Case# 3: 25y/o male with a complaint of lower abdominal pain

[Hanson]

Okay this is case number 3 of the CSA. Any thoughts?

[Doc]

I had this whole case workup written up and then realized that the question said male instead of FEmale ! So I guess that takes ectopic pregnancy and ovarian torsion off of my differential list!?! . The lesson here is to read the FULL question BEFORE answering....are you sure your patient is not a female

[Maria]

although you question is not that specific but this is my ansewrs

1-(lower urinary tract infection) you will see some discharge from the urethra.

2-(Urolithiasis) bladder or lower ureter stones.

3-(colitis) this will be pain+bloody diarrhea, pus maybe present.

4-(acute appedicitis) right quadrant.

5-(Crohn's disease) lower right abdominal pain+ fever+diarrhea.

6-(diverticulosis) lower left pain that disappear after bowel movement or passing gass.

7-(irritable bowel syndrome) lower abdominal pain.

8-(peritonitis)


please let me know what is the right ansewr and if there is any mistake or thing you think that i had to add or a right way to ansewr this question.

Thanks,
Maria

[Hanson]

I had this whole case workup written up and then realized that the question said male instead of FEmale ! So I guess that takes ectopic pregnancy and ovarian torsion off of my differential list!?! . The lesson here is to read the FULL question BEFORE answering....are you sure your patient is not a female

Look for case #4. This one is a female.

[Hanson]

although you question is not that specific but this is my ansewrs

1-(lower urinary tract infection) you will see some discharge from the urethra.

2-(Urolithiasis) bladder or lower ureter stones.

3-(colitis) this will be pain+bloody diarrhea, pus maybe present.

4-(acute appedicitis) right quadrant.

5-(Crohn's disease) lower right abdominal pain+ fever+diarrhea.

6-(diverticulosis) lower left pain that disappear after bowel movement or passing gass.

7-(irritable bowel syndrome) lower abdominal pain.

8-(peritonitis)


please let me know what is the right ansewr and if there is any mistake or thing you think that i had to add or a right way to ansewr this question.

Thanks,
Maria

Hi Maria,

Sorry, the case is very nonspecific. However, you came up with some very good differential diagnosis. There is no right answer since we have not questioned the patient yet. And even after we questioned the patient, sometimes we still have no correct answer .

Here is a typical CSA scenerio:

Mr. Zackeryki is a 25 y/o male football player who presents to the emergency room with complaint of lower quadrant pain.

Vital signs:
HR = 120 BP= 90/58 T=103F RR= 21


You have 15 minutes to take the history and 10 minutes to write the CSA note.

__________________________________________________ _______
Good things about this case:
1. How to avoid dangerous actions
2. Learning the Kaplan mnemonic LIQOR AAA


Pre-encounter [4 differential diagnosis there are more but for the CSA 4 is a good size]:
1. Splenic Rupture
2. Acute pancreatitis
3. Urolithiasis
4. Gallstone

Now you enter the room:
[Doctor] knock knock
[Zackeryki] Coming
[Doctor] I am Doctor N., nice to meet you.
[Zackeryki ] *#$@#$#@#
[Doctor] Please speak English
[Zackeryki ] Sorry, I am so much in pain.
[Doctor] I am sorry to hear that. Hopefully, I will try to make it goes away. First, I am going to wash my hands and will be there with you in a sec.
[Zackeryki ] Ok Doc


[Doctor] What bring you in here today?
[Zackeryki ] I have a horrible pain in my belly.

Pain so I am going to use Kaplan's LIQOR AAA mnemonic to ask about pain.

L- Location
[Doctor] Show me the location of the pain
[Zackeryki ] He pointed to his left upper quadrant.

I- Intensity
[Doctor] Can you tell me how much pain are you having. From 1 to 10, 10 being the most excrutiating pain.
[Zackeryki ] It is a 9

Q-Quality
[Doctor] Can you describe the quality of the pain: is it sharp/dull/colicky/coninous/intermittent.
[Zackeryki ]It is a dull pain right here [pointing to his left flank]

O-Onset
[Doctor] When is this all started?
[Zackeryki ] It started 2 hours ago.

R-Radiating
[Doctor] Does the pain radiate anywhere else
[Zackeryki ] Yes, it radiates to my left shoulder (Kehr's sign)

A-Aggrevating factors
[Doctor] What brought on the pain?
[Zackeryki] I was playing football two hours ago. My friend tackled me and I had the pain since.
[Doctor] Where did he tackled you?
[Zackeryki] Right here on my left flank.


A- Associated symptoms
[Doctor] Do you have any nausea or vomitting?
[Zackeryki ] Yes, I don't feel good at all. I did not vomit but I do feel nauseated.
[Doctor] Do you have dizziness or fainting
[Zackeryki] I feel very dizzy and almost fainted twice


A- Alleviating factors
[Doctor] Anything make it better?
[Zackeryki] No, nothing Doc. God, I feel horrible. Can I have something to drink now. I am thirsty.

????? Should I be nice to him and give him water or better yet Pepsi? No, this is a trick question to lure you into giving something to drink.
You don't give patients things to drink or eat while having an acute abdominal pain because you might have to go straight to surgery.

[Doctor] I know you are in pain, but I can not give you anything to drink for now because you might need to go straight into surgery.

I am going to do PAM HUG FOSS now.

P- Past Medical History
[Doctor] Mr. Zackeryki, do you have any significant past medical history recently?
[Zackeryki] Yes, I have mononucleosis a week ago.
[Doctor] I see. Did your doctor tell you not to play contact sports?
[Zackeryki] He did but I did not listen to him.

A- Allergy
[Doctor] Do you have any allergies?
[Zackeryki] None, Doc

M- Medication
[Doctor] Are you taking any herbal, OTC drug, or prescription drug, especially steroid?
[Zackeryki] Yes, I take vitamin F or Viagra.

H- Hospitalization
[Doctor] Have you ever been hosptalized before?
[Zackeryki] Never

U- Urinary System
[Doctor] Do you have pain when you urinate?
[Zackeryki] No
[Doctor] Do you see any blood in your urine?
[Zackeryki] No

G- Gastrointestinal
[Doctor] Do you have weight gain or weight loss
[Zackeryki] no
[Doctor] Do you have bloody or dark stool?
[Zackeryki] No
[Doctor] Is your stool smelly?
[Zackeryki] Doctor, of course all stools are smelly.
[Doctor] I mean, anything out of the ordinary.
[Zackeryki] No, my stool has always been smelly.
[Doctor] Does your stool float?
[Zackeryki] It shrinks like a rock.

F-Family History
[Doctor] Do you have family history of heart attack or diabetes?
[Zackeryki] No

O- OB history; irrrelevant in this case since the patient is a male.

S- Social history
[Doctor] Do you drink excessively?
[Zackeryki] Just a little bit.
Since he is a drinker. I need to ask him CAGE question to see if he is an alcoholic (one of the most common cause of pancreatitis along with steroid usage)
C- Do you feel you need to CUT down on your alcohol intake? No
A- Have anyone AGGREVATED by your drinking habit? No
G- Have you feel GUILTY about your drinking habit? No
E- Do you drink in the morning (EYE OPENING)? No

[Doctor] Do you do drugs?
[Zackeryki] No

S- Sexualy history
[Doctor] Do you have unprotected sex?
[Zackeryki] I am still a virgin. I kiss a lot though.

OK, so this is a typical of splenic rupture case. Why?

1. He had mononuceosis and played contact sport. He probably popped his spleen during playing.
2. He had Kehr's sign- pain radiating to the left shoulder, typical in splenic rupture
3. Nothing in the history to suggest that he has acute pancreatitis, urolithiasis, and gallstone.