So glad EM is a team sport (or why didn't my Spidey-sense tingle?)

[RetNavyPAC]

58yo woman comes in to the ED c/o about 2 weeks of irritative voiding symptoms: dysuria, hesitancy, frequency, LBP (that she attributed to mowing the lawn) and feeling "kind of tired". Also notes occ feeling feverish, mild suprapubic cramping and dry mouth for the last three days (that she attributed to her decr appetite and fluid intake).

 

Denied nausea/vomiting, constipation or diarrhea. Otherwise healthy woman taking Zocor for dyslipidemia and a baby ASA qd.

 

States she didn't seek care for 12 days because she has been busy taking care of her spouse who recently had ENT surgery

 

Seen at an Urgent Care two days ago and her UA was unremarkable. The FP working there sent her home with Pyridium. Didn't treat her empirically for UTI.

 

She was afebrile, and not tachycardic (oddly, she was slightly brady @ 58). Unremarkable exam with only some mild suprapubic TTP.

 

Figured she had a run-of-the-mill UTI/early pyelo cooking. UA confirmed WBCs and a + nitrite. Figured I'd give her a liter of NS for her dry mouth and while I was having the nurse stick her, order a CBC and a BMP.

 

Felt better after the fluids and the BMP was unremarkable and the CBC showed a slight elevation in WBCs of 12.1 and a bandemia of 12

 

I thought this was all consistent with an indolent UTI.

 

Ran it by my attending. He said the bandemia really had him concerned. Went to chat with the patient and came back and wanted to CT her (w/contrast). I asked why and he said "I don't know. There's just something about her. I'm worried that she may have something going on in her belly. It'll probably be negative, but humor me."

 

Okey-doke.

 

2 hrs later. . .

 

CT Abd/Pelvis showed "large complex collection in the midline of the lower pelvis with a maximum AP diameter of approximately 11 cm, maximum transverse diameter 8 cm, superior to inferior length of approximately 9 cm. This has air, fluid and potentially fecal material within it. This is closely associated, inseparable from the inferior wall of a loop of the sigmoid colon which is thickened and irregular. Despite the administration of the rectal contrast, contrast does not fill this collection but mostly distended the rectum. There is still suspicion of a connection to the sigmoid colon on the initial coronal reconstructions.

 

The complexity increases when trying to identify the uterus and adnexal structures separate from this complex collection. The uterus may be displaced to the right side but fistulous connection to the uterus with distention of the uterine cavity might be difficult to completely exclude or fistulous collection to the adnexa. The appearance of this collection at least raises the possibility of necrotic tumor although I would certainly favor that this probably started as a diverticular process perhaps with secondary involvement of adnexa or uterus. Percutaneous drainage might be challenging since these structures and adjacent bowel loops might be problematic. Endoscopic drainage through the rectum may or may not be an option."

 

 

Eff. Me. :O_O:

 

I was going to treat her with Cipro and have her f/u with her PCP in 1-2 days.

 

At least I won't walk in this week to, "Hey - remember that lady you saw on Sunday with the supposed UTI?"

 

Damn.

[EMEDPA]

Wow. Near miss. Could have been bad....

[rev ronin]

The hallmark of a good clinician is not "Well, I met standard of care" but "I'm very glad that we caught that"

[Just Steve]

offfftttaaa... humor the doc indeed. You not only humored them but tossed in a song and dance as well. Heck of a find. Glad it was discovered. It's amazing what the human body can tolerate. My belly hurt just reading the report.

[jsfelder0417]

Wow. That was a heck of a catch.

[ajnelson]

Wow! I've had one or two near miss cases like this, even though there isn't anything concrete, I feel that the patient needs an extra study...and it confirms my suspicion. It runs chills up my spine at how easily some things can be missed, and wonder how much we actually DO miss!

[RetNavyPAC]

Wow. That was a heck of a catch.

 

 

You forgot to insert "lucky" in between the 'a' and 'catch'. :-)

 

All things considered, I'd much rather be good than lucky - but I'll take lucky when I can get it.