Quiz week 35

Q1. A 24 year old lady comes to the ER. She has abdominal pain. She is writhing in pain. Trying to find a comfortable position. She is afebrile and has had multiple surgeries in the abdomen for various episodes of acute abdomen. She takes Naproxen for pain in her joints. She is allergic to "Sulfa".

Her abdomen is extremely tender in the peri-umbilical area.   CBC/Serum chemistry are normal. You order a CT scan of her abdomen.

Your nursing staff calls up the insurance company for authorization to treat and admit to hospital. She is told that she had a similar episode a month ago for which she was admitted to another local hospital. She has had 8 hospitalizations in 4 different hospitals over the past year. What should you do at this stage?

  1. Wait for results of the CT scan
  2. inject placebo to see the effect
  3. Operate with the presumed diagnosis of appendicitis
  4. Confront her that she is acting to get narcotics
  5. Confront her that this is not likely to be a physical disorder and is becoming very expensive - financially and emotionally.

The answer is choice 1. (Wait for results of the CT scan). In an acute abdomen, the best diagnstic evaluation would be a contrast CT scan. In a case with presumed diagnosis of appendicitis, it has been proven that CT will clarify the diagnosis and save morbidity and expense of unnecessary surgery. Now in this case we are all entertaining the diagnosis of Munchaussen's (Hospital shopping to get procedures done) Syndrome. It is all part of factitious disorders. CT would clarify that there really is nothing in the adomen and then one can confront the patient with choice 5. I would first give the patient the benefit of doubt and wait for the CT before I do that. (I have been burnt a couple of times when I did not).

Q2. She gets hospitalized. A Foley catheter is inserted as she cannot get up to go to the bathroom. The surgical team keep her under observation. She starts to get a fever on day 3 of hospitalization. What should you do next?

  1. Remove the Foley catheter
  2. Remove the Foley and start on Ciprofoxacin IV
  3. Remove the Foley, take a urinalysis sample and start on Bactrim/Septra (Sulfamethoxazole/Trimethoprim) PO
  4. Remove the Foley, take a urinalysis sample and start on Ciprofloxacin PO
  5. Check urine culture before you intervene

The answer is choice 4. . (Remove the Foley, take a urinalysis sample and start on Ciprofloxacin PO). Foleys bring with themselves, the risk of infection. The best treatment would be to remove the foley and treat with Bactrim/Septra but this patient is allergic to "Sulfa". the next best option is Ciprofloxacin. For those who did answer with choice 3, be careful of allergies in the questions. You need not wait for urine culture before initiating treatment. One can leave the foley inside and treat for 1-2 weeks but that option was purposely left out to avoid confusion.