Clinical case: Abdominal pain Carla B. Aamodt, MD, Heidi Chumley, MD, Michael Kennedy, MD University

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Clinical case Abdominal painCarla B.
Aamodt, MD, Heidi Chumley, MD, Michael Kennedy,
MDUniversity of Kansas School of MedicineKansas
City, Kansas
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Your patient

• A 39 year-old female comes in to the emergency
  room with a chief complaint of abdominal pain

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What are your top 10 differential diagnoses?

• Clinicians begin to think of diagnoses as soon as
  they hear the chief complaint
• The differential gets refined as you hear more
  problems
• How would your differential be different if this
  patient were 70 years old? 8?
• Would your differential be different if the
  patient had presented to outpatient clinic?

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Consider VINDICATES as a place to start

• V vascular
• I infectious
• N neoplastic
• D degenerative
• I intoxication/ingestion (and drug side effects)
• C congenital
• A allergic/autoimmune
• T trauma
• E endocrine
• S supratentorial/psych
• N neuro

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History of present illness

• Location epigastric
• Other symptoms nausea, vomiting, feels warm,
  sweaty, anorexia
• Chronicity similar symptoms occasionally in
  past, but nothing this severe. This week has had
  several episodes of pain, but they didnt last.
  Tonight pain has been much worse and present for
  3 hours.

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History of present illness, cont.

• Alleviating factors nothing seems to help, in
  past has tried Tums, ibuprofen, tonight tried
  Tylenol 2000 mg
• Things that make it worse Seems to have gotten
  bad after eating rehearsal dinner
• Experience of the pain sharp, wave-like episodes
• Severity 8/10

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Now what are your top 10 differentials?

• Put them in order of likelihood
• Put them in order of lethality
• Clinicians weigh both of these as they decide how
  to proceed
• What information do you need to help you commit
  to a Most Likely Diagnosis?

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Past medical history

• Hypertension
• Crohns dz (dx age 26 with ileitis and
  arthropathyquiescentlast colonoscopy ok 6 mo
  ago). Transfused 2 U PRBCs for this in past
• Depression
• G2P2, regular menses
• Previous surgery for C-section x 2
• Meds are Hydrochlorothiazide 25 mg, Zoloft 100
  mg a day, Methotrexate 10 mg a week,
  Ortho-Tri-Cyclen, Tylenol ES 6 a day

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Time to refine your differential

• How has it changed?
• Anything new to add to the list?
• Would your differential be different if this was
  a patient with HIV?

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Social History

• Married bank teller2 daughters 17 and 19. The
  19 year-old is getting married this weekend.
• Drinks 3-4 drinks a day. No tobacco. Cocaine
  and marijuana in teens. None since.
• Sedentary lifestyle
• Meat and potatoes diet

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FH

• FH Father died of heart disease at age 42he had
  high cholesterol and HTN. Mother, age 64 dx
  breast cancer 10 yr ago, doing well. 2 bros and
  1 sister all with HTN, hyperlipidemia. Remainder
  of FH either unknown or negative.

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What Review of Systems do you want?
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Any change in your differential?

• What physical exam do you want?
• Think What physical exam will help you determine
  which differential diagnosis is correct?

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Physical exam

• Vitals T 38.6C, BP 100/58, HR 112, RR 20
• Gen Well developed overweight WF who appears in
  mild distress
• HEENT, Heart and Lung exams All within normal
  limits (WNL) except slight yellowish tinge to
  sclerae

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Physical exam, cont

• Abd Obese abdomen, with decreased bowel sounds,
  soft, tender with guarding in RUQ and
  epigastrium, no rebound, liver is 12 cm in
  diameter at the mid-clavicular line, with a soft
  edge felt 2 cm below the right costal margin.
  Spleen not palpable.
• Extremities and Neuro exams within normal limits

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A few quick questions

• What do you think of this exam?
• Is this an acute abdomen?
• No rebound, although there is guarding. Could do
  other testsjostle bed, etc.
• What do you think about the liver size?
• Liver is a little larger than normal span (normal
  is about 10 cm in mid-clavicular line), and
  palpable slightly lower than normal.
• What do you think about the sclerae?
• Likely jaundiceusually means bilirubin 3.0

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What labs do you want?
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Laboratory studies

• CBC
• Hemoglobin/hematocrit 10/30
• White blood cell count 12 K 80 segs 10 bands
• Platelet count 100 K
• LFTs
• Serum bilirubin 4.0 mg
• AST/ALT 60/95 mg/dl
• Albumin 2.8 mg/dl
• Alkaline phosphatase 250 units

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Labs, cont

• Chem 7
• Na 132
• K 3.4
• Cl 100
• CO2 18
• BUN 28
• Cr 1.4
• Glu 108

• Coags
• PT 15 (INR 1.5)
• PTT 30
• Amylase 32
• Lipase 28

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What do you think of the labs?What is abnormal?

• What other labs do you wish you had?

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Abnormal labs

• Anemic (normal Hb about 12-14), mild
  thrombocytopenia
• Minimally elevated white blood cell count with a
  left shift
• Amylase/lipase minimally elevated
• What about the liver tests?
• High bilirubin and alk phos
• Minimally elevated transaminases
• Albumin low but normal PT/PTT 2.8 mg/dl

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Abnormal labs

• Mildly elevated PT/PTT
• Mild hyponatremia, hypokalemia
• Likely metabolic acidosis with low bicarbonate
  and elevated anion gap
• Increased BUN Creatinine (20) ratio suggests
  dehydration

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What diagnoses are most likely?

• What are you going to do next?

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What do you order BEFORE you get your imaging?

• IV Fluids typical hydration fluids for
  dehydrated patients are either Normal (isotonic)
  Saline (0.9 NaCl) OR Lactated Ringers (aka LR)
• Potassium replacementlikely IV as pt is
  nauseated
• IV antibioticsbroad-spectrum given clinical
  presentation consistent with cholangitis
• Pain control
• Surgical/GI consultsinvolve consultants early
  rather than late

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CT abdomen

• Gallstones with dilated biliary ducts, thickened
  gallbladder wall, gallstones
• Remainder of abdomen CT unremarkable

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What makes cholangitis the most likely diagnosis?

• Clinical diagnosis Charcots triad fever, RUQ
  pain, jaundice
• Elevated WBCit appears mild, but there is a
  clear left shift AND patient is immune suppressed
  (methotrexate)so WBC nlly low
• Additionally, signs of possible sepsis BP is low
  (particularly concerning in a normally
  hypertensive patient), pt tachycardic

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Which antibiotics would you use and why?

• What pathogens do you need to cover?
• E coli, Enterococcus, Klebsiella, Enterobacter
• What types of organisms are these?
• Need gram positive anaerobic and aerobic coverage
• Which antibiotics cover these?
• Could use ticarcillinclavulanic acid OR
  ceftriaxone plus metronidazole OR ciprofloxacin
  plus metronidazole

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What is the definitive treatment?

• ERCP to remove stones and/or cholecystectomy
• Initially may temporize by putting in a biliary
  stent

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Oral Presentations

• Medicine vs. Surgery
• Dealing with your attending

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General Advice

• Organization Systems
• Roundsmanship
• When I rounded on Ms. Jones 2 hours ago, her RR
  was 30

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Clinical Case Acute Renal Failure
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The patient

• 76 yo male patient is seeing you in the
  outpatient clinic
• Recent labs show that he has a creatinine of 2.0
  mg/dL. Six months ago, his creatinine was 1.2
  mg/dL.
• What is your differential diagnosis?

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What else do you need to know?

• PMH HTN, osteoarthritis. No PSH
• Meds lisinopril 10 mg a day, Aleve (naproxen
  sodium) 500 mg BID
• SH Widower. Lives alone. 3 children. Never
  drank alcohol. Smoked 20 pk year, but quit in
  1976. No drugs. TV dinner dietmainly Lean
  Cuisine
• FH Father died of prostate CA. Mother died of
  stroke with Alzheimers. Sibs with HTN, high
  cholesterol. Children healthy.

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How has your differential dx for the acute renal
insufficiency changed?

• Is there additional information youd like to
  know?
• Taking same dose of all meds for last 3 years.
• What are general categories of renal
  insufficiency?

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Categories of renal failure

• Pre-renal the volume coming into the kidney is
  too low (hemorrhage, hypotension, dehydration,
  pump failure (CHF), etc.)
• Intrinsic renal dysfunction of the kidney itself
  cause renal failure (glomerulonephritis, acute
  interstitial nephritis, toxins, etc.) Biggest
  category
• Post-renal obstruction. BUT, you can still have
  a fairly normal creatinine if one ureter is
  obstructed, so think obstruction of the urethra
  (BPH, a large kidney stone, etc.)

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What history questions could help you determine
type of renal failure?

• Think What might be symptoms of pre-renal,
  intrinsic renal OR post-renal
• failure?

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Our patient

• Feels pretty good. Hasnt really noted much in
  the way of symptoms.
• However, ROS positive for
• Sneezing, itchy eyes, nasal congestion in spring
• Chronic dry cougha couple times a day
• Diarrheal illness two weeks ago, has been a
  little fatigued since
• Nocturia 3 times a night. Sometimes feels like
  bladder does not completely empty.

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Our patient

• Notes some swelling of anklesespecially at the
  end of hot days
• Has some indigestion with spicy foods

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What is your differential diagnosis now?
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History some symptoms that might suggest
pre-renal azotemia

• Change in blood pressure medicine (h/o HTN)
• Nausea/vomiting/diarrhea
• Hx suggestive of GI bleed Heartburn, melena,
  hematochezia (BRBPRbright red blood per rectum)
• Dizziness/lightheadedness
• Fatigue
• Swelling in ankles or legs
• History of CHF, liver disease (hepatitis)

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Intrinsic renal History

• LOTS of causes for intrinsic renal failure (IgA
  nephropathy, acute interstitial nephritis, lupus
  nephritis, hypertension induced nephropathy,
  etc.) so, LOTS of possible symptoms
• So, you need to take a good, thorough history and
  do a good thorough exam
• Some specifics ask about recent illness, joint
  problems, rashes, new medications (incl OTCs), BP
  control, constitutional symptoms

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Post-renal azotemia History

• BPH Sx dribbling urine, difficulty starting
  urine stream, frequency, nocturia, feeling of
  not emptying bladder, etc.
• Nephrolithiasis sx (kidney stone) flank or pubic
  pain, blood in urine, past history of stones, use
  of certain medicines like furosemide
• Medicines that may cause urinary retention
  (tricyclic antidepressants, opiates, etc.)

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Has this additional information refined your
differential any?

• What physical exam would you do?

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Physical exam findings

• BP 142/92, HR 74, RR 12, Ht 510 Wt 178
• Gen WD WN AAM in NAD
• HEENT, Lungs, CV WNL
• Abd ND, NABS, soft, NT
• Ext no C/C, 1 edema, 2 pulses, multiple small
  non-tender varicose veins
• Rectal enlarged prostate without nodularity or
  masses hemoccult negative

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Physical exam some signs that might suggest
pre-renal azotemia

• Hypotension/orthostatic hypotension (most fairly
  acute causes will lead to one of these)
• Tachycardia (esp. with fairly acute causes)
• Pale skin/conjunctivae/mucus membranes (if
  hemorrhage a cause)
• Rectal exam with melena, red blood or simply
  guaiac positive brown stool
• Dry mucus membranes, rarely decreased skin turgor
  (in the case of dehydration)
• S3 gallop, peripheral edema, displaced PMI in the
  case of low ejection fraction/CHF
• Ascites, peripheral edema in the case of
  end-stage liver disease

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Post-renal azotemia Physical exam

• Enlarged prostate (BPH)
• Supra-pubic mass (often an enlarged bladder) from
  urine retention

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Labwork some findings that might suggest
pre-renal azotemia

• BUN/Cr ratio of greater than 20
• Urinalysis showing increased specific gravity
  (esp. greater than 1.020)
• Fractional excretion of sodium Na/Plasma Na divided by Urine osmolality/Plama
  osmolality)
• Low hemoglobin/hematocrit (in case of hemorrhage)

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Some labwork suggestive of intrinsic renal disease

• Urine eosinophilia (for acute interstitial
  nephritis)
• FeNa greater than 1-2
• Abnormal UA findings proteinuria (3 grams per
  day is suggestive of , red cell casts
  (glomerulonephritis), muddy brown casts (ATN)
• Elevated BNP (in CHF), abnormal LFTs (possible in
  liver disease)
• Positive ANA (lupus), HIV test (HIV-associated
  nephropathy), etc.

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Post-renal azotemia Labwork

• Before you get labwork, try putting a Foley
  catheter in your patient (if you get lots of
  urine out or if you cant get the catheter in,
  you probably have your diagnosis)
• Ultrasound may show enlarged bladder or BPH
• PSA may be enlargedesp for prostate CA, but
  small elevations also common in BPH

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Our patient

• Foley catheter released 2 LITERS of urine and was
  left in place.
• PSA done and moderately elevated at 7.
• Pt placed on medications for BPH.
• Urology performed prostate biopsy and found no
  cancer. TURP performed and patient doing well.

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Write-up (A/P depends on what point you do it!)

• Cc increased creatinine
• HPI 76 yo male called to come to clinic to
  follow up on abnormal creatinine. Cr was 1.2 6
  mos ago, now 2.0. Pt has not noted any new
  symptoms except fatigue after a bout with
  diarrhea 2 wks ago. However, he does have
  nocturia x3 at night and a feeling of incomplete
  bladder evacuation. Ankles swell with heat. No
  new medications in last 6 mos. Denies dribbling,
  hematuria, dysuria, edema, urine incontinence.

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H and P cont

• PMH HTN, OA. No PSH
• Meds Lisionopril 10 mg po qday, Aleve 500 mg po
  BID
• NKDA
• SH Remote 20 pk year cigarrette smoker. No EtOH.
  No drugs. Retired widower. Lives alone.
• FH F died prostate CA, mother died
  CVA/Alzheimers. Sibs HTN, hyperlipidemia.

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H and P cont

• ROS Constitutional see HPI, no dizziness/
  fevers/chills/sweats/wt loss or gain
• HEENT sneezing/itching eyes/nasal congestion in
  springnone currently
• Lungs chronic dry cough (2 yr), no
  dyspnea/wheezing
• CV no CP/pressure/edema/orthopnea/DOE/
  palpitations
• Abd diarrhea 2 wk ago, now resolved.
  Indigestion with spicy foods. Currently no
  N/V/diarrhea/constipation/abd pain/hematochezia/
  melena
• GU see HPI
• Msk chronic arthritis is knees and hands for
  several years. No joint swelling or warmth.
• Derm no rashes, change in moles
• Lymph no LAD

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H and P cont

• BP 142/92, HR 74, RR 12, Ht 510 Wt 178
• Gen WD WN AAM in NAD
• HEENT, Lungs, CV WNL
• Abd ND, NABS, soft, NT
• Ext no C/C, 1 edema, 2 pulses, multiple small
  non-tender varicose veins
• Rectal enlarged prostate without nodularity or
  masses hemoccult negative

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H and P

• Labs (6/20/06) Na 135, K 4.4, Cl 100, CO2 27,
  BUN 18, Cr 2.0, Glu 86
• Procedure upon insertion of Foley catheter 2000
  cc of pale yellow urine drained out. Catheter
  left in place.
• A Elevated creatinine in setting of urinary
  retention. Possible causes prostate CA, BPH,
  urethral stricture
• P 1. 23 hour Admit to Medicine for eval and
  treatment. 2. Urology C/S for eval, possible bx,
  possible surgery. 2. Check PSA/chem 7 in AM. 3.
  Leave Foley catheter in place for now. 4. Trial
  of doxazosin and tamsulosin. 5. U/S of prostate.
  6. Hydrate with ½ NS at 75 cc/hr during
  post-obstructive diuresis. 7. Stop Aleve and
  lisinopril. Doxazosin for BP

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SOAP note the following day

• S Pt tired of catheter b/c it pulls. Ready to
  go home. ROS negative
• O T 37 C BP 124/72 HR 76 RR 14
• General WDWM in NAD
• Lungs BCTA
• CV RRR no M/R/G
• Abd ND, NABS, soft, NT
• GU Foley catheter in place with pale yellow
  urine, no erythema, no blood
• Labs BUN 12 Cr 1.8 PSA 7
• Prostate US showed enlarged prostate without
  dominant masses

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SOAP cont

• A/P 76 yo M with HTN/OA admitted for urinary
  obstruction
• 1. Urine obstruction Urology to perform prostate
  bx as outpt, recommend leaving Foley catheter in
  until follow up in 5 days. Social work to teach
  patient Foley care. D/c IVF. Cont
  tamsulosin/doxazosin. Recheck Cr at f/u with
  Urology.
• 2. HTN doxazosin 2 mg po qday for now.
  (Lisinopril stopped.)
• 3. OA Tylenol prn for pain. Avoid NSAIDs
• 4. Discharge to home today

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EMR
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EHR Documentation

• Some clinics have EHR.
• Benefits Added structure your note will look
  fantastic previous notes are legible
• Common pitfalls
• Forms
• Information carried forward
• Click boxes, especially normal
• Easy access to peoples information but
  traceable

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Clinical Case A Child with Cough
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The patient

• 4 year-old brought by mom to the office for
  cough
• What is your differential diagnosis?
• Try to generate a differential based on age and
  chief complaint before entering the room.

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What else do you need to know?

• HPI about 4 months worse when sleeping worse
  outside playing tried Claritin once without
  relief
• PMH Normal birth and development Immunizations
  UTD Eczema until 4 y/o
• Meds None
• SH Lives with mom and dad 2 siblings first
  grader, no school problems dad smokes outside
• FH Mom with allergies

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How has your differential dx for the cough
changed?

• Shift to causes of chronic cough
• What are causes of chronic cough in children?
• Hints for a great differential diagnosis
• Think in broad categories first (i.e. infection
  v. adenovirus infection)
• Think about common and dangerous (if applicable)

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Causes of cough in children

• Reactive changes Asthma or Postnasal discharge
  
• Infection Viral causes , Pertussis , Mycoplasma
  pneumonia, Tuberculosis
• Passive smoke
• Cystic Fibrosis
• Foreign body

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What specific questions could help you determine
the cause?

• Think What might be symptoms of reactive or
  infectious?

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Our patient

• Feels pretty good. Hasnt really noted much in
  the way of symptoms. She and mom tell you
• ROS positive for
• Gets out of breath easily
• ROS negative for
• Fevers, chills, fatigue
• Runny nose, itchy eyes
• Wheezing or chest tightness

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Has this additional information refined your
differential any?

• What physical exam would you do?
• What parts do you think you could leave out?

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Physical exam findings

• BP 90/50, HR 98, RR 14, 50 height and weight
• Gen WD WN WF in NAD
• HEENT no nasal discharge no swollen turbinates
  no fluid behind TMs normal pharynx
• Lungs Clear to auscultation
• CV RRR without murmurs
• Abd NDNT, no HSM
• Ext no C/C/E
• Skin no rashes

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Assessment

• What/how much to write differs by setting
• Look at prior notes
• General guidelines
• OK to use symptom, followed by diff. diagnosis
• Often more than 1, include health maintenance
• Chronic cough asthma, allergies, or chronic
  infection
• Expand either in writing or presentation
• Edit after discussion with attending

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Plan

• Always have a plan
• What/how much to write differs by setting
• Look at prior notes
• General guidelines
• Match plan items to assessment
• Have a plan for every assessment
• Plans can be watch, provide reassurance,
  lifestyle changes, medications, tests or
  procedures, etc.
• Edit after discussion with attending

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What makes a good note

• Legible with legible signature/printed name
• Order SOAP or HP
• Relevant positives and negatives
• Demonstrates your understanding
• Matched assessment and plan
• Accurate record of visit
• Clear to an outsider what was going on

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What makes a bad note?

• Illegible
• Disordered
• Containing personal biases/beliefs (yours)
• Advised that (some behavior) is wrong
• Inaccurate or misleading
• I listened to the heart yesterday nothing
  changed
• Neuro exam WNL
• Check boxes on electronic health record

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Yes, this was actually written

• She has no rigors or chills, but her husband
  states she was very hot in bed last night.
• The pelvic exam will be done later on the floor.
• She stated that she had been constipated for most
  of her life until she got a divorce.
• On the second day the knee was better and on the
  third day it had completely disappeared.
• Between you and me, we ought to be able to get
  this lady pregnant.

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What about this

• Patient is non-compliant with medications
• Previous physician did not order an XRay
• General rule Nothing you wouldnt show the
  patient.
• Did not take meds due to concerns about safety.

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Sometimes it is hard

• Patient refuses to consider smoking cessation
  even though I told her that is causing her
  childs asthma.
• Discussed risks of smoking concerning childs
  asthma. Patient voiced understanding and is
  pre-contemplational.

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Panel Discussion

• What questions do you have for us?