22-Year-Old Woman with Abdominal Pain Case Study
This case study explores a 22-year-old woman presenting with abdominal pain, discussing the chief complaint, history of present illness, and possible diagnoses based on illness scripts. It includes an outline of illness scripts for the top three diagnoses, covering pathophysiology, epidemiology, symptoms/signs, diagnostics, and treatment.
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Teaching slides based on: Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain. J Gen Intern Med. 2014 Jul;29(7):1074-8. Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Scripts An illness script is a structured mental summary of a provider s knowledge about a specific disease Illness scripts are unique to individual clinicians, but 3 main categories are generally included: Risk factors for the disease Pathophysiology Clinical characteristics Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Scripts Clinical characteristics contained in illness scripts often include: Time course Characteristic Symptoms/Signs Typical Clinical Course Diagnostics Treatment Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Script Example: Community Acquired Pneumonia Pathophysiology Infection of the lower respiratory tract Epidemiology Older age, structural lung disease Fever, cough, shortness of breath for days, typically less than one week. Symptoms/Signs Leukocytosis,infiltrate on chest x-ray support the diagnosis. Diagnostics Treatment Antibiotics Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
The Case Chief Complaint: Abdominal Pain HPI A 22-year-old woman presents to the emergency department with abdominal pain for the last 48 h. Her pain is diffuse in location, aching in nature, 9/10 in severity, and does not localize. She has no clear aggravating or alleviating factors. She had uncomplicated cystitis 1 week prior and is now completing a course of trimethoprim-sulfamethoxazole. Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause Outline your illness scripts for your top three diagnoses Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
More History More History PMH Medications Depression Intermittent opioids PSH Social History Appendectomy Cholecystectomy Hysterectomy Lives with boyfriend Monogamous Unemployed Modest alcohol use Smokes 1/2 ppd Family History Unknown, adopted Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Physical Exam T 370C BP 112/73 HR 114 RR 16 Sat 98% RA Young woman in moderate distress, no jaundice Chest: clear CV: tachycardic but no murmurs Abdomen: old surgical scars, soft, non tender, hypoactive bowel sounds, no rebound, voluntary guarding present Remainder of the exam is normal Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause How does this information change your differential diagnosis? Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Labs Protein 7.5 Albumin 3.9 ALT 23 AST 18 Alk Phos 60 PT 11.4 Tbili 0.4 13 132 102 22 7.9 164 102 39 4.3 23 0.9 Urinalysis: Red-brown, SG 1.030, pH 6.5, 1+blood, 1+LE, 1+ nitrite, 0-2 RBC, 10-20 WBC, trace bacteria Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Imaging Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Imaging CT abdomen/pelvis with contrast Surgically absent gallbladder, appendix, and uterus; otherwise normal. Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause What is your one line summary at this point? Compare/Contrast illness scripts for diseases in your differential Pathophysiology Epidemiology Symptoms/Signs Diagnostics Treatment Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
CASE CONTINUED Imaging Negative Abdominal Pain Luminal Neurologic Herpes Zoster Herpes Zoster Diabetic Polyradiculopathy Lead toxicity Abdominal Migraine Crohn s Crohn s Eosinophilic Gastroenteritis Hereditary Angioedema Vascular Other Primary Adrenal Insufficiency Acute Mesenteric Ischemia Primary Adrenal Insufficiency Hypercalcemia Acute Mesenteric Ischemia Median Arcuate Ligament Syndrome Uremia Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Pause What would you do next? Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
More Information Father was of Finnish descent Urine in collection bag was reddish-brown Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Diagnostic Test Was Performed Urine porphobilinogen 184 mg/L (normal: 0-4 mg/L) Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Acute Intermittent Porphyria Porphobilinogen Deaminase deficiency Pathophysiology Young Women > Men, Scandinavian heritage. Multiple prior surgeries Epidemiology Episodic, diffuse abdominal pain, constipation, depression, seizures, dark urine Symptoms/Signs Elevated prophobilinogen Diagnostics IV Dextrose, IV Hemin Treatment Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Patient Outcome IV dextrose started at diagnosis IV hemin given the next day Discharged home on hospital day 6 Significant emotional relief after diagnosis No further attacks one year later Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Your Take-Homes? Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Illness Scripts Illness scripts for rarer diseases are inherently less detailed The key to diagnosis lies in appropriately selecting which details to commit to memory The skillful workman is very careful indeed as to what he takes into his brain-attic. - Sherlock Holmes, A Study in Scarlet Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Teaching slides are based on: Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22- year-old woman with abdominal pain. J Gen Intern Med. 2014 Jul;29(7):1074-8. This work by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
References Anderson K. Recommendations for the diagnosis and treatment of the acute porphyrias. Ann Intern Med 2005; 142:439-450 Benjamin Jones, Walter A. Brzezinski, Carlos A. Estrada, Martin Rodriguez, Ryan R. Kraemer. A22-Year-Old Woman with Abdominal Pain. J Gen Intern Med. 2014 Jul; 29(7): 1074 1078. Bloomer J and McGuire B. The diagnosis and management of acute porphyrias. Medscape Hematology-Oncology. Medscape.com Bowen JL. Educational Strategies to promote clinical diagnostic reasoning. N Engl J Med. 2006 Nov 23; 355(21):2217-25. Bylesjo I. Clinical aspects of acute intermittent porphyria in northern Sweden: a population-based study. Scand J Clin Lab Invest 2009;69:612-618 Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Crohns Disease Granulomatous transmural inflammatory disorder of the GI tract Pathophysiology Bimodal; peaks distribution: 20-40, 50-60 Family history Epidemiology Episodic abdominal pain, diarrhea, extra- intestinal manifestations Symptoms/Signs Colonoscopy: Skip lesions Path: Inflammation. Granulomas in 30% Diagnostics Treatment Immunosuppression Previous Slide Previous Slide Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Acute Mesenteric Ischemia Impaired perfusion of the mesentery Pathophysiology Atrial fibrillation, endocarditis, atherosclerosis Epidemiology Hyperacute abdominal pain out of proportion to exam. Peritoneal symptoms in later stages Symptoms/Signs Angiography: Non-invasive angiography (CT, MR) may be negative in the early phase. Diagnostics Treat the underlying cause, anticoagulation, bowel resection often necessary Treatment Previous Slide Previous Slide Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Primary Adrenal Insufficiency Most commonly autoimmune or infectious destruction of the adrenal gland. Pathophysiology History of autoimmune endocrinopathy, Exposure to tuberculosis Epidemiology Subacute Abdominal pain, weight loss, orthostasis. Hyponatremia, hyperkalemia Symptoms/Signs Diagnostics Low AM cortisol, positive cosyntropin stim test Treatment Glucocorticoid, mineralocorticoid replacement Previous Slide Previous Slide Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
Herpes Zoster Pathophysiology Reactivation of latent varicella virus Epidemiology Older age, immunosuppression Acute neuropathic pain, dermatomal distribution, followed by rash Symptoms/Signs Diagnostics Classic appearance of rash on exam, biopsy, antigen or DNA testing Treatment Acyclovir Previous Slide Previous Slide Based on Jones B, Brzezinski WA, Estrada CA, Rodriguez M, Kraemer RR. A 22-year-old woman with abdominal pain J Gen Intern Med. 2014 Jul;29(7):1074-8 Created by R Geha, DM Connor, J Kohlwes, R Sedighi Manesh
