Student case

[True Anomaly]

I thought this would go over better here than in the ER forum- yes, it's an ER patient, one I saw yesterday in fact, and one that I think emphasizes an important point when seeing patients.

 

This is how it was presented to me: 34 y/o female presents with abdominal pain.  BP 134/78, HR 108, Temp 100.8, Resp 16, O2 sat 99% on room air

 

We can work through this as if I sent you in the room to see the patient.  What do you want to know?

[Simplify]

OPQRST  and/or any other HPI tidbits.

[True Anomaly]

Started the day after Christmas, was initially intermittent in bilateral lower abdominal quadrants, and she states she noticed it as the day went on- no particular event at that time which started it.  Nothing made it worse initially, and it didn't coincide with eating/drinking/defecating/urinating or movement.  A couple days ago it became constant and severe, described as "sharp, stabbing", still in b/l lower quadrants, but seemed to be worse on the right compared to the left.  She hadn't tried taking anything for it.  When it became constant, the only thing that seemed to make it worse was sitting up.  No associated N/V/D or dysuria or vaginal bleeding or discharge.  + chills, but no reported fevers at home.  No history of the same.  

 

Next?

[medicine2014]

Pregant before? Any IUD?

PID with TOA.......

Was think ovarian....but this case presents with bilateral lower abdominal pain with right been worst....well some peritonitis case seem possible.

[REMPAC]

Pregnancy test and what did you find on Physical Exam?

[True Anomaly]

Her G's and P's are G1P1001.  No history of IUD.  

 

Since you asked for a pregnancy test, it is negative

 

For physical exam:

Vitals- already given

General- lying on the bed curled up, tired-appearing

CV- Tachycardia but regular rhythm with no m/r/c/g

Resp- Lungs CTAB with no accessory muscle use

Back- nontender, normal ROM, no stepoffs or crepitus

Abd- voluntary guarding b/l lower quadrants, + obturator, + mcburney's, neg psoas.  normal bowel sounds

GU- you're a student so you wouldn't be doing this part alone

MS- normal

 

So it's at this point you come back to me and report and give your differential and an initial plan on what you want to do.  I've already got PID/TOA

[Timon]

I guess I'll take a shot in the dark on this one.

 

1. Draw U/A | CBC / CMP / Lipase / Amylase

 

2. U/S Abd / Pelvis r/o appy / ovarian cyst.

 

3. Abd CT w/ triple contrast r/o appy, SBO, abscess, malignancy, & colitis. (If all neg r/o familial Mediterranean fever).

 

Give 2mg morphine + 2 if needed.

Start ringers lactate IV drip Maint. fluids.

 

Start keflex & Metronidazole if appy and send for surgical consult.

[True Anomaly]

Timon- a few points to address your list

 

1- From an ER standpoint, amylase doesn't really tell us anything. I know what we're taught, but when it comes to diagnostics of abdominal pathology, I haven't even ordered an amylase in years

 

2 and 3- how would you differentiate which test you're going to order? What is your thought process behind this?

 

Your morphine order- what is the weight-based dose of morphine?

 

Your antibiotics- if you're thinking of covering abdominal pathology, a good first choice would be Cipro/Flagyl instead of Keflex/Flagyl- it will adequately cover abdominal flora, ie gram neg's and anaerobes.

 

So I have a list of some differentials- PID/TOA, appy, colitis, SBO, malignancy. What is our next step? At this point I'm going to go into the room with you to see the patient- what are we going to do first?

[Timon]

I've read that weight based dose of morphine would have an incremental titration with an initial loading dose of 0.1 mg/kg and then subsequent dosages of 0.025 to 0.05 mg/kg q 5 minutes. I also read that you can also do a loading dose at 0.15-0.2 mg/kg. But as long as you don't go above 10mg total you're ok. Just watching my docs when I was an ER Tech they'd always start with 2 and then work up from there.

 

I didn't see any surgical history mentioned so I'm assuming that her appendix is still there and anytime I see fever with abdominal pain it's appy until proven otherwise. Since we're going to start with the least invasive test first and something you can do at the bedside I figure we could do Abd / Pelvis U/S and look for an appy and to also rule out an ovarian cyst while were at it. In that process we would also figure out if we got some false negative on the pregnancy test (which is unlikely) to further rule out ectopic pregnancy. I have PID in my differential, but its low for right now because it's not going to kill her and I can't check for chandeliers sign just yet since you mentioned above that we're not doing a pelvic. I also didn't see anything mentioned about n/v, painful urination, vaginal discharge, vaginal odors, irregular menses or dyspareunia. 

 

You also mentioned positive McBurney's / RLQ abd pain / pos psoas and even in the history the patient is indirectly telling you they have a positive Markel Sign / Jar Sign when she says it hurts more when she tries to sit up. 

 

I wouldn't r/o appy if we didn't see it on U/S so I would move to our next test which is CT abd / pelvis with triple contrast (gold standard to r/o appy). With that I may see the appy, colitis, adhesions, malignancy (which you always rule out but I don't suspect since there is no weight loss mentioned). 

 

Lets say I don't see an appy, I know that familial Mediterranean fever presents with the same type of onset with the lower abdominal pain, almost like an appy / PID but its rare so I'll save that at the end of the bag of tricks when I've ruled out the most commons.  So I'm looking for that elevated white count in my CBC and serositis in my CT abd. 

 

It can be crohn's since the pain is more on the right, but if I'm going to Dx that I'll rule out other autoimmune issues too and I'd be referring to GI for further workup to possibly include pANCA, ASCA, ANA, anti-ds-DNA and with colonoscopy w/ biopsy and also rule out other items like Celiac disease. But I'm not ready to head down that road yet. 

 

 

So the 1st thing I'm going to do is IV Access and while I get the IV access I'll draw up blood for the labs to be drawn and then get some morphine in her to make her comfortable. NPO, IV hydration as mentioned earlier based by weight 4+2+1 rule.

 

 

Next I'm going to do the U/S and see what happens from there.

 

 

Not going to lie.. pretty intimidated doing this so hopefully I'm not messing up too badly. Just finished my first 2 months of rotations (Internal Med x 2) and its a lot to process. I was going to initially say cipro and flagyl.. not sure why I went the keflex route first. I think its all this EOR reading I've been doing on pance masters.

[EMEDPA]

many places are getting away from using morphine and using dilaudid or fentanyl as first line as they cause less nausea. just an FYI.

TA- thanks for posting this case.

carry on.

[Timon]

Thanks for the heads up! I'll remember that when I start my ER rotation in a few months. 

 

= o)

[LT_Oneal_PAC]

many places are getting away from using morphine and using dilaudid or fentanyl as first line as they cause less nausea. just an FYI.

TA- thanks for posting this case.

carry on.

Less histamine release too.

[True Anomaly]

I didn't see any surgical history mentioned so I'm assuming that her appendix is still there and anytime I see fever with abdominal pain it's appy until proven otherwise. Since we're going to start with the least invasive test first and something you can do at the bedside I figure we could do Abd / Pelvis U/S and look for an appy and to also rule out an ovarian cyst while were at it. In that process we would also figure out if we got some false negative on the pregnancy test (which is unlikely) to further rule out ectopic pregnancy. I have PID in my differential, but its low for right now because it's not going to kill her and I can't check for chandeliers sign just yet since you mentioned above that we're not doing a pelvic. I also didn't see anything mentioned about n/v, painful urination, vaginal discharge, vaginal odors, irregular menses or dyspareunia. 

 

 

Not going to lie.. pretty intimidated doing this so hopefully I'm not messing up too badly. Just finished my first 2 months of rotations (Internal Med x 2) and its a lot to process. I was going to initially say cipro and flagyl.. not sure why I went the keflex route first. I think its all this EOR reading I've been doing on pance masters.

 

I mentioned that you wouldn't be doing a pelvic on your own as a student...but now we're going into the room together ;)  So that being said, I have no problem with providing analgesia first, but then what are we going to do?  And I did mention in my first post that she had no nausea/vomiting/diarrhea, nor any dysuria, vaginal bleeding or discharge.  You're correct that I didn't mention irregular menses or dyspareunia.  

 

Don't fret!  this is why we talk about cases so you can work through the mental exercise of how to approach these types of patients.  This is a "safe place"

 

Thanks EMED for the opioid point- we haven't quite moved on from morphine yet, but we do have all three available.  

[Forensikchic]

I am so interested in this case!  Carry on please!  I want to know what happens!

[whoRyou]

Yes, carry on ... 

[True Anomaly]

All right, I'll just skip ahead to the in-room visit- we do a pelvic exam.  Lo and behold, there is a condom in the vaginal vault.  When asked when her last sexual contact was, pt states the day after Christmas- the day her pain started.  After removal of the condom, she has no CMT or adnexal masses or tenderness, but some whitish-yellow discharge.

 

So, we have a 34-year-old female with about 1.5 weeks of initially intermittent now constant lower abdominal pain with a documented fever and no N/V/D or reports of dysuria, with a concerning abdominal exam but retained foreign body in the vagina/pelvis.  What are your top concerns, and how are we going to evaluate her and/or treat her now?  By the way, she feels a bit better after the condom is removed.  Do we stop there, or continue forward?

[EMEDPA]

o,o,o,o,o,o,o,o pick me , pick me!

(never mind, just kidding student case)

[gbrothers98]

Great case.

Not trying to steal your thunder but several questions for students...

What lab test is missing from what has been listed so far?

Likely this pt meets what criteria?

Any simple and quick imaging that can be done?

Can you diagnose this pt at the bedside to drive her evaluation and treatment quicker?

What is the first question you should ask yourself about this patient?

G Brothers PA-C

[whoRyou]

Please continue because I assume there was an ultrasound taken, but can you share a little more without divulging too much? 

 

From all what you have said TA I'll take a guess ... Uterine Fibroid 

[EMEDPA]

do fibroids cause fever?

swing and a miss!

[whoRyou]

do fibroids cause fever?

swing and a miss!

LOL my bad you are right ... Pfft  

[Guest JMPA]

Timon- a few points to address your list

 

1- From an ER standpoint, amylase doesn't really tell us anything. I know what we're taught, but when it comes to diagnostics of abdominal pathology, I haven't even ordered an amylase in years

 

2 and 3- how would you differentiate which test you're going to order? What is your thought process behind this?

 

Your morphine order- what is the weight-based dose of morphine?

 

Your antibiotics- if you're thinking of covering abdominal pathology, a good first choice would be Cipro/Flagyl instead of Keflex/Flagyl- it will adequately cover abdominal flora, ie gram neg's and anaerobes.

 

So I have a list of some differentials- PID/TOA, appy, colitis, SBO, malignancy. What is our next step? At this point I'm going to go into the room with you to see the patient- what are we going to do first?

I must interject. amylase can be a very important tool for evaluating abd pain. I will leave it to you to do the research why. Do people not do flatplates anymore? cheap, quick, can tell you a lot

[EMEDPA]

I find the upright abd gives more info (free air, sbo, etc) so sometimes I order "kub with diaphragms" or 1 view upright abd.

I don't order amylase in an ED setting either. I have not seen any of my attendings order it in over a decade.it does give some info, but is very nonspecific. a salivary tumor, an sbo, and pancreatitis all cause it to become elevated for example.  Lipase is a more specific test if you want to evaluate for pancreatitis. xray or CT is better for SBO.

[Will352ns]

Beginnings of toxic shock syndrome? I would really like to know what the results of the CBC was.

[medic25]

I'm with the rest of the old guys; no benefit to amylase if you are running a lipase. The only time I order it now are the occasional parotitis patient; the nurses are always impressed that someone with facial pain and swelling has a bumped amylase!

I would also argue that the CT with triple contrast is overkill these days for 99% of patients. With the quality of today's scanners, we now just do IV contrast on most patients; the PO contrast is mainly for very skinny patients, those who can't receive IV contrast, etc.