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

by andygrock • July 4, 2014 • 3 Comments

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

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

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

Resident Editor In Chief of blog.clinicalmonster.com.
Co-Founder and Co-Director of the ALiEM AIR Executive Board - Check it out here: http://www.aliem.com/aliem-approved-instructional-resources-air-series/
Resident at Kings County Hospital