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Abdominal Pain - Not The Usual Suspects

Nate Finnerty, MD and Mike Weinstock, MD
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19:58
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Abdominal pain is the black hole of differential diagnostics! It can be anything. Mike and Nate review a case of a young man with LUQ pain who suffered an interesting complication.

 

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Richard H. -

Please expand on the thought process in getting from abdominal pain to an outpatient CT abdomen. I can't get a CT easily in the UC, and when I do (usually by sending to ED) I want to explain to the patient and myself why I need it, and why now. I see UC providers getting outpatient CTs for acute/months/years of abdo pain, often with normal vitals and a benign/minimal exam. Usually they're negative. Some seem to have a 1 out of 10 positive return rate. My checklist to get to an outpatient CT is:

1) significant change, usually severe pain or abnormal vitals/exam
2) no response to an intervention (GI cocktail, Toradol, Miralax) if time permits
3) a realistic ddx of what I'm looking for (& thus test needed - contrast?, ultrasound, ..)
4) likelihood of going home

So, it's not often. For this case, was exam significant with rebound/peritoneal signs? Any analgesia tried/failed? Was Mono in ddx, and if so why not get an ultrasound (less radiation)? Lastly, if they're sick enough need a CT now, why not send to ED for a) pain control b) extended observation or anticipated admission? Obviously, getting a CT worked out for this case. But, what do you think is an acceptable rate for getting a "normal" CT back, which seems like should be lower than, say, plain films or EKGs, or even bloodwork?

Enjoy your show. Thanks

Mike W., MD -

Thx for you comments Richard - this reason this CT was done was the repeat exam had changed and was more significant. Maybe that did not come out clearly enough in the discussion, but I have found that if there is some time between exams and if there is a change (worse pain/more impressive exam) then I will bump up the level of testing. Of course, a little luck never hurts... sometimes there is a 'sense' that everything doesn't fit and there may be a serious cause of symptoms - I have always struggled w 'the art of medicine' and an evidence based approach to diagnosis and mgmt. Thx!

Scott H., MD -

About 10 years ago I had a frightening case in a tiny critical access hospital in rural NH with limited resources.

During tourist season in the Lakes Region of NH presents a mid 20s healthy Caucasian male that was the most pale I have ever seen among the living and I knew that shock was present before even talking to him, although he managed to still be alert. His family drove him in.

He had come to vacation with family and played a round of golf. During one swing he felt some brief abdominal pain in the LUQ, but "shook it off" and finished the round. When they came home a couple hours later he felt tired and layed down and napped. Fortunately, he woke up and felt poorly and his family brought him in, although he didn't want to.

Our staff is great and called me to his room immediately and in one look and rapid assessment established large bore multi-access IV and called the lab for uncrossmatched O neg (or + if that is all that they had as we have a very limited supply in the woods) immediately.

What follows is the difficulty of being in such a small place. The lab actually started to give me a hard time about uncross matched blood and this kid was in shock! They heard from me that I was sending a runner and that if they didn't immediately release the blood there would be repercussions; and the poor technician probably felt stuck among their policy, ignorance of the situation and my needs. I kid you not that I actually got a phone call from a pathologist about my using uncross matched blood and its risks and I had to tell him that I was going to hang up now as I needed to be at the bedside and we could talk later, and that I was aware of the risks; including the risks of exsanguination before my eyes. Resuscitation was successful and CT showed a major splenic hemorrhage (pre bedside ultrasound availability era in this ED).

Next I though, what wonderful luck, my on call surgeon walked into the ED regarding another case right as I was looking at the CT before our radiologist (remote) called me in a panic. I showed her the scan and she agreed with the need for blood; but then actually not only left the department but left the hospital. When I called her as soon as I realized that she had left, her reply was to "transfer" him. Oh $%^&! I was dismayed, perplexed and angered but had to deal with what I had on a weekend with even more limited resources than usual. Thank God that the New England weather was cooperative and I was able to quickly fly him to MGH (Boston) where there team was very accomodating and had the OR ready prior to his arrival. The surgeon told me that there experience as that spontaneous splenic ruptures were very often much more complicated to manage than traumatic ruptures, and that these cases frightened them as they usually required rapid laparotomy.

In followup 2 things occured:

1. The general surgeon was ultimately dismissed from the medical staff
2. A few months later the patient walked into the ED to thank us and I happened to be on shift. He was fine, but had a lap incision that was the largest exposure that I've ever seen, stem to stern with widening. But he was happy to be alive.
3. We slipped in a pneumovax and looked for a meningococcal vaccine prior to his flight while we continued to stabilize him for I was taught in medical school by my ID professor that even the last few minutes/hours of having a spleen will boost the immune response to these encapsulated organisms that can give splenectomized patients a hard time later in life - so why not? That is, they will respond better than if you give it to them post-op.

Anyway, I was very aware that this patient likely had mononucleosis and ran a monospot that FWIW was +. But clinically he had a compatible syndrome for the week or more prior to his spontaneous golf swing rupture.

A case I won't forget anytime soon.

Best, Scott Horton

Mike W., MD -

Wow Scott, this is an AMAZING story - thx so much for sharing! You are not the only one who won't forget this story any time soon!!

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You Broke It Where?? Full episode audio for MD edition 198:23 min - 93 MB - M4Ahippo Urgent Care RAP - March 2017 Summary 328 KB - PDF