Louisville Medicine Volume 65, Issue 3 | Page 30

FROM THE BLOGOSPHERE KEEP YOUR Differential Broad Patrick Barrett, MD I had a case in our department that I won’t forget for a while. It remind- ed me to keep my differential broad even if the suspected diag- nosis seems blatantly obvious. An early 40’s female presented to our ER about 5 days after an MVC in which she was the restrained driver, where the car rolled onto its side going about 40s-50s MPH. She lost consciousness, and airbags deployed. Paramedics arrived on scene after a while when she was up and walking, and she refused to be taken to the ER. Over the following 5 days, she had near constant neck pain as well as a worsening headache and worsening abdominal and rib pain on the lower left side. She presented to our ER in a hallway bed, where her initial HR was in the mid 80s, but BP was 80s/40s on multiple checks. O2 sat and temperature were normal. Mental status was normal, and there were no phys- ical signs of trauma on her body. She had tenderness to the L lower and lateral ribs, as well as LUQ/LMQ abdominal tenderness, and lower midline C-spine tenderness. I quickly had her placed in a cervical collar, and brought the ultrasound to bedside and performed a FAST (Focused Assessment with Sonography in Trauma), which was 28 LOUISVILLE MEDICINE negative, to my surprise. I ordered fluid boluses, trauma labs, type and crossmatch, and planned to send her for a man scan, but her kidney function showed an AKI and therefore had to wait for one fluid bolus before she could go to the scanner. BP slowly started to trend upwards, but not reaching over mid 90s systolic before she went to the scanner. Of note, she did have a slightly elevated white count in the mid-to-upper teens. My differential? Trauma, trauma, trauma. She has to be bleeding somewhere, she may have a fractured C-spine, intracra- nial injury, intraabdominal injury, likely splenic laceration - My FAST just must not have picked it up. Given the history and clinical circum- stance, I don’t think I was badly wrong for not having anything else on my differential for this hypotensive patient with concerning physical exam findings 5 days out from a serious car accident. But once her man scan was done, I looked though the imaging and noticed her right kidney was heterogenous with contrast enhancement with stranding around it. She had no fluid in her pelvis, and the rest of the man scan was entirely negative. Radiology soon called and said she had the “worst case of pyelonephritis I think I’ve ever seen.” A urine sample was finally collected after the scan resulted, which was (no longer to my surprise) infected. When I asked the patient, she denied any dysuria or frequency, but said her urine had been “green” this morning. She never had any suprapubic pain. That is the story of how I admitted a pa- tient to medicine for pyelonephritis after getting a man scan and diagnosing it on CT. I don’t think I’ll be changing the top item on my differential, but I think I will keep other causes of hypotension and shock on my differential until they are ruled out in cases of delayed trauma presentation, such as this one. Patrick Barrett is a resident at the Univer- sity of Louisville Department of Emergency Medicine. This blog entry was featured on Room 9 Blogs, a blog for ER Residents. You can view other entries at www.room9er.com