Simplify Posted January 8, 2015 Share Posted January 8, 2015 Gram positive TSS? Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 8, 2015 Moderator Share Posted January 8, 2015 and most folks refuse rectal contrast...that was the rage maybe a decade ago but the techs hate to give it and the pts hate to receive it. Link to comment Share on other sites More sharing options...
MedicinePower Posted January 8, 2015 Share Posted January 8, 2015 STDs? Link to comment Share on other sites More sharing options...
whoRyou Posted January 8, 2015 Share Posted January 8, 2015 STDs? I was thinking the same thing, but it seemed to obvious ... Link to comment Share on other sites More sharing options...
MedicinePower Posted January 8, 2015 Share Posted January 8, 2015 I was thinking the same thing, but it seemed to obvious ... Hoofbeats, horses, zebras and all... Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 8, 2015 Moderator Share Posted January 8, 2015 sounds like a couple of the older folks have some ideas but lets let TA continue with the case. Link to comment Share on other sites More sharing options...
GreatChecko Posted January 8, 2015 Share Posted January 8, 2015 She meets SIRS criteria, possibly septic d/t TSS. We need a lactate and I need to look up whatever sepsis guideline the hospital I'm sitting in likes to use. Link to comment Share on other sites More sharing options...
whoRyou Posted January 8, 2015 Share Posted January 8, 2015 Beginnings of toxic shock syndrome? I would really like to know what the results of the CBC was. I, too, was thinking this, but the reason I didn't 'say' anything is because you didn't mention about a rash resembling a sunburn, particularly on her palms and soles. BTW, did you find any bacteria? Link to comment Share on other sites More sharing options...
MedicinePower Posted January 8, 2015 Share Posted January 8, 2015 STD or microbial infection secondary to the foreign object are the directions I am leaning. At this point I think culturing and treating antimicrobial agents is prudent, while controlling for BP, fever, N/V/D, etc. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 8, 2015 Moderator Share Posted January 8, 2015 what other lab was George fishing for.... Link to comment Share on other sites More sharing options...
MedicinePower Posted January 8, 2015 Share Posted January 8, 2015 DFA? Link to comment Share on other sites More sharing options...
GreatChecko Posted January 8, 2015 Share Posted January 8, 2015 what other lab was George fishing for....Blood cultures before ABX? I might have missed it in a previous post though. Link to comment Share on other sites More sharing options...
PAtoB Posted January 8, 2015 Share Posted January 8, 2015 vaginal culture? Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 8, 2015 Author Moderator Share Posted January 8, 2015 Lots of good discussion, and I really appreciate the "old guys" chiming in (experience, not age!) I'm glad no one would just send the patient home just because she feels better after we removed the condom- that's the first obvious point. The consensus also seems to be that she needs some sort of imaging of her abdomen and pelvis- the questions is, do we do X-rays, CT or an ultrasound? The choice can really affect the timing of her disposition depending on what you find, and one has risks associated with it (radiation, contrast dye load affecting renal function), and the other is operator dependent. I'll go ahead and tell you that I did abdominal films and they showed no obvious free air, either upright or L lateral decubitus. And I'll provide labs since we gave her parenteral analgesia CBC- WBC elevated at 14.8K, elevated segs at 84%, and bandemia at 12%. H/H normal (by the way, if her CBC was normal, would you continue to image her?) CMP- normal Lipase- normal UA- grossly contaminated, but + nitrites/leuk esterase, microscopy shows RBC's 50-100, WBC's 50-100, numerous bacteria with frequent epithelial cells HCG- neg ( we already covered this) GC/Chlamydia cultures- sent Microscopic wet prep- + WBC's, no clue cells, no trichomonads, no candida Lactate- normal So....what imaging are you going to get and why? Since triple contrast was mentioned, I'm in agreement with E- I got out of PA school at a time when it had fallen out of favor. The only time I use it is when we know there is rectal/distal colon pathology clinically, or otherwise requested by consultant Link to comment Share on other sites More sharing options...
MedicinePower Posted January 8, 2015 Share Posted January 8, 2015 Did we forget to draw labs and send out cultures? Vaginal swab? Link to comment Share on other sites More sharing options...
PAtoB Posted January 8, 2015 Share Posted January 8, 2015 Ultrasound first. Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 8, 2015 Author Moderator Share Posted January 8, 2015 Ultrasound first. Why? Link to comment Share on other sites More sharing options...
PAtoB Posted January 8, 2015 Share Posted January 8, 2015 imo given her age, micro bleeding, etc, ectopic or fallopian tube rupture still not ruled out, and US is least invasive modality of the three. Link to comment Share on other sites More sharing options...
Moderator EMEDPA Posted January 8, 2015 Moderator Share Posted January 8, 2015 imo given her age, micro bleeding, etc, ectopic or fallopian tube rupture still not ruled out, and US is least invasive modality of the three. we have a neg preg test. Link to comment Share on other sites More sharing options...
PAtoB Posted January 8, 2015 Share Posted January 8, 2015 then CT to r/o appendix vs. abscess from infection? Link to comment Share on other sites More sharing options...
gbrothers98 Posted January 8, 2015 Share Posted January 8, 2015 This is great, can't wait for the wrap up. After the punchline, if you have a spare hour and are interested in going into EM or have a rotation coming up, spend some time with this guy: GB PA-C Link to comment Share on other sites More sharing options...
PACdan Posted January 8, 2015 Share Posted January 8, 2015 Condom is a red herring. Peritonitis? Diverticulitis? Link to comment Share on other sites More sharing options...
GreatChecko Posted January 8, 2015 Share Posted January 8, 2015 Is the imaging to rule out access/other intra abdominal syndrome or am I missing something? We have the source of infection and could theoretically proceed from there, right? Link to comment Share on other sites More sharing options...
Moderator True Anomaly Posted January 8, 2015 Author Moderator Share Posted January 8, 2015 Is the imaging to rule out access/other intra abdominal syndrome or am I missing something? We have the source of infection and could theoretically proceed from there, right? Ah see, that's the question- presented in a certain light, you can somewhat reasonably make a case for a disposition without further imaging- "34 y/o female, no past medical hx, presents with lower abdominal/pelvic pain, is febrile and tachycardia without any N/V/D who has grossly contaminated urine and is not pregnant- she has a UTI that might progress to pyelonephritis- I should at least place her in observation with IV antibiotics and watch her over the next 24 hours". This is not totally unreasonable, but there are two things that aren't taken into account- her abdominal exam and this finding of a condom that's been sitting in there for a week and a half. She may not have been truly peritonitic with a rigid abdomen, but her abdomen is not benign. So...the punchline. My main concerns were appendicitis and PID/TOA- they were 1a and 1b on my list- they had to be ruled out before any other disposition or treatment was considered. Given the finding of the condom and her lack of N/V/D and anorexia, I felt PID/TOA was slightly more likely. As PAtoB noted earlier, given her age and that ultrasound would be the least harmful to her, I decided to go with the pelvic ultrasound first (I did request they try to look at the appendix), BUT with the caveat that if her US was normal that she needs a CT abdomen/pelvis with contrast. And that is how I signed it out to the oncoming provider who relieved me. I got a text at home about an hour later- "US shows bilateral tubo-ovarian abscesses with a very small amount of fluid in the pelvis". So OB/GYN was consulted and she was admitted to their service with antibiotics started- unclear if operative management/IR intervention was initially planned. The reason I wanted to present this case was not because of the diagnosis being some really strange zebra, but because to me it emphasizes the physical exam making a key difference in how you approach a patient overall- and that you need to examine ALL systems that might be affected in order to make an informed clinical decision. We all know there are providers out there that would have examined her abdomen and not done a pelvic exam, proceeded with a CT and come up with this weird finding of some foreign body in the pelvis with the abscesses seen in both fallopian tubes and may or may not have seen the appendix- but then you have to go back and complete the physical exam to remove the foreign body, and you've exposed her to a large amount of radiation and a large dye load that could have been avoided if you had done an initially thorough physical exam gbrothers- I haven't seen that video you posted yet, but I'm hoping it's along the same lines as what I try to emphasize to students- how to think in an ER manner with each and every patient. Link to comment Share on other sites More sharing options...
PAtoB Posted January 8, 2015 Share Posted January 8, 2015 Skimmed over a couple of posts that I missed earlier. So was I on right track? still in didactic year here. Link to comment Share on other sites More sharing options...
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