Day 8 - the acute abdomen
Working until 12.30am on a Friday night / Saturday morning is not exactly my idea of a perfect start to the weekend, but it important to work on pre-weekends and weekends because more problems tend to show up, purely because GP offices close early on these days.
My first patient was a guy who was suffering fevers, sweats, rigors since 1pm Friday. This occured while out shopping. His past history suggests: MS (15 years), BP, permanent condom catherisation, chest infection 3 weeks ago, recurrent UTIs. His current problem is just fevers. He was physically unwell. He complained or not other problems except for a nagging productive cough (yellow sputum) which was not substantial and has been going for the past month. I assessed him, and his vitals were okay when I did that. There was no evidence of further symptoms on extensive questioning. This presents a problem, because we have not narrowed to any particular system of the body. Students are often presented with systems based illness, rather than symptom based illness. A collection of symptoms will point to the right diagnosis, but sometimes if not enough symptoms are present then you might have wide variety of options. In this particular case, two obvious aetiologies are evident: 1) Chest infection persisting despite 1 course of antibiotics, 2) Recurrent UTI. His examination findings were unremarkable except for: unwell looking, temp of 39.8, BP 120/70, PR: 80 regular with no delays, sweats, and peripheral leg swelling (which has occurred for as long time). His urine was dark. A general work up is done: FBE, UEC, sputum (M/S/C), urine (FWT, M/S/C), blood culture, BSL, CXR. His blood results were not spectacular, and his urine results took a while to come back. I ducked out to help out with a below knee plaster cast for an undisplaced fibular fracture, and came back to find out he had crashed and was transfered to the acute care area of ED. His BP dropped to 90/60, and he was feeling worse off. A decision is made to treat him emperically with antibiotics, his CXR was clear. So could it be a UTI? Call the Med Registrar. My responsibility ended there.
The 2nd patient was a young (31yr old) Muslim lady who presents with right lower quadrant abdominal pain for past 24 hrs, 72 hx of nausea/vomiting, no relationship to food, no blood, no other symptoms (bowel motions okay, no LOW/LOA), 24 hx of mild vaginal bleeding (bright red, some clots) with no discharge, nil urinary symptoms. Okay, what are you thinking of now? Here are some options:
Non-pregnant:
Appendix (highly likely)
Renal (can occur)
AAA (always exclude)
Gall Bladder (unusual)
Liver (unusual)
Caecum
Small Bowel (unusual)
PID (likely)
Ovarian pathology (not likely, need ultrasound)
UTI / Kidney infection /Cystitis (possible)
Gastroenteritis (history no suggestive)
Non-specific viral (possible, but other causes must be excluded first)
Pregnant:
Ectopic pregnancy (must be excluded)
Threatened miscarriage (likely)
Other miscarriage (further tests required)
That is a hell of a lot of options, so lets narrow it down. Here is more information: PHx: C-Section, nil further. Meds: nil, Allergies: nil, Family Hx: Miscarriage - elder sister (6th baby), Menstrual hx: regular 30 day cycles, lasts for 4 /5 days, LMP - 31st Oct (Friday’s date: 9th Dec), Gynae hx: no STI, Past Pregnancies: nil hx of miscarriages, no past pregnancies, baby healthy - no delivery complications.
O/E patient is stable, vitals normal, not in considerable pain, sleeping comfortably in the bed. Chest: clear, Abdo: moderate tenderness in RIF, nil rebound, nil guarding, abdomen soft, nil masses, nil superficial inflammatory signs.
When you find that the patient’s period has not come on time, then one must exclude PREGNANCY. This is mandatory. Not doing so, is an automatic fail in an OSCE situation.
I ordered the following bloods: B-HCG, FBE, UEC, LFT, Lipase (in case), Group and Hold, Micro: Urine (FWT). Ultrasound is not available after hours. Ideally this would helped to diagnose an intra-uterine pregnancy (depends on gestation). ON further question, patient states she has been trying to get pregnant for their second baby.
Results: B-HCG - 5 (result of 5-25 must be repeated within 48 hrs to exclude early pregnancy), FBC (raised WCC - not impressive), UEC (normal), Urine (blood on FWT –> contaminant?), LFTs (normal), Lipase (normal). What is your next step in management? Her history does not sound UTI(ish) therefore rule this out, and other sinister aetiologies (AAA). Does the results still rule out ectopic, well it doesn’t completely but highly unlikely. Is it possible that she is having a threatened miscarriage, well BCG is not high enough to warrant that, but possible. Non-specific causes: highly likely. Appendix: well, no rebound, no guarding - so if she is having it, its probably self limiting. PID: no evidence on questioning, Liver: normal, Pancreas: normal, SB: history shows no signs of obstruction, Gastroenteritis: bowel motions essentially normal in this case, so highly unlikely, family not sick, hasn’t eaten uncooked meat or unusual foods recently, hasn’t eaten outside recently, Ovarian pathology: ?cyst, could be not serious enough for a diagnosis of torsion or rupture. Risk factors for ectopic pregnancy: her only risk factor is C-section (previous abdominal surgery). She has no history of uterine abnormalities, IUCD use, multiple partners (i.e.: PID), past history, or family history of ectopics etc.
I examined her again in about 1 hour, and her pain has considerably been relieved despite no analgesics being given. She is feeling comfortable at rest, vitals normal.
Plan: discharge on analgesics, query non-specific viral?, query ovarian cyst?, visit GP in 48 hrs for pregnancy test - plan management there after, ?ultrasound required to rule out ovarian cyst, if pain persists or worsens come back on weekend.
Was VE performed? No. A medical student performing a VE on a female with no chaperoning is a court case waiting to happen. In this case, there is no evidence of a gynaecological problem warranting a VE, if pregnancy result was conclusive then a VE might be warranted - perhaps by Gynae reg.
I saw a couple of other patients, one with chest pain but this was towards the end of my shift so I don’t know the management for them. I left at 12.30am.
I hope this covers the acute abdomen well. Note that a lot of it is mentioned in lectures, but also note the inability to perform an ultrasound after hours. This is reserved for acute cases where the patient is in significant distress. An ultrasound was not warranted (decided by the consultant) in this case. Also note that if you suspect ectopic pregnancy, you MUST Group and Hold her blood type in case she crashes and emergency surgery is required.