Case of the Month

Case of the Month #1 – Presentation, 7/4/14

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This is a fictitious patient seen at a fictitious hospital called Janus General. Don’t believe me? I’m on staff there – see

 

65 yo F pmhx HTN/DM presents with worsening abdominal pain for 2 days. Pain is generalized, 10/10, no radiation, previously intermittent, but is now constant for hours. No known exacerbating/alleviating factors.

Eating less, but still drinking. Last BM yesterday – watery, non-bloody diarrhea x 2. +Nausea, vomiting, NBNB x 1 this AM.

 

ROS: + subjective fevers/chills without measured temp, +mild pedal edema x few days

ROS: no joint pain, no red or black stool, no dysuria/frequency/urgency, no trauma, no back pain, no weakness or numbness, no recent travel or URI, no recent antibiotic use or hospitalizations, no neck stiffness, sick contacts.

 

Denies toxic habits
No previous surgeries.

 

VS HR 155, BP 170/60, RR 23, Temp (oral) 100.3, O2sat 99% on RA

 

PE agitated, uncomfortable, appears to have active abdominal pain

CV: tachycardic, 2/6 systolic murmur, no g/r

Pulm: CTAB w/o w/r/r

Abd: soft, nt,nd.

Neuro exam diff as pt uncooperative. No obvious neuro deficitis.

No meningismus/rashes

 

Please see the attached EKG

 

 

Untitled

 

Before looking at the links below, please think about your differential diagnosis and what interventions/tests you think the patient needs. Bonus points if you put this in your final answer.

 

Medications/actions
IV x 2/O2, Tylenol/Morphine 6mg, 1 L NS.Rectal temp 101.2.

 

Initial Imaging
cxr

 

Labs
VBG sig for lactate 6, o/w unremarkable. WBC 18, H/H/plts at baseline/unremarkable. CMP unremarkable. Trop detectable but not significant. BNP 907. Ua neg for uti. Blood/urine cultures sent.

 

After reviewing the lab results and presentation what must be done?
Order antibiotics given elevated lactate with SIRS criteria (tachycardia, tachypnic, febrile…later elevated wbc). No risk factors for hospital acquired infection, but I think most would order vanco/zosyn. CTA abd/pelvis for mesenteric ischemia NEGATIVE for mesenteric ischemia or other abdominal catastrophe (fooled you)

 

 

For the prize of the week: After reviewing the above presentation, what additional test do you want and what is the diagnosis? Please describe an appropriate treatment plan including disposition.

 

 

 

 

By Dr. Andrew Grock

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.
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andygrock

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3 comments for “Case of the Month #1 – Presentation, 7/4/14”

  1. bberzon
    July 10, 2014 at 12:43 pm

    in summary, 65 yo F w DM HTN c/o diffuse abd pain w/ nonspecific ROS except infectious and heart failure, exam with tachy, fever, agitated, benign abdomen. labs with lactate, high WBC, high BNP, CXR with congestion ekg with sinus tachy and signs of rate related ischemia, neg CT AP.
    so…. we have infectious signs with failure signs. this leads me to suspect a cardiac source of infection like endocarditits. her cc is abd pain but no such pathology was found. the chest would be my next guess.
    A TTE followed by TEE would be my first test of choice, looking at her valves for a vegetation, she has no real risk factors for it but i cant afford to miss it. If thats negative a CT chest with contrast to look for chest pathology would be my next test.

    If her VS remain as above after fluid resuscitation, anti-pyretics and pain control i would get the MICU on board. if she improved, I would admit her to medicine with abx monitoring and further testing.

  2. dzeccola
    July 10, 2014 at 8:05 pm

    I think I would order a TSH/Free T4. Abd pain, altered mentition, nausea vomiting, fever, tachycardia, pulmonary edema on CXR – all features of thyrotoxicosis and all of whichcontribute to the scoring system (Burch watofsky http://flexikon.doccheck.com/en/Burch-Wartofsky-Score) for hyperthyroidism. I think this could be thyroid storm. In her case she would have a score of somewhere around 70 – which would qualify as frank thyroid storm.

    If TSH low and t4 high I would start with a beta blocker (propanolol) and then add methimazole. She would also be a clear cut ICU player – not appropriate for tele or floor because the pulmonary edema, when present could be signal of impending decompensation.

  3. ablumenberg
    July 10, 2014 at 10:00 pm

    The patient’s severe abdominal pain, SIRS picture, and pleural effusions makes acute pancreatitis a possibility. Spontaneous bacterial peritonitis would be possible too, but I’m guessing the CT would have showed ascites.

    More zebra-y possibilities TB/systemic fungi, colon cancer +/- S. Bovis endocarditis, and ovarian CA.

    I would order lipase levels and perform a paracentesis if there were evidence of ascities. SICU if positive lipase, MICU for most other diagnoses.

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