Hot Seat Case #97: 18 yo F with Abdominal Pain
Posted on: August 15, 2017, by : Haroon Shaukat MD
Haroon Shaukat, MD Children’s National Medical Center
with Pavan Zaveri, MD Children’s National Medical Center
18 yo female was in her usual state of health until 12 days prior to arrival. She was visiting Tennessee when she acutely began complaining of nausea and abdominal pain that persisted for 48 hours. Once she spiked a fever to 102F, her parents took her to a local ED. There she was found to have a ruptured appendicitis and admitted for IV antibiotics. She was ultimately discharged home 3 days later on oral Ciprofloxaxin and Metronidazole for a total course of 10 days. She reports an improvement in symptoms for her last day out of town and then began the drive back home 2 days prior to arrival, however, on the way home she began complaining of intermittent abdominal pain. This pain felt duller than the previous pain, without associated emesis. Today she began to have fevers, worsening abdominal pain, chest pain, and dyspnea which prompted her return to the ED.
ROS: + L arm paresthesia and nausea. Denies urinary symptoms, sore throat, cough, headache, lethargy.
PMH: None
Medications: No prescription, OTC, herbal, or OCP’s.
Social Hx: Denies ETOH, drug use, sexual activity. LMP 3 weeks ago.
PE: T 37, P 93, BP 106/70, R 18, Sats 98% RA
General: Uncomfortable appearing
HEENT: Dry lips, oropharynx nonerythematous
CV: RRR no murmurs or rubs. Cap refill <3secs. No reproducible tenderness to palpation.
Pulm: Good air entry bilaterally, no wheezing or crackles. No retractions but splinting. Mild tachypnea.
Abd: +BS, soft, mildly distended, RUQ/RLQ tenderness to palpation, no HSM
Neuro: Awake and alert, No focal deficits.
MSK: No extremity or calf tenderness.
Skin: No rash, bruising, or pallor.
Labs are pending.
WBC: 7.65: 10.8/31.5: 283
CMP: Normal except albumin 3.0
UA: Negative, Ucx: Pending
CXR: Small focus of airspace disease within the lateral aspect of the RUL posteriorly, atelectasis vs. infection.
ABD CT: Appendicitis with multiple abscesses.
She was given morphine, which brought her pain down to 2/10, yet she continued to appear as if she was splinting.
A spiral CT was ordered and revealed a pulmonary embolus within the segmental LLB with associated airspace disease and pleural fluid.
Repeat vitals are:
T 37.2, P 82, BP 111/71, R 25, Sats 98% on RA
The over-read by radiology returns with the following additions:
-Decompression of the majority of the colon except dilated loops of sigmoid colon, possible closed loop obstruction.
– Prominent L gonadal vein with multiple collaterals, possible thrombosis of pelvic veins.
– Relative enhancing of iliac vein walls, possible phlebitis.
The information in these cases has been changed to protect patient identity and confidentiality. The images are only provided for educational purposes and members agree not to download them, share them, or otherwise use them for any other purpose.
So, as teaching attending, I’ll take first crack at it, and then maybe come back later for further comments if this case discussion gets as twisted as the case itself…
Right from the getgo, I was with the appendicitis and its complications, so don’t need to dwell more on that.
I’m going to use this comment field to talk out my thoughts as I read through the case.
Initial exam: RR 18, but noted to have splinting and mild tachypnea. The note of mild tachypnea didn’t totally square with RR 18, though we know it is fast for an adult, but particularly when you write that in your exam, it sure means it something that the examiner noted…let’s keep this in mind….
One vital sign that was missing was weight which may have directly affected my decision on Abd CT vs. US. As we saw, we quickly moved to Abd CT with its expected findings on the abdomen.
As above, the splinting is concerning and more pain meds may be indicated. The real answer to giving more is actually that I would ask her, you look uncomfortable, yet your pain is better, what’s bothering you or where is your discomfort?
Going back now to the CXR findings of RUL disease – quite unusual and further specific…I can see now why there may have been a thought to get the CT Chest sooner than later combined with the splinting. A great lesson in combining all the pieces of the puzzle to try to get a more complete picture where everything fits together.
A curious question at this point to me would be whether IV contrast was given again (after the Abd CT) or was that able to be done with the same contrast. Likely too detailed to include in the already complicated hot seat case, but something to think about for sure.
So, let’s move along….the oft irritating CT over-read revealing so much….is that the attending? is that the resident looking more carefully? always check your source and know that the supervisor is on the right page….So, now we’ve got all these clots to deal with….what’s the risk? Hmm, I think we could be dealing with multiple more clots coming down the pike increasing her risk of critical illness. So, yes that puts her in the category of needing the ICU….that’s about all i can think of on that. So, despite stability of VS, the risk of illness is what can take her to the ICU. The other topic embedded there was about coordinating care from multiple services, and despite it all, our hospitalist colleagues are great at understanding the complications and working it out, along with of course our critical care colleagues.
I will let others comment on the clinical care/case though this turned out to be more of a management question-laden case.
So, take home points:
– Note subtle exam findings
– Try to put the pieces together into a unified puzzle
– Examine your risk and incorporate that into your medical decision-making (not just for documentation)
Maybe some further CT over-read will further complicate the denouement….
I agree, and I will say the point that I struggled most with this case was that often we try to put the pieces of the puzzle together to come together into one zebra rather than two, but this case was the contrary, in that two different processes occurring simultaneously were playing along hand in hand.
I will also say as above, the over-read was by the attending.
And the initial RR18 was the triage set of vitals, yet she was visibly tachypneic on my exam.
The other DDX I toyed with was myocarditis hence the cardiology consult and echo consideration but didn’t quite pull that trigger.