NON-ENGLISH SPEAKING FEMALE PATIENT WITH LEFT LOWER QUADRANT ABDOMINAL PAIN. Bihter Korbeci, PGY3 St. Joseph s Health

Transcription

1 NON-ENGLISH SPEAKING FEMALE PATIENT WITH LEFT LOWER QUADRANT ABDOMINAL PAIN Bihter Korbeci, PGY3 St. Joseph s Health

2 History of Presenting Illness

3 The rest of her history PMH Viral pharyngitis PSH none Allergies NKDA Medications none Social history negative x3, Sexually active with her husband only. FMH Parents and siblings generally healthy

4 Physical Exam Vitals: BP 133/84 Pulse 84 Temp(Src) 98.1 F (Oral) Resp 18 Wt kg (135 lb) LMP 04/30/2015 Abdominal: Soft. Bowel sounds are normal. She exhibits no distension. There is tenderness. There is no guarding. LLQ tenderness, non radiating. Genitourinary: Vagina normal. No vaginal discharge found. Bimanual exam exam showed cervical motion tenderness, positive adnexal tenderness bilaterally, no adnexa fullness/mass

5 Discussion Abdominal pain in Healthy young Female Does Pelvic Exam in the Emergency Department add useful information to patient s management? Which imaging modality to choose to further investigate pelvic pain?

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9 Brown et al Prospective Cohort Study 320 patients selected from list of patients where attending physician determined need for pelvic exam. Provider was asked reason for pelvic exam and prediction of result. After pelvic exam, provider was asked of actual findings on exam. Laboratory and radiographic tests also collected to correlate with predicted and actual findings of pelvic exam.

10 Brown et al Limitations Providers were not asked of their management prior and after pelvic exam. They were not asked how particular unexpected findings changed their management. Patients needing cervical cultures were excluded from study.

11 Williamson and Aldeen 2010 American College of Emergency Physician current recommendation regarding management of pelvic inflammatory disease Reviewed current research regarding diagnosing and treatment modalities of pelvic inflammatory disease Despite nonspecific nature of the presenting signs and symptoms of PID, they see pelvic examination as the most useful component of the physical exam to aid in diagnosis.

12 Does Pelvic Exam in the Emergency Department add useful information? Johnson et al (2013) and Brown et al (2011) performed a study to determine if vaginal examination improves diagnostic accuracy in women who presented to the Emergency Department. Johnson et al (2013) looked at first trimester pregnant females and Brown et al (2011) looked at any woman who required a pelvic exam. Providers would predict pelvic exam findings and diagnosis Ultimately, there was no significant predictive factor added by performing a pelvic exam. Isoardi (2009) performed a medline search review of 43 articles looking at routine use of pelvic exam in the Emergency Department. Pelvic exam did not add to diagnosis more than checking ultrasound and a Bhcg. Williamson and Aldeen (2010) looked at evaluation and management of PID in the emergency room patients. Their recommendations are on American College of Emergency Physicians. ACEP recommends performing pelvic exams as the most useful component of the physical exam to aid in diagnosis.

13 Does Pelvic Exam in the Emergency Department add useful information?? Yes/No. Ultimate answer depends on differential diagnosis.

14 CT scan vs U/S imaging Modalities for Investigation of Pelvic Pain American College of Radiology Appropriateness Criteria Based on expert panel on women s imaging and literature review comparing risks vs benefits of each imaging modality. Recommendation provided based on clinical condition and variants.

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19 CT scan vs U/S imaging Modalities for Investigation of Pelvic Pain American College of Radiology Appropriateness Criteria 1 Acute pelvic pain in reproductive age group presents diagnostic challenges. 2 The choice of the correct imaging test depends on the results of a careful clinical evaluation in order to narrow the differential diagnosis. 3 The first step is to measure Bhcg 4 Pregnant patients with acute signs of infection and suspected gynecological etiology for pain Pelvic u/s with adnexal Doppler would be initial modality to assess the etiology If u/s is inconclusive then MRI would be the next modality of choice. 5 Non-pregnant patients with suspected gynecologic etiology for pain, u/s is still the best imaging modality contrast enhanced MRI Contrast enhanced CT scan 6 Non pregnant with non-gynecological origin of pain contrast-enhanced CT scan is the modality of choice.

20 Returning to our patient What is your differential and what would you like to order?

21 Differential and Work-Up My differential at the time I saw patient Ovarian torsion STDs/PID Ectopic pregnancy TOA GI (IBD, IBS) GU (UTI, kidney stone) Labs ordered Urine Dipstick, Urine Pregnancy test CBC, CMP U/S pelvis/transvaginal GC/CH, Vaginitis Direct

22 Lab results Urine dipstick within normal limit Urine pregnancy test - negative 139/4.1/102/28/6/0.7<82,8.6, LFTs are within normal limits 7.8>11/33.3<243. positive left shift, PMN 77.5 GC/CH negative Vaginitis Direct positive for Gardnerella only U/S thick fluid collection suggestive of abscess

23 1. There is a complex thick-walled fluid collection superior to the left ovary, potentially an abscess. 2. The left ovary is heterogeneously enlarged and hyperemic. This could potentially be reactive to the adjacent inflammatory process. Within the left ovary is a probable hemorrhagic cyst. 3. No uterine or right ovarian abnormality is detected and there is no free fluid in the pelvis.

24 Patient asked to come to the hospital for direct admission.

25 Hospital Course Upon admission patient is septic but hemodynamically stable. Her physical exam is unchanged. She received triple antibiotic therapy, blood cultures taken and OB/GYN consulted. Careful review of ultrasound revealed that abscess is not ovarian in origin.

26 OB/GYN consultation recommendations U/S findings were reviewed; collection is superior to the left ovary Triple antibiotic coverage, STDs cultures, blood cultures and urine cultures. CT scan of pelvis to further define fluid collection and consideration for IR drainage. Repeat U/S in 6-8 weeks if patient remains stable

27 CT Pelvis with IV contrast Impression Multiloculated rim enhancing collection involving the left iliopsoas muscle with an additional component extending anteroinferiorly long the left hemipelvis, compatible with abscesses. Distal left gonadal artery courses along the medial aspect of the collection proximally and the left external iliac artery courses along the proximal medial portion and anteriorly and laterally along the mid to distal portions of the collection.

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29 Hospital Course Continued Infectious Disease consulted. Antibiotics narrowed to Zosyn IV IR consulted to drain abscess and send samples for cultures; AFB cultures, fungal cultures, aerobic/anaerobic cultures. 48hrs later cultures remain negative. Patient s antibiotics switched to oral Augmentin.

30 Infectious Disease Consult Burmese immigrant who migrated to USA three years ago after spending sometime in Malaysia at a refugee camp. PPD negative prior to migration to USA. Patient at the time of examination was asymptomatic. Plan to send patient home on oral Augmentin (3 weeks) Check HIV, syphilis, MRSA nares screen, Quantiferon gold test

31 Lab results Repeat CBC and BMP are within normal limits throughout hospitalization HIV negative Syphilis negative MRSA nare screen negative Quantiferon Gold positive

32 About a month later after discharge Infectious Disease receives a call from infectious control reporting AFB cultures positive for Mycobacterium Tuberculosis Complex by DNA probe. Onondaga County TB director informed of patient who will reach out to patient to start her on TB medication DOT.

33 Questions?

34 Thank you! Bihter Korbeci, PGY3 St. Joseph s Health Family Medicine Residency Physician Office Building, Suite Prospect Ave, Syracuse, NY, 13203