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D-dimer

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 32-year-old female with a recent dry cough that has been improving presents to the ED with 6 days of right upper quadrant pain that is worse when she coughs, moves or takes a deep breath and is associated with nausea but no vomiting.  She has some very mild SOB but denies fever, chest pain, leg swelling, diarrhea, dysuria or any other complaints.

Vital Signs & Physical Exam:

Vital signs are completely normal.  Physical exam is normal except for RUQ tenderness.

Initial Differential Diagnosis:

  • Pneumonia
  • PE
  • Gallstones
  • Other liver disease

Initial Diagnostic Testing:

  • CBC: normal
  • UA: normal
  • Chem: normal except for AST/ALT of 88/95
  • D-dimer: elevated
  • Imaging: Abdo US, CXR and Pulmonary CTA all normal

QUESTIONS:

  1. What do the lab results suggest?
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What do the lab results suggest? With LFT’s that low and a negative US, liver disease would not likely cause pain.  The differential diagnosis for elevated D-dimer includes Fitz-Hugh-Curtis, a condition which should always be on the differential for RUQ pain with no other explanation in a sexually active female.
  2. What should you do next?  Obtain a sexual history and GC/chlamydia swab.  Consider empiric treatment.  This patient tested positive for chlamydia.  It is unusual that the LFT’s were a bit elevated as they are typically normal in Fitz-Hugh-Curtis, which is a perihepatitis.  No baseline LFT’s were available.  The cough is also unusual and may or may not have been related.
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

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CASE CONCLUSION: We’ll just have to see

CASE LESSONS:

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