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CPC Case for April 15, 2005
  Discussant: William Norcross, MD Presenter: Dr. Brent Whitworth, MD
CC

Abdominal pain
HPI

A 43 year old Mexican female presented to the emergency room with a one hour history of severe epigastric pain.  The pain began while she was doing household chores and was initially 5/10 in severity, increasing to 10/10 at presentation. The pain was described as a constant aching that was relieved by sitting upright.  She also had nausea, vomiting, shortness of breath, non-productive cough, and diaphoresis associated with the pain.  She denied radiation of the pain, fever, orhematemesis.
PMH

Diabetes mellitus-treated with diet and exercise
MEDICATIONS

Acetaminophen  500mg po prn (took 1000mg prior to arrival)
FH Denied family history of abdominal aortic aneurysms

SH

 She was employed by a housekeeping company, and was divorced with two children (ages 17 and 13).  She had emigrated from Mexico 10 years ago, and she did not have any family in the United States.  She denied smoking, drug use, tattoos, transfusions, or recent travel.
ALLERGIES none
ROS

She denied any history of jaundice, diarrhea, or dysuria.
VITAL SIGNS T   98.6° P   125 R   38 BP   135/96   SaO2   75% (room air)
PHYSICAL EXAM:

Gen:  Non-obese, diaphoretic Mexican female sitting upright in bed in moderate respiratory distress

HEENT:  Anicteric conjunctivae, mucous membranes were pink and moist

Abdomen:  Mild discomfort with palpation of epigastrium, but soft,

Neck:  Supple without lymphadenopathy, thyromegaly, or jugular venous distention.

Lungs:  Increased work of breathing, clear to auscultation bilaterally

Cardiac:  Regular tachycardia, normal S1 and S2 without murmurs, non-distended, with normal and active bowel sounds.  Stool hemoccult was negative.

Extremities:  Cool and clammy, faint peripheral pulses, no edema

Neurologic:  Lethargic, moved all four extremities spontaneously and purposefully, sensation/gait/reflexes not tested.
LABS:
Na
135
K
 3.7
Cl
 101
HCO3
 19
Glucose
 413
BUN
 10
Ca
9.3
Mg
  
Phos
 
 
Creatinine
 0.8
Alk Phos
 107
AST
27
ALT
26
TP
7.1
Alb
 3.7
T Bili
0.5
Lipase
 235
Lactic Acid
  
Glob
 3.4
 
 
 
   
 
 
 
 
 
Trop I
 <0.1
CK
 31
CKMB
 0.70
 
D-dimer
>1050
 
   
 
 
 
 
 
WBC
 11,900
Hgb
 12.3 
Hct
 36.8
Plts
 346, 000
Differential
 (N63 L24 M8 E4)
MCV
  
ABG:
  
pH
 7.322  
pCO2
35
pO2
53  
HCO3
18
(on room air)
  
UA:
hazy, gluc > 1000, prot >300, RBC 1,  WBC 3, few bact        
Imaging and Other Studies
EKG:
see image
CXR:
Patchy bibasilar atelectasis
Abdominal Sono
  
   

Hospital Course/ Outcome

Upon arrival to the ER, she was given normal saline as a 2L bolus followed by 250 ml/h, and a dopamine drip was started.  Blood cultures were drawn, radiographic studies were ordered, and she was empirically given vancomycin 1 gram and clindamycin 900mg intravenously.  Shortly thereafter, she had a seizure and went into pulseless electrical activity (PEA).  She had three separate episodes of PEA and was given a total of 3mg of atropine and 4mg of epinephrine.  A pulse was regained and a diagnostic test was performed.  A few minutes later, her blood pressure plummeted, her pulse was lost, and the PEA protocol was initiated once again.  Her cardiac rhythm deteriorated to 3rd degree atrio-ventricular block, to atrial fibrillation, to an agonal rhythm, and ultimately, to asystole.  She was pronounced dead and an autopsy was performed.

ECG