EM situational question! (did my attending do the right thing?)

[hackinmage]

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The situation:
There was a 22 y/o asian female patient that came into our ER complaining of adnexal pain, it was characteristic for an ovarian cyst and she had a h/o ovarian cysts. Not on birth control because she couldn't stand the effects. Anyways, she had an unexpectedly bad episode the pain had never been as bad to the point where it was debilitating, nausea and vomiting x1 episode.

I worked the ER ultrasound machine (nothing fancy but it does a bang up job) and couldn't visualize any cysts, my attending couldn't either, but since her pain was well managed with IV tramadol he d/c'd her with orders to take motrin/see her ob/gyn asap.

I was wondering whether that was the right call, in my whole 3 years of experience haha i can't obviously make a clinical judgement, and i know CTing young females in their ovaries is a risky call (or so i've been told, does anyone know the answer to whether the RAD's are enough to be teratogenic?).

Anyways, could anyone weigh in their opinion?

 

[docB]

It's tough to say any given doc did something wrong in a clinical situation when I wasn't there so I'm going to look at this more in the abstract. I think a patient like this certainly needs a pregnancy test. I usually get a B quant before I do the US (assuming stable vitals) so I have a better idea what I'm looking for.

Did you mean "IV Toradol?" I don't think tramadol comes IV. And I tend to avoid Toradol in these patients. I don't like Toradol anyway. It's expensive and has a higher degree of nephrotoxicity than the other NSAIDs even though it's only got similar effecacy. I only give it in kidney stones when the patient is vomiting too much for Motrin or if a seeker just has to have something in a shot.

 

[hackinmage]

urine Beta was negative, and yup IV toradol, it was the DOC for pain mgmt in the ER and according to another attending the only way to give it since the PO formulation is semi-useless.

 

[hackinmage]

thanks for the reply! yeah i understand totally i guess there's no way to get an answer for this question unless you had personally been there.

 

[docB]

So with a negative preg I'm not worried about an ectopic. The two other things that would need to be considered for this patient would be appy and ovarian torsion.

 

[southerndoc]

Why would you CT if you suspected ovarian pathology? Was her pain in the RLQ?

 

[Arcan57]

I think the OP's question ignores the fact that attendings are never wrong.

 

[hackinmage]

very valid differentials, definately not worked up, the attending (and i) couldn't visualize the ovaries with the ultrasound. While there wasn't any signs of peritonitis, i've had atypical appendicitis presentations before w/o peritonitis signs before so that couldn't be ruled out either. She didn't ask to eat anything while in the room for a couple hours and i didn't think to ask her if she felt hungry (so can't really use the hamburger sign).

Her pain was bilateral in her lower abdominal quadrants, and she stated it felt the same initially. Non-toxic appearance aside from the pain.

about the ct, well i was more worried that this was an atypical presentation for a long standing condition and since we didn't visualize anything on ultrasound i wasn't really comfortable with saying "your fine go see your ob/gyn tomorrow" (i broached the topic with my attending and nearly got dropped from a high pass to a pass because of it)

can cysts small enough that their unable to be seen on ultrasound cause debilitating pain?

 

[Arcan57]

My first response was flip, but I will be serious for a moment. What was on your differential that would inflict serious morbidity and mortality in the day it would take her to follow up with GYN? If the patient had a non-tender abdomen (not mentioned although implied), this is someone that I would feel comfortable sending home without imaging if their pelvic and labs didn't reveal any significant abnormalities. I could hypothesize a ruptured cyst that is no longer showing on U/S (+/- some trace free fluid) causing severe pain. But more importantly, we send people home with pain NOS and good discharge instructions all the time. I would submit (working with midlevels who routinely order CTs in this situation) that it would be extraordinarily unlikely that the CT would reveal the cause of the patient's pain. And if it did reveal a cause, it would likely be something self-limited.

Also, why would you do an EP performed pelvic U/S on a woman with stable vitals and a negative Bquant? What's the clinical question? Ovarian cysts are common in reproductive age females, and the presence of an ovarian cyst on the U/S does not mean the cyst is the source of the patients' pain.

 

[deleted65604]

Was the ultrasound transvaginal? I believe an ovary could be torsed, but not seen on trans-abdominal ultrasound. Less likely on transvaginal ultrasound.

If all abdominal tenderness goes away and labs are normal, I think good discharge instructions for early appendicitis is reasonable.

If an ovary is torsed, it is dying, so there should be more pain, but intermittent torsion or early torsion might be normal.

The way you describe it, this is a ballsy move.

 

[Rendar5]

I just don't see how a judgment could be made. I don't know the physical exam, I don't know the pelvic exam. I don't know the clinical course in the ED. If he had no tenderness on exam, is not pregnant, she goes home. If she has cervical motion tenderness maybe I treat for PID and send for f/u after getting an u/s to r/o tuboovarian abscess and ovarian torsion. If there is RLQ pain I get a CT or an U/S to r/o appendicitis. Only other thing that I might care about but doesn't seem to be suggested by the extremely little information I have to go on is colitis or diverticulitis.

Anything else I don't care about whether it's a zebra or something more common. Why? My working it up won't help the patient and a 1 day delay isn't going to affect anything else pretty much.

 

[hackinmage]

I guess the scarier differentials can be ruled out by clinical judgement, sorry! i'm still pretty bloody green and am trying to get this triage business under my thumb. The following is the case basically written up in a better moock up. Thanks all for weighing in on it for me, i do appreciate it!

21 y/o G0P0 FPt came by ambulance from work due to debilitating pain and n/v x 1 episode. Upon admission patients vital signs were stable aside from mild tachycardia. Only PMHx of ovarian cysts, controlled in the past by birth control which was d/c'd 1 year ago due to patients wishes. States she's had other episodes of similar pain occuring around her menstrual period but never this bad. No other ROS, no recent trauma, recent illness, or fever. pain was 10/10 sharp and w/o radiation.

physical exam showed exacerbation of pain upon palpation of lower quadrants but no guarding no rebound none of that. Rest of physical exam was benign, pelvic exam wasn't done (i wasn't allowed to do them and my attending didn't do one)

B-Hcg in urine was only test run, which was negative.

trans-abdominal ultrasound was done with visualization of a normal uterus and no visualization of the ovaries.

Clinical Course: patient was given toradol (ketorlac) for the pain via iv, which was sufficient, s/p administration patient complained of no pain and was able to walk around etc...

d/c orders were typical get motrin, see ob/gyn for follow up within the next few days and come rushing back if anything changed

 

[Flopotomist]

In a broader view, this case demonstrates the difference between EM and all other specialties in terms of the goal of the patient encounter.

In EM, the goal is disposition, not diagnosis. Very often in the course of attempting to identify an appropriate disposition, an accurate diagnosis is made incidentally, but that is not the mission of the ED.

In the case you present, the frustration seems to come from your desire to identify an accurate diagnosis (which was not done) and your attending's desire to identify an appropriate disposition (which was done).

As other posters have pointed out, once life-threatening pathology was excluded, pain was controlled, and follow-up arranged at an appropriate interval, the work of the ED was over.

 

[deleted65604]

I would be a little more liberal with people who call the ambulance. Transabdominal ultrasound just isn't adeqate for a non-pregnant exam. If you are going to do an ultrasound, you should do a complete ultrasound (including transvaginal), or just ask the tech to come in.

It could have been a passed kidney stone. Did you get a UA? However, if pain was sudden in onset and is now gone, and there is no tenderness whatsoever, I would tend to agree with your attending that etiology is most likely a ruptured cyst. Like was said above, it is hard to know whether the treatment was appropriate without first-hand history and physical. If there is a bad outcome, a jury could maybe be convinced by a good lawyer that the work-up was inadequate.