Student case two: the bad belly

[winterallsummer]

You are a PA working in patient at a busy hospital. Between transferring your crashing HCAP patient to the ICU on a non rebreather and answering a page about a blood sugar of 642 on a patient your colleague asked you to cover for so he could go out of town, the ER MD calls you requesting an admission. As your pager goes off yet again you head down to the ER.

 

The patient is a white female in her late 30s. She presents with three weeks of lower abdominal pain. She had been to an Urgent care clinic last week and was sent home without any labs and a trial of PPI. The ER doc doesn't tell you much else and neglected to send labs but knew she had to be admitted since she bounced back. He gave her a so called GI cocktail and says the patient thinks it maybe helped a little. ((The fact that no labs were sent is obviously only because this is a teaching case. In reality we did have labs prior to admission.)). However he did send a KUB which the result of is pending.

 

Upon entering the exam room you see a healthy appearing white female sitting up in bed with one hand on her stomach. She used to smoke socially but otherwise doesn't drink and lives at home with her husband and has no children. She takes no medicine besides the PPI she was prescribed last week. It did not seem to help her symptoms much if at all.

 

She tells you a few weeks ago her lower abdomen started hurting. The pain is crampy in nature and was intermittent but over the past few days has become constant to the point she has a hard time staying asleep. She denies palliative or provocative factors. Her appetite is decreased but she denies any vomitting or weight loss. She denies fever or chills. She appears in no apparent distress. She denies any past medical or surgical history and works in an office. She has not seen a doctor for a few years but states that at her last routine check up she was told she was healthy.

 

On exam she is mildly tender to palpating in the lower abdominal quadrants. However her abdomen is soft and non distended. The rest of her exam is benign. Her temperature is normal, BP 165/92, HR 91, and she is breathing at a normal rate on RA with 96% oxygenation.

 

What else do you want to know? What labs and/or imaging studies would you like?

[Deanj59]

Is she making stool and or passing flatus? If so, how often? Any change in the frequency of stool, color, quality? Any foul smelling stool? Is pain relieved with defication?

 

Any urgency, frequency, or dysuria? Any CVA tenderness on exam?

[cop to pa]

Urine hCG

[cop to pa]

Please.

[DiggySRNA]

urinalysis

GFR and creatine levels

hcg results, if negative, order A&P w/ contrast ct

 

 

 

....that's all I can think of

[winterallsummer]

Her UA is unremarkable. She is not pregnant.

 

Upon asking, she admits to two weeks of constipation. Her flanks are NT. She has no urinary symptoms.

 

For anyone coming to the hospital we usually check CBC and CMP. Her labs are unremarkable except a calcium of 16. Her KUB returns unremarkable except an incidental finding of a possible 4.5 cm lung nodule.

 

Next steps?

[winterallsummer]

Still want the CTAP and if so w or wo contrast?

[winterallsummer]

Also UA is unremarkable. (Sorry cannot edit on phone)

[DiggySRNA]

what does nt mean?

she's hypercalcemic 

does she have a h/x of hyperthyroidism?

yes include that chest, abdomen, and pelvis w/ contrast scan...that lung nodule is throwing me off.

edit:
acute pancreatitis?

appendicitis?

diverticulitis?

best case scenario benign lung mass. 

...iv contrast is not needed to expose malignancies. 

[winterallsummer]

What is your differential at this point?

 

Do you need the AP part of that CT or just chest? Do you need contrast to look at malignancy? Any other tests?

 

Someone post a differential then I will post the imaging results we checked.

[winterallsummer]

NT is common abbreviation for non tender. NT CVA b/l would mean her flanks are non tender bilaterally.

[winterallsummer]

Also she re confirms with you she has no history of hyperthyroidism or any other remarkable PMH.

[JoeM]

DDx:

 

hyperparathyroidism

ovarian ca with mets 

lymphoma

renal ca

lung ca with paraneoplastic (she seems too young and not enough smoking though?)

 

those aren't in any specific order ;)

[PACdan]

Let's add Sarcoidosis (or other granulomatous disorder) and PID to the ddx as well.

[JoeM]

Good call on the sarcoidosis

[winterallsummer]

Great differential everyone. So when we see a clinical problem after addressing any life threatening emergencies (this woman had none), the next step is to formulate our differential. A good differential should include three categories. The first is what is the most common 1-3 diagnoses. In clinics, hyperparathyroidism is the most common cause of hypercalcemia. In hospitals the most common cause is secondary to a paraneoplastic syndrome of cancer. However we tend to always consider both (but this is a good fact to know for the tests.)

 

Sarcoidosis is another good cause and she fits the sex and age group but not ethnicity (black) to make this fairly high on the differential. While sarcoidosis can cause any type of symptom it tends to affect the lungs and she had no pulmonary complaints or exam findings. Also anecdotally the calcium doesn't tend to run this high.

 

Another extremely common cause of hypercalcemia is dehydration. However the patient was euvolemic on exam with normal labs (eg Cr and BUN were normal and no hemoconcentration) so this was essentially excluded.

 

Some other less common causes include hypothyrodisim, Addison's disease, excess vitamin D, excess exogenous calcium intake known as milk-alkali syndrome (eg in the patient who drinks half a gallon of milk a day or eats handfuls of gummy vitamin D "candy"). Calciphlaxis is another cause however in ESRD patients. Finally many drugs can cause hypercalcemia (thiazides in your hypertensive patients and lithium in your bipolar patients, most commonly). There also are genetic, metabolic causes however these are really more considerations for the pediatrician.

 

The bottom line is when you see hypercalcemia, think first of the diagnosis you cannot miss - cancer (breast, lung and multiple myeloma but also hematological, GI, renal and essentially any other cancer) and hyperparathyroidism. Or if your patient is dehydrated it may simply be due to dehydration. Next check the drug list for thiazides such as HCTZ or lithium. Also consider hypothyroidism. Work these common causes up first (cancer: look for other symptoms to guide your work up and always image the lungs, and order appropriate labs), hyperparathyroidism and hypothyroidism (lab work and imaging studies), ask specifically if they take any psych med or BP med, and consider if they are dehydrated. If none of these causes pan out then start considering the other rarer causes listed above and also consider endocrinology consultation. Also hyperparathyroidism has several different causes itself - we may address that later.

 

Now regarding imaging. A CTAP (CT of abdomen and pelvis) is not indicated just yet however some providers may check this. However it is not sensitive enough to truly rule out a GI malignancy. For that you need colonoscopy type procedures. A CT chest is warranted however at this point because the hypercalcemia and large lung nodule are concerning for a pulmonary malignancy. Adenocarcinoma of the lungs is the most common cause of lung cancer in non smokers and women (but also common in smokers and men). The fact that she doesn't smoke, have radiation or other overt carcinogen exposure or have a family history is not enough to exclude lung cancer in this scenario though it makes it unlikely.

 

Irregardless, once you see a pulmonary nodule on an x Ray, you must come up with some strategy to address it whether it is finding an old x Ray to prove it hasn't grown, getting a repeat image in 3-6 months, or jumping right to a CT scan. This woman had no prior films for comparison. The size and characteristics of the nodule will guide your strategy. Often the radiologist will include the guideline recommendation in his or her note. In this case the recommendation was for a CT scan of the chest. Whether or not to use contrast differs per opinions. In this case I checked a CT chest without. To my delight but also chagrin, the CT chest was totally clear and the nodule seen on the KUB was actually a misread. This is uncommon for such a small nodule. In hindsight perhaps I could've got a CXR but overall a CT chest was certainly justified.

 

Now what other studies would you like? You will still need more bloodwork and possibly further imaging to crack this case.

 

What orders do you enter since you need to admit her to the hospital? Any other questions? Great job so far everyone and keep the replies coming.

[winterallsummer]

Also regarding your post about pancreatitis. Hypercalcemia is a rare but possible cause of pancreatitis (note I said cause of, not vice versa, to my knowledge). In pancreatitis, typically the patient has epigastric (less commonly diffuse, peri umbilical or RUQ) pain that often radiates to the back. Except early in the course, there is almost always a history of nausea and frank emesis. The patients often appear in distress from dehydration and pain. That being said you are free to request whatever you want to look into this.

 

PID... Possible in lower abdominal pain but these patients tend to present looking quite sick and with a history of vaginal discharge and STI risk factors. Leukocytosis and fever are also common and the presentation may or may not be a shorter course than several weeks. A pelvic exam was deferred but the answer to this case is not PID and PID is not related to hypercalcemia (unless the pt is markedly dehydrated.) But good thought regarding lower abdominal pain in a young female.

 

Also typo in above post: meant to say a misread is uncommon in such a LARGE nodule. Cannot edit on phone.

 

Also lymphoma or any hematological cancer cause is possible. But recall that her CBC is unremarkable.

 

Renal carcinoma is another possibility. CTAP would be one way to look for this. Renal ultrasound would be a cheaper way that also spares your patient radiation. In this case I was able to find the answer without either of these imaging modalities. But good thought.

 

What else?

[winterallsummer]

Also do you want to ask any other specific questions? What signs and symptoms are common in hypercalcemia?

[winterallsummer]

Also a hint. You will need more labs and imaging to find your answer here. Review the CT chest is negative (radiologist misread the KUB and yes this does happen in real life, unfortunately) and consider your differential.

 

Also what orders do you want since you need to admit her? What other symptoms might she be having and how can you help her feel better while gathering your studies to find the underlying etiology of her disease process?

[SERENITY NOW]

 Great case!  Looking forward to seeing the result.  Thanks for taking the time to do it.  

[JoeM]

probably should get an EKG and ask if she's feeling faint, drowsy, palpitations, etc. 

and cover the stones, moans, groans, psych overtones symptoms

 

Can you give her some fluids, maybe a loop diuretic to get rid of some of the Ca++, and a stool softener?

 

maybe check an albumin level, ionized Ca++, TSH, Phos level, an Alk Phos level, and of course a PTH level

 

imaging i'd like a thyroid sonogram

[winterallsummer]

Specifically waiting to hear:

 

1) what signs and symptoms are common in hypercalcemia? For this patient how can we address those while continuing her work up?

 

2) what orders do we need when admitting this patient to the hospital?

 

3) what other labs and or imaging studies are indicated? It may be helpful to rethink the differential with the CT chest being negative now.

 

Also earlier I meant to say you should always address life threatening emergencies first and then come up with a differential. A good DDx is divided into three categories. 1) in this presentation and taking age/gender/ethnicity into account, what are the 1-3 most likely answers to the case? 2) what are the diagnoses that cannot be missed even if less likely? This would include cancer in this case. As another example if a patient presents with chest pain the most likely diagnosis might be muscular pain but the one not to be missed would be acute MI.

 

Concurrently you should be working towards the likely dx while also ruling out the more dangerous ones. This doesn't always mean a big work up. Someone mentioned PID which can lead to or present as sepsis. A mere abdominal exam and review of vitals and labs and a good history is sufficient to rule this out. If you could not do so (eg she had some Leukocytosis) then a pelvic exam would be warranted (some providers may do pelvic exam on any female with lower abdominal pain but in real life this is not always the case). Etc.

 

The third category are the more fun, rare causes. This is the list you keep in the back of your mind if you rule out the common causes and still don't have your answer. These typically should not be worked up (unless the testing is cheap and non invasive perhaps) unless the work up of the common diagnoses are all negative.

[winterallsummer]

She denies feeling faint or having palpitations. An EKG shows NSR.

 

She denies the classic excruciating flank pain that radiates to the groin in nephrolithiasis. She also lacks N/V and appears in NAD. You recall that about 70-80% of stones involve calcium and thus would show up on her KUB (the type you'd expect in this setting). There are none. You consider the gold standard of CTAP without contrast but decide the pre test probability of kidney stones is too low to warrant this expensive test that has significant radiation exposure.

 

Upon asking, she does admit to increased depression and anxiety over the last week.

 

How much fluids? Bolus or continuous, and if the latter what rate? What type of fluids?

 

Loop diuretics were once thought to help with hypercalcemia but modern evidence showed otherwise. Thus they are not indicated.

 

Stool softener - yes. This is an easy way to address the symptoms that brought her in (abdominal pain and no BM for 2.5 weeks). What medications specifically?

 

Ionized calcium was greater than 1.65 (the highest the lab can go).

 

Alk phos is part of CMP and was normal.

 

TSH was normal as was the free T4 you checked.

 

Phosphate - I forget if I checked this or not.

 

PTH was around 600. PTH-related-peptide (the PTH analogue seen in paraneoplastic syndromes) was within normal limits (WNL).

 

Thyroid sonogram reveals a 3x3x3 mass in the right side of the neck. Now what?

[winterallsummer]

Also what's another medication to help with symptoms here (something specific for hypercalcemia)?

[JoeM]

You can give her calcitonin or a bisphosphonate for the hypercalcemia. The calcitonin will work acutely and the bisphosphonate will take a few days to kick in. 

 

As far as fluids go, I'm don't know how much to give. I wouldn't think much would be necessary as she is euvolemic. If you can enlighten me on determining 

how much fluid to give I would appreciate it. A lot of my preceptors never really give me a straight answer!

 

for the stool softener maybe dulcolax or milk of magnesia 

 

As for the thyroid mass

-with an elevated PTH, a parathyroid adenoma is likely

-I don't think a thyroid carcinoma with bone mets can be ruled out yet

-since it's 3 cm and she's symptomatic I think an FNA is warranted

 

Thanks for posting this btw I enjoy all these cases and how you help guide us through them. As a student, this is great learning tool!!!