Teaching case: 16 y/o/f sent to your ED from an UC with transient belly pain

[ohiovolffemtp]

This is an actual case I had come into my ED within the past several weeks:

16 year old female comes in to the ED with complaints of now resolved abdominal pain.  She was seen at an urgent care earlier that day after she had a 1-2 day history of generalized abdominal pain that seemed to be more lower abdominal but poorly localized.  She said she had some mild nausea but no vomiting, perhaps loss of appetite yesterday but eating OK today.  She reports normal BM's and pain free urination with no urgency, frequency, or flank pain.  She has no history of any abdominal surgeries, no history of any previously diagnosed abdominal complaints, no history of painful menstrual periods or of ovarian cysts.

The urgent care has lab capability but no imaging.  Patient comes with the following labs:

• CBC: WBC 20,  H&H normal, platelets normal
• CMP: electrolytes normal, glucose normal, LFT's normal, alk phos elevated
• Lipase: normal
• UA: no nitrites, no leukocyte esterase, no blood, no elevated WBC's
• Urine pregnancy: negative.
• Provider's notes express concern for possible appendicitis.

Patient's exam:

• positive cell phone sign
• normal vitals: not febrile or tachycardic.
• abdominal exam: no tenderness - actually ticklish, no masses, no pulsatile masses, normal bowel sounds.
• no flank tenderness, no suprapubic tenderness

Should you (you can pick several of these if it's what you think is right):

• observe her for 1-2 hours then repeat the abdominal exam
• send her home with strict return precautions
• repeat labs
• image her (your site has CT but no ultrasound at night when she's there)

Please explain your rationale.

Let's give the students several days to think about this, then the practicing PA's can chime in.

[Mayamom]

Hmm positive cell phone sign?   Not entirely sure what that is  Has anyone completed a pelvic exam on  the patient?  With a WBC=20 that would be my next step. 

[SedRate]

10 hours ago, Mayamom said:

Hmm positive cell phone sign?   Not entirely sure what that is

It's when a pt is on their cell phone. It generally implies the pt is not acutely ill as they are able to comfortably crush Candy Crush while on the stretcher in the ER. 

[kweb011]

I will put myself out there, here goes:

I would want to get imaging, an abdominopelvic CT w/ contrast, plus I would consider getting additional lab work, such as a serum quant hcg. I don’t think there would be any labs I would repeat right now, but if she was worsening I would think about trending labs (WBC and alk phos). Or maybe repeat these now to see if they are indeed rising despite no change in patient's appearance, I'm not sure.

DDX: 

Cholecystitis/choledocholithiasis (transient pain + leukocytosis + elevated alk phos- 16 is a little young compare to "classic" patient, but also not sure of BMI)

Appendicitis (lower ABD pain + leukocytosis)

Ectopic (feel like have to consider and has to be definitively ruled out)

Other GYN complaints (mittelschmerz- but wouldn't explain the lab abnormalities, PID, TOA, ovarian torsion)

Ischemic colitis (transient pain but does have normal BMs)

 

The CT would hopefully rule in/out an appy or biliary pathology. (An US would be really good here for initial image of appy and biliary and evaluation of adnexa). 

Not sure if in practice an ectopic is considered effectively ruled out with just a u-preg or if a serum quant hcg is needed, but I would get one just to be sure. 

The negative ABD PE findings and no fever are reassuring for appy/TOA/torsion/ectopic, and the negative UA and no dysuria make me lean away from PID.

I would like to know more history (pain relationship to eating, sexual history). Other things I would consider if the CT comes back negative would be a pelvic exam (as another member already said) to evaluate cervical motion tenderness and discharge. Was Murphy's sign evaluated?

 

This is tough, of course real life is never clear like in school! Looking forward to some feedback from someone who actually knows something!

[ohiovolffemtp]

Folks,

There are some good thoughts out there:

• pelvic exam: excellent idea, was deferred pending other evaluation
• repeat labs: good for:
  • trending, esp. of white count
  • if there is suspicion that the outside labs are not accurate - which does happen occasionally
• serum quantitative HCG: probably not necessary.  A negative urine HCG is considered a solid enough finding to rule out pregnancy.
• elevated alk phos: can often be normal in kids and teens d/t bone growth.  At 16 and female patient is probably close to the end of this period.
• ultrasound: excellent way to start if available - but isn't available at night at this site and in my experience often it's only the large facilities that have 24 hour ultrasound coverage and places that have call-back it's limited to a few conditions like suspected ectopic, which would be hard to claim with a negative urine pregnancy
• Murphy's sign - I didn't mention it but negative as part of a benign abdominal exam.
• Several folks have hit on the key point: significantly elevated white count.  That's the key point: this can't be ignored, even in the presence of a benign abdominal exam.  There's not been any N/V to suggest that this might be reactive.

So:

• imaging is needed to evaluate and rule in/out the various potential badnesses identified is folks' differential.  Pelvic exam, etc. can't really do this.  Even if there are significant findings, you can't stop there.  From the time management point of view, doing the imaging 1st then the pelvic exam or seeing other patients is the best way to parallel process.
• CT imaging has it's limitations.  For example, it's less sensitive that U/S for gall bladder and can't evaluate for blood flow to evaluate for ovarian torsion.

So:

• CT ordered.  Radiologist called with critical finding which explained both the transient pain and the elevated white count - and to a large extent this unusual presentation.

Guesses?

[SedRate]

Ddx: Retrocecal appendicitis, diverticular abscess/microperf, intraabdominal abscess of some sort

Psoas or obturator sign?

The "critical finding" with a benign exam is throwing me off. 

[Reality Check 2]

Free air in the abdomen..............

Walled off appendix abscess

Ovarian torsion but usually horribly painful unless it spins back off and on

PID but should not be happy on her phone

More caffeine needed.....................

[kweb011]

Perforated ulcer, volvulus, fecal impaction, displaced IUD, foreign body, unilateral hydronephrosis...

[ohiovolffemtp]

CT of the abdomen & pelvis was read as acute appendicitis with perforation, with a small amount of free air and free fluid in the pelvis, with adjacent fat stranding.  All portions of the reproductive system described as normal.

Most likely explanation for the patient's presentation is that she had pain which resolved once the appendix perf'd.  I've seen this several times before.

Teaching points:

• It's a good idea to get labs on all abdominal pain presentations.  Abnormal findings can reveal the need to look further, even in the event of benign abdominal exams, even serial benign exams.
• Once one clinician has explicitly included something on the differential,  it needs to be explicitly addressed in subsequent evaluations at other facilities.
• It's helpful to know the reliability of your own and outside labs.  Sometimes it's necessary to repeat the labs to confirm that reported abnormalities are correct.

I wouldn't recommend scanning all belly pains, but abnormal labs, especially an elevated white count, should make you at least think seriously about it even if the abdominal exam is benign.

[SedRate]

7 hours ago, ohiovolffemtp said:

Most likely explanation for the patient's presentation is that she had pain which resolved once the appendix perf'd. I've seen this several times before.

Ah, yes, great observation. That's classic. And then they can become septic if it's not recognized. Good case review! Keep em coming.