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HPI: A 35 year-old female with a 1-week history of constipation, indigestion, back pain, and severe left-sided abdominal pain when rising from a seated position. She had a history of chronic headaches, back pain, and iron deficiency anemia (Hb 5.2; ferritin, 8 ng/mL) requiring transfusion 1 month ago. No fever, chills, or melena.
PMH: Current smoker, asthma requiring prednisone as needed (PRN), hx of peptic ulcer disease, SP hysterectomy, appendectomy, and cholecystectomy.
Medications: A prednisone taper for asthma exacerbation begun 1 month ago; Wellbutrin, methadone, and Celebrex for back pain; Fiorinal for headache
PE: In the emergency department (ER): temperature, 96.6; blood pressure, 136/83; heart rate, 100; lungs, clear, 95% O2 saturation on room air, distended abdomen, guarding and rebound noted by ER physician
Diagnostic tests: WBC 20,100, 10% bands, Hb 10.6. PA chest and abdominal radiographs read in ER as “no free air, no infiltrates, normal bowel gas pattern, no mass, normal mediastinum.” EKG NSR with nonspecific ST-T changes.
Admission diagnosis: ER physician records “abdominal pain—acute.” The primary physician gave a preliminary diagnosis of gastroenteritis and constipation.
Day 1 20:00: Admitted, started on levofloxacin for gastroenteritis, multiple treatments for constipation, Demerol (100 to 150 mg q 2 h PRN), and fluids at 100 mL/h. Celebrex and prednisone were continued. No physical. Day 2 01:30: Nursing noted increasing distention of the abdomen and markedly increased pain. A Foley catheter was inserted. 05:10: Creatinine was 2.0 up from 1.3 on admission; BUN was 20 up from 12 on admission, potassium was 4.3 up from 3.0 on admission, WBC 11.0, Hb 11.8. 07:00: Temperature (T) 98.2, blood pressure (BP) 91/51, heart rate (HR) 66, O2 saturation 88% 14:30: On-call physician ordered colonoscopy, computed tomography scans of the abdomen and pelvis for the following day. 15:00: T 96.5, HR 137, BP 108/56, O2 saturation 89% 18:00: Input/output since 0600 was 2381 mL in and 150 mL out. 20:00: T 96.5, BP 90/60, HR 131, O2 saturation 88% The patient had to be aroused with a sternal rub to administer oral medication. No physician wrote progress notes on this day. Day 3 Physicians were given details of deterioration on day 3. 1. What is your differential diagnosis for this patient (with probabilities) at the time of hospital admission? Please explain why you think the first diagnosis in your differential is most likely. 2 Are there any diagnostic tests or consultations that should be ordered at this time? Please explain. 3 Please indicate any additional diagnostic tests or referrals you would have ordered for this patient and at what stage you would have ordered them. Only list those tests or referrals you consider critical for the care of the patient. 4 Please comment on any other aspects of the care that may have had important consequences for the patient. 5 How would you rate the quality of the hospital care provided by the primary physician? Terrible Minimally acceptable Excellent 1 2 3 4 5 6 7 Random IMS survey (n = 18) Academic Family Medicine Faculty(N = 16) P Values Randomly Selected Physicians versus Academic FM Faculty Overall care unacceptable (<4) 89% 100% 0.17 Overall care near terrible (1 or 2) 78% 94% 0.19 Patient has an acute abdomen based on initial data available on admission 100% 100% NS Peptic ulcer disease—first diagnosis in differential 22% 44% 0.18 Peptic ulcer disease—anywhere on the differential diagnosis 50% 63% 0.46 Recommends surgical consult on admission 100% 81% 0.05 Recommends CT on admission 100% 88% 0.12
