AUGUST MYSTERY: RUQ PAIN
Thirty minutes into your shift you take pass-ons from your colleague. The one case with loose ends is a 26-year-old woman who presented with 5 days of worsening right upper quandrant pain. The pain is pleuritic and non-radiating without fever, vomiting, shortness of breath, cough or urinary symptoms. Her past medical history and systems review is unremarkable. On exam she is very tender in the right upper quadrant, but otherwise normal, including a pelvic exam with no discharge or cervical motion tenderness. All labs including UA, LFT’s, lipase, beta-HCG, CBC and wet mount are normal except for a very elevated D-dimer. A CXR and CT of the abdomen have already been done and are negative. Your colleague leaves you with a request to “check a V/Q scan” and send her home if it’s normal – which it is.
What test needs to be done to confirm the correct diagnosis? ***
HINT: This is a classic case of a rare presentation for a common disease with significant morbidity. You’ve probably heard of this condition, and even seen it, though maybe not diagnosed it.
Posted: July 7th, 2007 under Main.
Comments: 4
Comments
Comment from wealthandtaste
Time: July 8, 2007, 2:12 pm
addisonian crisis and DKA come to mind… BG level and a serum cortisol would be nice.
did a lowly medic get it ?
i was thinking pylonephritis until i saw no fever mentioned.
Comment from wealthandtaste
Time: July 8, 2007, 5:32 pm
DKA resulting in hypercoaguable state, hence elevated d-dimer…?
Comment from Brook
Time: July 10, 2007, 7:45 am
I would want a CXR to disposition a patient with pleuisy and an elevated ddimer (if not more). In this case, I wonder if the patient had cervicitis to suggest Fitz-Hugh-Curtis.
Comment from Richard Steele
Time: July 24, 2007, 1:48 pm
I would want an ultrasound to rule out ectopic along with a quatitative HCG. Even though the HCG level is normal, there is still a possibility of a pregnancy that is better ruled out with an ultrasound.
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