White Coat Underground

Morning Report

Here’s how this is going to work. Thanks to a reader, I have a case for you, which I’ll present in parts. I will try to make the information accessible to both professionals and lay-people. I’ll start with the barest of information and rather than guess what’s going on right away, I’d like to see people organize their thoughts into broad categories based on the initial symptoms. One way to think about this is to think about what, anatomically, is in the area of question—in other words, what can go wrong there. Then, think of types of disease—vascular, anatomic, infectious, allergic, etc. I will, of course, help you with this.

A 32 year old woman presents to the emergency department with a chief complaint of abdominal pain. She reports that the pain is in her lower abdomen. It began as a vague, dull ache about one week prior to presentation but now it is sharp, severe, and does not radiate. Nothing seems to make it better or worse.

So think about what structures could be affected and by what mechanism. If you guys can’t come up with it, I’ll give you an example. After a while, I’ll addend this post with a summary of the comments and the next set of findings.

Addendum

I really shouldn’t do this without providing an example, so I’ll start off a bit for you so you see how to approach this.

Lower abdominal pain can be due to (but not necessarily limited to) some of the following structures:

  • Skin
  • Mesentery/Omentum
  • Large intestine
  • Small intestine
  • Appendix
  • Iliac artery or other large arteries branching off the aorta
  • Female reproductive tract, including ovaries, fallopian tubes, uterus
  • round ligament
  • bladder
  • ureters
  • referred pain from somewhere else, and anything else I might have forgotten

One or more of these structures may be affected by one of these general processes(incomplete list):

  • Infectious
  • Auto-immune
  • vascular
  • neoplastic
  • anatomic/structural

Once we complete this “Templeton Grid” (more on that later) we can fill in some possibilities.

Addendum

Strong work by all. Good questions, good ideas. Most of my medical students and interns like to jump right to guessing a diagnosis, but I tell them to hold up. If you jump to conclusions before you systematically approach the case, you’re going to make mistakes, and so while all of the guesses were excellent, they are premature.

Dianne’s response is a typical one from someone with a good medical education. Once you have a fairly comprehensive list like that, you can gather more information and start to cross things off.

When I present a case, I like to give data out in the order real life would allow. So…

On further questioning, the patient has no significant family history of medical problems. She herself has no history of medical problems. Her last period was five weeks ago. She doesn’t smoke and drinks alcohol and uses marijuana from time to time. She doesn’t take any medications.

The patient appears to be in mild distress due to pain.

Her heart rate is 108, respirations are normal, blood pressure is 165/90. Her temperature is 37.8 C. She weighs 90kg.

She isn’t jaundiced. She is not emanating any unusual odors. Her mouth is moist. She is not pale. Her heart was regular but fast. Her lungs were clear. Her legs were not swollen. Her abdomen was soft to the touch, but pushing on the lower abdomen caused her to tense up a bit. She was especially tender in across the lower abdomen, perhaps slightly more on the right. On rectal exam, she has normal brown stool which does not have any trace blood in it.

Addendum

Some time has passed and some of the investigations you’ve asked for are available.
A urine pregnancy test is negative. A white blood cell count is 10.2 (slightly elevated). A urinalysis shows no blood, no pus, and no other abnormalities. Standard blood chemistries were normal.

I would use this information to cross out some of the possibilities that Dianne outlined.

Addendum

After presenting the case to your attending physician, she reminded you to do a pelvic exam. On exam, there was physiologic (normal) vaginal discharge, and normal external genitalia. Her cervix was grossly normal. There was tenderness of the adnexa (ovaries and tubes) and some minimal tenderness when the cervix was moved around. Slides of the vaginal secretions were normal (pH 4.5, no hyphae, no trichomonads, no clue cells).

Addendum

We’ve been narrowing things down to a few basic structures. Here they are:

i-38de5c8c3652081e59db33d19403ac11-Appendix_(PSF).png

Human appendix ( (Source)

i-7630332b554ebc261eb8cf849ee524ed-481px-Scheme_female_reproductive_system-en.svg.png

Female reproductive tract

(Source)

The classic teaching of appendicitis is that the os of the appendix becomes obstructed with fecal material, and in the human body, stasis often leads to infection. When the appendix becomes blocked and infected, the patient often develops vague lower abdominal pain around the navel which eventually migrates to a point between the navel and the right hip. Appetite declines, bowel movements stop, and the patient gets very sick.

Ovarian torsion involves an ovary turning around on it’s stalk with the blood flow being cut off. It’s usually unilateral and very painful.

Pelvic inflammatory disease, a common complication of gonorrhea and chlamydia, causes lower abdominal pain, fevers, and tenderness of the cervix and ovaries. Sometimes an abscess forms and you can feel a discrete mass.

Endometriosis tends to come and go with periods and the pain can be nearly anywhere.

Ovarian cysts, physiologic or otherwise, can get worse peri-menstrurally, and can even rupture.

In this case, an ultrasound showed some free fluid in the pelvis, normal blood flow to the ovaries, and some fullness to the tubes and ovaries, including what appeared to be a large, ruptured cyst on the right. There was no intrauterine or extrauterine pregnancy.

A CT scan of the abdomen and pelvic showed a normal vermiform appendix and was otherwise normal.

A genetic probe for Neisseria gonhorroeae and Chlamydia trachomatis came back positive for the latter.

This tells me two things: the pain may be due to a ruptured ovarian cyst (a benign condition) or to pelvic inflammatory disease (PID), which can lead to infertility. Given the opportunity, I would treat the pain of the cyst, and treat the PID with a long-ish course of antibiotics according to current guidelines. I would counsel the patient to speak to any sexual partners about her diagnosis and provide counseling on STD prevention and contraception. I would also check her blood for syphilis and HIV, and perhaps hepatitis B.

Comments

  1. #1 elissa
    September 29, 2009

    Okay, I’m not a medical person, so don’t laugh when this is wrong :) I’m going to guess any of the various reproductive organs – ovary being my primary guess. Maybe a cyst or an ectopic pregnancy?

  2. #2 PalMD
    September 29, 2009

    Don’t rush to specific diagnoses, no matter how good they sound…stay general to start…i put an example above.

  3. #3 Binny
    September 29, 2009

    Are you looking for test suggestions? I would ask about bowel moments and urination, the basic panel of blood counts, pregnancy test. I’d also ask about sports/activity level and any recent injuries. Any new drugs prescribed recently? Any other symptoms – headache, nausea, any arm pain or tingling?

  4. #4 Kururin
    September 29, 2009

    I am overwhelmed by the possible differentials given this stem! Things I jump to want to rule out include ectopic pregnancy, ovarian torsion, acute appendicitis or something that’s been inflamed then perforated.

    Going by anatomy, there’s the hindgut derivatives, gynaecological organs and bladder and ureters to think about. Might even be pancreatitis. But the character of the pain suggests visceral pain that localised once some peritoneum got involved and that might be classical appendicitis. I’m hoping it’s something horribly complicated though ;D

  5. #5 Art
    September 29, 2009

    Gallstones, intestinal obstruction/laceration (pica, or other non-food items. Swallowed chicken bone, etc.), tumor or mass, ectopic pregnancy, infection and appendicitis. Food allergy possible.

    Get more complete history. Any changes in types/amounts of food eaten in the last two weeks? Ask about bowel function, diarrhea, sexual activity within the last six months, eating habits and anything that might bruise or damage liver, spleen, pancreas. Car accident or boyfriend likes to punch her. Is pain worse/better after eating or defecating, AM/PM, lying down, standing.

    Have patient gently jump up and down and see if pain increases and times with jumps – yes = increase odds of appendicitis.

    Palpation to localize mass and/or pain. Not often definitive but it gives the patient that loved over feeling.

    Blood test for pregnancy, liver function and white cell count and anything else that comes to mind.

    Ultrasound for gallstones, swollen appendix and/or foreign objects.

    One has to assume the obvious has been looked into. Like perhaps an infected belly button ring.

  6. #6 Brian
    September 29, 2009

    Lower abdomen, eh? So we’re dealing with a female of reproductive age – affected could be any reproductive structures: Ovaries, fallopian tubes, uterus, broad ligament. Also possible is bladder, and some of the lower gut.

    Could be infection/inflammation, ectopic/tubal pregnancy… those are ideas that spring to mind.

    When was her last menstrual period? Pregnancy status? Significant history? Fever?

  7. #7 Dianne
    September 29, 2009

    Ok, a few thoughts about abdominal pain to start with…

    My first reaction was “an obvious case of familial meditarranian fever”. (The joke, for the non-medical types is that FMF is a rare cause of abdominal pain but if one is seen in an academic medical center it is almost certain to end up in morning report, making it appear quite common.)

    The lower abdomen has lots of interesting structures and the possible reasons for pain are multiple.

    GI problems: She could have a problem in her colon ranging from appendicitis, vascular insufficiency in the colon, diverticulitis, obstruction or pseudo-obstruction, or inflammatory bowel disease. Has she had prior surgery? Adhesions may be an issue. She could even just have constipation: constipation with colon dilation due to gas can be quite painful, even in the absence of obstipation.

    GYN problems: She could have ovarian problems ranging from ectopic pregnancy to ovarian torsion. Uterine problems including perforation, adhesions, and even just severe dysmenorrhea might cause lower abdominal pain.

    Infectious/inflammatory etiologies: A pelvic or GI infection could easily cause this pain. Particularly an abcess that ruptured. Peritonitis from any number of initial causes including problems in the upper abdomen (ie pancreatitis, an ulcer which perforated, etc) might cause lower abdominal pain.

    Metabolic: The FMF mentioned above does, in fact, cause abdominal pain. Diabetic ketoacidosis can present with abdominal pain as well.

    Kidney/GU: Kidney stones or pyelonephritis might present with lower abdominal pain.

    Malignancy: I’m putting this separately even though it really overlaps with many of the above: A colon cancer might cause severe constipation or obstipation leading to pain. An ovarian cancer could cause pain either directly or through blockage of the colon or urinary tract. A metastatic lesion on the peritoneum might cause pain. A uterine cancer which has grown excessivly might as well. Pain from pancreatic cancer might be poorly localized and be felt mostly in the lower abdomen.

    Other: Musculoskeletal pain, psychosomatic, etc.

    Sorry, I’m not being very systematic. Looking forward to hearing more…

  8. #8 Catharine
    September 29, 2009

    Simple things first: sounds like a marvelous combination of constipation and gas. But somebody already guessed that, didn’t s/he?

  9. #9 antipodean
    September 29, 2009

    One of the fabulous things about working with physicians when you are a scientist is realising that despite physicians being a little scientifically naive at times you as a non-medico are utterly ignorant of diagnosis.

    So I shut up and listen.

  10. #10 PalMD
    September 29, 2009

    Props to the one who analyzed this embryologically!

    It doesn’t surprise me that dianne thinks like i do, given her previous contributions.

    Anyway, thanks folks, I’m gonna summarize your ideas and give you some more data as an addendum above.

  11. #11 Kim
    September 29, 2009

    Wait, she presented in the ER with these symptoms and the triage nurse didn’t give her a urine collection cup? :-P

  12. #12 BaldApe
    September 30, 2009

    What antipodean said. (except that I’m not so good at shutting up :-)

    Sounds a lot like when I had my appendix go bad. I was asked to rate the pain 1 to 10. I said 7. The emergency room doctor didn’t believe it was my appendix because I wasn’t wimping out over the pain. By the time they removed it, it was starting to rupture.

    Working with people is certainly more art than science, especially when they are not uniformly either logical or emotional. (to me, it would be meaningless to say “on a scale of 1 to 10, it’s 11)

  13. #13 fishboy
    September 30, 2009

    could she be pregnant?

  14. #14 Dianne
    September 30, 2009

    Does she have rebound? And how about that pregnancy test?

  15. #15 PalMD
    September 30, 2009

    OK, some time has passed so i’ll add some details.

  16. #16 Kururin
    September 30, 2009

    I think she’s too young to really entertain malignant disease as a cause… not saying it isn’t impossible though. Presence of faeces in the rectum without blood or mucus points away from intestinal obstruction and inflammatory bowel disease and the negative pregnancy test helps negate ectopic gestation. No blood, leucocytes or other stuff in the urine, so infection and stones less likely too.

    She doesn’t sound septic enough for perforation, pyelonephritis or abcess. She’s mildly pyrexial with a minor leucocytosis and not a great deal else. By normal blood chemistries I’ll assume LFTs and glucose are OK, as is blood glucose to help rule out diabetic ketoacidosis. What about amylase and CRP?

    I’d still put appendicitis as top of my differential list since the history fits and it’s just so common. Things like ovarian torsion, ovarian cyst haemorrhage, fibroid haemorrhage even, those are still possible.

    Can we have an abdominal film and erect chest to see if there are any bowel loops or faecal loading proximally or free air under the diaphragm? I’d expect it to be negative, but a blood culture should be sent off. I haven’t worked in surgery for a year so my evaluation of the acute abdomen is not at the forefront of my mind but this is what I’d be thinking about.

  17. #17 PalMD
    September 30, 2009

    An acute abdominal series includes a PA and Lateral chest xray and it’s fairly easy to get, so I’ll tell you that the chest film was normal, there was no free air under the diaphragm (indicated no perforated intestine/stomach), and a benign non-specific gas pattern in the large and small bowel.

  18. #18 PalMD
    September 30, 2009

    BTW, not including facilities charges and physicians fees, we’ve spent about 400 bucks so far.

  19. #19 AusMed
    September 30, 2009

    I think with the somewhat localized pain and tenderness, and the leukocytosis on top, you’d almost be at diagnosis time, but with the missing signs…

    I’d hate to suggest it right after a post about the money we’ve spent, but abdominal CT?

  20. #20 PalMD
    September 30, 2009

    Kururin has given a nice narrowing of things:

    • Appendicitis
    • Ovarian Cyst
    • Ovarian torsion
    • uterine fibroid
    • To this I would add diverticulitis or other colitis, even though the lack of blood in the stool makes them somewhat less likely. We must also consider infectious diseases of the female genital tract.

      Anatomic problems such as volvulus and intussusception seem less likely—as K mentioned, the pain is in an embryonically hindgut distribution, and the abdominal exam is quite benign.

      In the past, a suspected appendicitis was taken to the OR and a 14% negative surgery rate was considered optimum to make sure none were missed. This was before sophisticated imaging.

      Ultrasound was used for a while but did not prove all that great.

      CT is excellent for identifying appendicitis.

      Now, for a serious vs non-serious assessment.

      Of the possibilities listed, which may still be wrong, appendicitis and ovarian torsion are the most serious. Undiagnosed appy can lead to peritonitis and death, and ovarian torsion can lead to loss of the ovary.

      Ultrasound is probably the best test for torsion, and CT is probably the best for appy. If it were me, I’d consider doing both.

      Things that argue against appy are presence of appetite and lack of constipation, so i suppose we could consider doing an US first.

      But before we do imaging, we need a pelvic exam.

  21. #21 fishboy
    October 1, 2009

    dysmenorrhea, give her some ibuprofen and send her home.

  22. #22 Kururin
    October 1, 2009

    I’m wondering what the significance is of the fact that she’s not menstruated for 5 weeks. She should be due a period round about now. I don’t think you can call it dysmenorrhoea if she’s not menstruating and it’s too late to just label it as mittelschmertz pain. MD is right, we need a proper pelvic exam to check the adnexae.

  23. #23 Hildy
    October 1, 2009

    Which adnexa? Is it localised to one side, or is it both adnexae?

    Since this is emergency, I’d do a bedside ultrasound (free) to look for free fluid in the Pouch of Douglas (as well as having a look at the ovaries, depending on body habitus).

    Causes of both adnexae being tender:
    - free fluid, most likely blood (endometriosis?)

    Causes of one adnexa being tender
    - inside the adnexae
    — ectopic (r/o by preg test)
    — PID
    - outside the adnexae
    - adjacent bowel

  24. #24 Dianne
    October 1, 2009

    Ultrasound is probably the best test for torsion, and CT is probably the best for appy. If it were me, I’d consider doing both.

    I agree, but if I had to get only one, maybe in some conservative dystopia rationing fantasy, I’d probably go for the ultrasound. Ultrasound isn’t great for appy but can sometimes be vaguely useful (though you’d need both abdominal and vaginal probes most likely). Also it’s almost impossible to kill someone with an ultrasound whereas CTs use radiation, creating a small but real risk and contrast can cause nasty reactions if used.

    In real life, one would probably get both tests and the order of the tests would probably be determined by availability, that is, which one is free at the moment. My guess is that the ultrasound would go first.

    So how was that pelvic exam?

  25. #25 Dianne
    October 1, 2009

    Oops, just read the update. Were both adnexa equally tender? And how tender were they? As much as would be expected for the amount of expressed pain? They could be tender because she’s got a ruptured appendix which is starting to leak nasty stuff into her peritoneum.

  26. #26 JohnV
    October 1, 2009

    The longer this thread goes on, the more I question my decision to not take anatomy and physiology because it was at 8 am.

  27. #27 Kururin
    October 1, 2009

    Useful reminder that co-infection with more than one STD is very common and this should be considered when giving one-stop treatments to prevent re-admission.

  28. #28 Dianne
    October 1, 2009

    I would also check her blood for syphilis and HIV, and perhaps hepatitis B.

    You might consider testing for hep C as well. If all her hep B markers come back negative she should probably be vaccinated: it rarely hurts and can prevent an infection which can lead to cirrhosis and hepatoma.

  29. #29 Hildy
    October 1, 2009

    Hep C isn’t really sexually transmitted.

    I wouldn’t do any of this stuff in the emergency department, other than the antibiotics and pain relief. It’s for primary care.