Doczilla
06-20-2008, 22:58
28 yo obese F comes to the ER on a Saturday with a chief complaint of RUQ abdominal pain. She says the pain has been steady for 3 days, waxing and waning in severity. It was not associated with eating or drinking. She has had some nausea and 2 episodes of nonbilious, nonbloody vomiting. She has had no fevers, no rash, no vaginal bleeding or discharge, no diarrhea, melena (black digested blood in stool), or hematochezia (bright red blood in stool). She has not had any dysuria (pain with urinating) or urinary urgency. She denies flank pain. Review of systems is otherwise negative.
She visited the ER 2 days ago for it, had CBC, BMP, UA, UHCG, and a noncontrast abdominal CT done at that time, all of which were normal/negative. She was sent home with instructions to follow up if the pain persisted/got worse or if she had any fever, inability to eat or drink, or other symptoms.
On physical exam, she is smiling and pleasant, not in acute distress.
T: 98 P: 76 R:14 BP: 140/86 Sa)2 99% on room air.
Lung sounds clear and equal bilaterally.
Heart sounds reveal regular rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Abdomen is soft without any organomegaly. RUQ is tender to palpation, with percussion tenderness. Normal bowel sounds. No pelvic tenderness.
Pelvic exam is unremarkable, with no adnexal or cervical motion tenderness or cervical discharge.
Extremities reveal no rash, cyanosis, or edema.
Neuro exam is grossly intact.
CBC, BMP, LFTs, Lipase, UA, UHCG are all normal. GC and chlamydia cultures are sent and won't be resulted for 2 days.
Ultrasound of the gall bladder shows no stones, ductal dilation, wall thickening, or pericholecystic fluid.
D-Dimer is positive at 1500, so CT of the chest for PE is ordered. There is no PE, but the radiologist notes fluid around the spleen, which is nonspecific.
CT scan of the abdomen is obtained based on the finding from the chest CT, and other than the fluid around the spleen, is normal as read by the radiologist.
The patient is sent home with Nexium and Vicodin, and follow-up is arranged for Monday with surgery to obtain a HIDA scan (nuclear gall bladder scan).
The ER doc Sunday morning is called by the radiologist on the over-read of the abdominal CT. The radiologist says there is some "nonspecific weirdness" in the pelvis, and recommends a transvaginal ultrasound. The patient is contacted to return to the ER, which she does, Monday morning.
When she returns at 9am Monday morning, her RUQ pain continues. Exam is unchanged from previous. Vitals are normal and she is afebrile. She has no RLQ or LLQ tenderness, but based on the fact that the CT was weird, and that it's cheap, harmless, and fast, transvaginal ultrasound is obtained. This is read as having some nonspecific free fluid in the pelvis, but nothing out of sorts. The data from previous visit is reviewed, and other than the cultures not being back yet, there is nothing missing or abnormal. Because of her continued RUQ pain, and the fact that this is her 3rd ER visit for this complaint, I order the HIDA scan, which takes roughly all damn day.
CBC, BMP, LFTs, Lipase, UA, UHCG, are all again normal. HIDA scan is read as normal, with normal gall bladder uptake and 61% EF.
Pelvic exam is repeated. There is no discharge or adnexal tenderness, but this time there is cervical motion tenderness. Based on this, I tell her that I'm going to treat her for cervicitis empirically with the usual antibiotics. I return to the desk to order her rocephin and zithromax, and recheck the cultures from the previous visit. The chlamydia PCR is positive. I return to the room to tell her the confirmed diagnosis, and that her boyfriend is a schmuck.
The patient has Fitz-Hugh-Curtis syndrome, a disease of inflamed liver capsule that is caused by chlamydia or gonorrhea. This is often diagnosed by laparoscopy when the patient is referred to surgery. Treatment with azithromycin and doxycycline is curative in the case of chlamydia, and rocephin in the case of gonorrhea (fluoroquinolones no longer recommended for GC).
I bring this up because many of the folks in this forum will be taking care of young women in the clinic and in the sandbox, and it was interesting to have a case of PID with no pelvic symptoms (and initially a normal pelvic exam). This mimicked an acute surgical issue, and had we not had a wide range of diagnostic data available, she might very well have gone to have her gallbladder out. It also brings home the point that the pelvic exam is important in young women with abdominal pain, no matter where the pain is.
'zilla
She visited the ER 2 days ago for it, had CBC, BMP, UA, UHCG, and a noncontrast abdominal CT done at that time, all of which were normal/negative. She was sent home with instructions to follow up if the pain persisted/got worse or if she had any fever, inability to eat or drink, or other symptoms.
On physical exam, she is smiling and pleasant, not in acute distress.
T: 98 P: 76 R:14 BP: 140/86 Sa)2 99% on room air.
Lung sounds clear and equal bilaterally.
Heart sounds reveal regular rate and rhythm, S1, S2, no murmurs, rubs, or gallops.
Abdomen is soft without any organomegaly. RUQ is tender to palpation, with percussion tenderness. Normal bowel sounds. No pelvic tenderness.
Pelvic exam is unremarkable, with no adnexal or cervical motion tenderness or cervical discharge.
Extremities reveal no rash, cyanosis, or edema.
Neuro exam is grossly intact.
CBC, BMP, LFTs, Lipase, UA, UHCG are all normal. GC and chlamydia cultures are sent and won't be resulted for 2 days.
Ultrasound of the gall bladder shows no stones, ductal dilation, wall thickening, or pericholecystic fluid.
D-Dimer is positive at 1500, so CT of the chest for PE is ordered. There is no PE, but the radiologist notes fluid around the spleen, which is nonspecific.
CT scan of the abdomen is obtained based on the finding from the chest CT, and other than the fluid around the spleen, is normal as read by the radiologist.
The patient is sent home with Nexium and Vicodin, and follow-up is arranged for Monday with surgery to obtain a HIDA scan (nuclear gall bladder scan).
The ER doc Sunday morning is called by the radiologist on the over-read of the abdominal CT. The radiologist says there is some "nonspecific weirdness" in the pelvis, and recommends a transvaginal ultrasound. The patient is contacted to return to the ER, which she does, Monday morning.
When she returns at 9am Monday morning, her RUQ pain continues. Exam is unchanged from previous. Vitals are normal and she is afebrile. She has no RLQ or LLQ tenderness, but based on the fact that the CT was weird, and that it's cheap, harmless, and fast, transvaginal ultrasound is obtained. This is read as having some nonspecific free fluid in the pelvis, but nothing out of sorts. The data from previous visit is reviewed, and other than the cultures not being back yet, there is nothing missing or abnormal. Because of her continued RUQ pain, and the fact that this is her 3rd ER visit for this complaint, I order the HIDA scan, which takes roughly all damn day.
CBC, BMP, LFTs, Lipase, UA, UHCG, are all again normal. HIDA scan is read as normal, with normal gall bladder uptake and 61% EF.
Pelvic exam is repeated. There is no discharge or adnexal tenderness, but this time there is cervical motion tenderness. Based on this, I tell her that I'm going to treat her for cervicitis empirically with the usual antibiotics. I return to the desk to order her rocephin and zithromax, and recheck the cultures from the previous visit. The chlamydia PCR is positive. I return to the room to tell her the confirmed diagnosis, and that her boyfriend is a schmuck.
The patient has Fitz-Hugh-Curtis syndrome, a disease of inflamed liver capsule that is caused by chlamydia or gonorrhea. This is often diagnosed by laparoscopy when the patient is referred to surgery. Treatment with azithromycin and doxycycline is curative in the case of chlamydia, and rocephin in the case of gonorrhea (fluoroquinolones no longer recommended for GC).
I bring this up because many of the folks in this forum will be taking care of young women in the clinic and in the sandbox, and it was interesting to have a case of PID with no pelvic symptoms (and initially a normal pelvic exam). This mimicked an acute surgical issue, and had we not had a wide range of diagnostic data available, she might very well have gone to have her gallbladder out. It also brings home the point that the pelvic exam is important in young women with abdominal pain, no matter where the pain is.
'zilla