like the cheap, quick upright KUB when getting CXR, assuming she can tolerate being upright. She's also had surgery so one can't discount adhesions in unusual places. Link to comment Share on other sites More sharing options...
skyblu Posted April 11, 2014 Share Posted April 11, 2014 Radiation is not what will kill her at this age. Definitely would get a CT of abd/pelvis. And for sure, EKG and cardiacs, CXR, and a UA. And I'd probably have grabbed the bedside u/s for a quick look at her aorta, even. No way would I discharge this patient from the ED! 10/10 non specific abdo pain in an elderly person? Welcome to the hospital! Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 11, 2014 Share Posted April 11, 2014 ^^^ A play on words regarding "killing her" (she is too old to have this be a concern). The point being made was to keep this in mind with a younger population by considering other viable alternatives (upright KUB for example, which could show free air that the specific GB sono wouldn't necessarily). The u/s initially performed was low-risk, and would provide specific information with regard to a specific suspected diagnosis. It has been my experience that I see many utilize a "throw it against the wall and see what sticks" philosophy without a specific diagnosis to be excluded or ruled in. BTW, anyone bother to check distal pulses or listen for femoral bruits? Link to comment Share on other sites More sharing options...
medic25 Posted April 11, 2014 Share Posted April 11, 2014 Radiation is not what will kill her at this age. Definitely would get a CT of abd/pelvis. ^^^^^^^ This. I'm not worried about increasing her chance of getting cancer when she's 110. If there's one rule that new grads should learn from this coming into EM, it's that badness likes to hide in the bellies of the elderly. You should have a very low threshold for scanning a 74yo with abdominal pain and a white count. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted April 16, 2014 Share Posted April 16, 2014 So......... What's the outcome? Link to comment Share on other sites More sharing options...
winterallsummer Posted April 29, 2014 Share Posted April 29, 2014 Not to be cliche but a better h&p would go a long way in this case. We have no idea about a thorough exam or history and at 74 is htn really her only PMH? Anyway a LA could be useful in a pt like this. CT not inappropriate if really her PMH is so nil and this acute abd came from nowhere. Regarding pancreatitis a normal lipase and amylase can suffice without ct unless I'm mistaken. EKG? A lot could be done here even before ct. Link to comment Share on other sites More sharing options...
Guest Paula Posted May 13, 2014 Share Posted May 13, 2014 RetNavyPAC: What is the rest of the story, as Paul Harvey would say? Link to comment Share on other sites More sharing options...
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