Med Student Corner: an atypical presentation flank pain

By Richard Cunningham, OSU M4 // Edited by Michael Barrie, OSU EM Attending

Case:A 54 year old woman with a history of diabetes mellitus type 2, obesity, kidney stones and multiple episodes of pyelonephritis presents with flank pain. It started 3 days ago, has been constant, and intermittently increases in severity. She rates the pain as 4/10. The pain is described as a dull ache, at times sharp, and radiates to the right upper quadrant. The patient endorses some nausea but denies fever, emesis, diarrhea, constipation, chest pain, SOB, dysuria and hematuria. Upon further questioning she says this feels very similar to the times she had kidney infections. She has no history of abdominal surgeries.

Her vital signs are within normal limits and she is afebrile. On exam, she is comfortable appearing and has mild CVA and RUQ tenderness. Her abdomen is soft without guarding or rebound. The rest of her exam is benign.

After reviewing the above case, what is the one lab test (not including imaging) you would order? If you think like me, you would go straight for the UA. Flank pain, history of kidney stones and pyelo, it’s got to be a slam dunk, right? Wrong. Her UA was significant for only trace protein. Well shucks, looks like she’s heading to the CT scanner.

What is your backup diagnosis now? The pain did radiate to her RUQ and she is obese; maybe she has gallbladder pathology? Wrong again…

This woman had appendicitis confirmed on the CTAP.

Atypical Appendicitis:

Appendicitis is a common surgical condition traditionally managed with early appendectomy and is associated with low morbidity and mortality. The classic presentation is vague peri-umbilical pain that migrates to the right lower quadrant; this however only accounts for about 50% of patients. The others vary in their presentation due to the age of the patient, the position of the appendix and coexisting conditions such as pregnancy. Retrocecal appendices can be shielded from the anterior abdominal wall by overlying bowel, leading to less severe pain in a non-classic location. A gravid uterus can push the appendix higher into the abdomen, leading to RUQ pain. These atypical presentations can lead to delays in diagnosis and treatment, so it is important to remain vigilant and keep a broad differential.

Some other learning points to consider include being wary of the chief complaint of flank pain. When I see this in the chart I automatically think of the kidney, mainly stones and infection. But it is critical to keep in mind what other pathology can lead to pain in this area and keep a broad differential: low back strain, rib fracture, AAA rupture, zoster of the thoracic dermatomes, pulmonary embolism, cholecystitis, and of course, appendicitis (among others).

Also keep in mind that when the patient tells you when gathering the history that this feels like a condition they have had before, do not let that pigeon hole you into that diagnosis. Stay broad, be creative in constructing your differential. It very well may be a recurrence of that same condition, but sometimes it won’t be and you will get burned. Remember one of the 10 Commandments of Emergency Medicine: Trust No One.

Take home points:

  • 50% of patients with appendicitis presents atypically (it’s normal to not be normal!)
  • Infants and elderly patients are more likely to have atypical presentations
  • Patients with a retrocecal appendix will have more flank pain
  • Pregnant patients will have pain in atypical locations depending on trimester.
  • In flank pain, always keep a broad differential!

References:

Liu CD, McFadden DW. Acute abdomen and appendix. In: Greenfield LJ, et al., eds. Surgery: scientific principles and practice. 2d ed. Philadelphia: Lippincott-Raven, 1997:1246–61.

Ong EMW, Venkatesh SK. Ascending retrocecal appendicitis presenting with right upper abdominal pain: Utility of computed tomography. World Journal of Gastroenterology : WJG. 2009;15(28):3576-3579. doi:10.3748/wjg.15.3576.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2715990/

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Med Student Corner: Saving Sepsis, Early Recognition and Response

Author: Nisha Crouser, MS4 // Editor: Michael Barrie, OSU EM Attending

One of the first questions Emergency Medicine physicians have to ask themselves is “Do I think this patient is sick or not sick?” A simple question, that takes years of practice and experience to answer. Once a patient is deemed “sick” the questions to follow become more difficult, “How sick?” “What should we do next?” The following case presentation helps elucidate some of the difficulties faced in the ED when sick patients arrive and how to act on the dangerous diagnosis of septic shock.
A 58-year-old patient with several past medical problems including hypertension, hyperlipidemia, and heart disease; presents to the ED with a fever and back pain. Upon arrival the patient is a diaphoretic and ill-appearing obese female who is able to follow commands and answer a few questions. It is difficult to obtain a history from the patient and there is no family present to contribute any information. She is tachycardic and hypotensive when placed on the monitor. Given these vitals in combination with her fever, a Septic Shock alert is initiated. The ED is very busy and there is another severely ill patient that the physician is also covering. Several tests are ordered and fluids are started, there is no obvious source of infection. Over the course of the next half an hour, the internal medicine doctors lay eyes on the patient who has now become more unresponsive. As another half an hour goes by, the patient’s skin become extremely mottled and blue. Her oxygen saturation and blood pressure drop precipitously and she goes into asystole.

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Med Student Corner: My Arm’s on Fire! Or the Clever Masquerade of Cellulitis

Author: Lilamarie Moko, MS4 // Editor: Michael Barrie, OSU EM Attending

It’s another late Thursday night in the ED and the waiting room is backed up with patients needing care. As you finish up with your seventh patient presenting with undifferentiated abdominal pain, your eyes rove the board for something new.  You assign yourself to a gentleman in his 60s, a “John Doe” with left arm swelling. Hopefully his abdomen has been behaving itself…

Upon entering the patient room, you see a pleasant, comfortable appearing gentleman in his mid-60s. He’s been having left arm pain and swelling that started 6 days ago. His arm is “on fire”. He first noticed some redness in his left elbow, associated swelling, tenderness, and restriction flexion and extension of his elbow. After about a day, he noticed the redness spreading down to his left wrist, with similar swelling, tenderness, and restricted flexion and extension of both wrist and fingers. He’s had a temperature to 100F, diaphoresis and chills. Also he reports some diarrhea, and urinary frequency in the past 2 days. With some further probing, he reveals that he just returned from Florida several days ago, had no noted scrapes or wounds, and spent most of his time fishing. He works as a farmer, but hasn’t been working for the past couple weeks.

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Med Student Corner: Ankle Pain – Reviewing the Ottawa Ankle Rules

Chief Complaint: Ankle Injury–Does this patient have a fracture?

Author: David Sacolick, MS4 // Editor: Michael Barrie, OSU EM Attending

Musculoskeletal injuries are common chief complaints in both emergency medicine and primary care settings. In particular, over 5 million ankle injuries occur in the United States each year. This patient population includes both young active patients as well as elderly patients. And while ligamentous sprains are more common, fractures are also common and can have long term consequences if not appropriately treated.

When a patient presents with a chief complaint of an ankle injury, how do you answer the question: Does this patient have a fracture?  Continue reading

Fussy Neonate – a Jeopardy game!

Maya S. Iyer, MD, FAAP, Clinical Assistant Professor of Pediatrics, Nationwide Children’s Hospital, Section of Emergency Medicine

Fussy Neonate Jeopardy

This jeopardy game highlights key clinical considerations for infants who present to the emergency department with the chief complaint of fussiness. In particular, the topics highlighted in this game include: fever in the neonate, sudden infant death syndrome (SIDS), brief resolved unexplained events (BRUE) and apparent life threatening events (ALTE), non-accidental trauma (NAT) and a potpourri of other interesting clinical conditions.  The questions require second order thinking. After completing this game, emergency medicine residents should be able to describe the cardinal signs and symptoms, management and possible complications of the above conditions.

 

Medical Student Corner – “If your patient is sweating, so should you…”

Authors: Patrick Mescher, OSU MS4 // Michael Barrie, MD OSUEM

Standing in the physician’s office of a local Emergency Department I heard the familiar clunk of a chart being dropped into the metal bin. I walked over and picked up the chart and read “Chief Complaint: Chest Pain,” thinking to myself how this was the fifth “chest pain” I’ve seen this shift. After diagnosing GERD, costrocondritis, and pneumonia with previous patients, I felt comfortable evaluating this chief complaint so I went calmly to the patient’s room. But as I walked to the bedside I found a visibly uncomfortable patient, profusely perspiring. He told me he was having crushing chest pain. I was immediately concerned this may be the real deal STEMI.

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When to send the patient home? Medical Student Notes

Author: Hiro Miyagi OSU MS4 // Editor: Michael Barrie OSU EM Attending

Medical Student Corner – When do kidney stone patients need immediate intervention?

A 51yo female presents with an acute episode of severe right sided back pain with nausea and vomiting. Patient has a past medical history of HTN and chronic back pain. The pain is intermittent, described as sharp and stabbing 10/10 pain. She has not been able to tolerate any liquids since the onset of pain. The patient denies fevers or chills, with no recent infections or illnesses. No dysuria, but with mild urinary frequency. She has a past surgical history of appendectomy 30 years ago.

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