The CIA World Factbook 1992

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#intro LOWER ABDOMINAL PAIN IN A 16-YEAR-OLD GIRL A microcomputer-based patient simulation for Continuing Medical Education for physicians. Prepared by the University of Washington and produced by CME, Inc. Content Author: Walter Henze, M.D. Clinical Instructor, Department of Family Medicine University of Washington Seattle, Washington Computer System Design: Mark Gaponoff Copyright (C) 1984, CME, Inc., all rights reserved. #credit The University of Washington is accredited by the American Council for Continuing Medical Education to sponsor CME (continuing medical education) for physicians. The University of Washington designates this CME activity for 2 credit hours in Category 1 of the Physician's Recognition Award of the American Medical Association, and this program has been reviewed and is acceptable for 2 prescribed hours by the American Academy of Family Practice #instr ask Would you like to review the instructions for running this program? (Press a Y or N, then press ENTER.) # Remember, the command words are: STOP to start over SCORE to see current score RECAP to review results thus far TEACH to review tutorial (IF you have the password) #instr GENERAL INSTRUCTIONS After typing any response, always press the ENTER key. The backspace key (or left arrow) can be used to correct typing errors. The program will ask for one of the following types of responses: "To continue press ENTER-->" ...press the ENTER key to continue. "Enter one number-->" ...select one choice at a time from the list and press ENTER. "Enter one or more numbers, separated by spaces or commas, then press ENTER-->" ...you can enter several choices at a time. # For yes-or-no questions, a Y or N followed by ENTER will suffice. At key points in the program you will be asked to "Type in your diagnosis...," You may type in any text you wish (you may use abbreviations). The computer will store your answer and compare it later with the author's diagnosis/ diagnoses. (No scoring is assigned for these diagnoses.) Note that some lists of options have a choice for "finished." Enter the number for "finished" in order to leave that choice list and continue with the program. # At any time, you may type in one of the following four command words: STOP to start the program over again. SCORE to obtain your score thus far. RECAP to review the data collected thus far regarding your patient. TEACH to review only the teaching summary and references for this case. You will be asked to type in the "password." (The password is given at the end of the case, so that after you finish the case once, you may refer to the teaching part at any time.) SCORE, RECAP, or TEACH return you to where you left off in the program. # Laboratory tests and procedures can be ordered at several points in the program. Results will be made available after a suitable time delay that approximates a real-life situation. These results will appear on the screen automatically after the "simulated" time has passed. # Note: The editors and the publisher of this work have made every effort to ensure that the information contained herein is accurate and in accord with the accepted standards at the time of publication. The users are advised, however, to check the package of each drug they plan to administer to be certain that changes have not been made in the recommended dose or in the contraindications for use. #system What type of RECAP do you wish? 1. All data gathered 2. History items only 3. Physical exam items only 4. Laboratory tests only 5. "Other" items only (e.g., diagnostic procedures, x-rays, etc., EXCLUDES history, physical and lab results) 6. List of tests or procedures with results still pending 7. Return to where you left off in program # Teaching summary... Please enter the "password" and press ENTER. # That was not the correct password. You will be given the password at the end of the program. Write it down in the space provided on the diskette jacket for future use. #refs only? TEACHING SUMMARY Would you prefer to see ONLY a list of references, rather than the entire teaching summary? #standard You have not yet selected all the correct responses. Please try again.... # You have already just done this. No need to repeat it. #hello CME (Inc.) patient simulation: LOWER ABDOMINAL PAIN IN A 16-YEAR-OLD GIRL Before preceding with the case presentation, please select the practice setting that most nearly approximates your own, or the setting you would prefer for this simulation. The appropriateness of answers may vary depending on the setting you choose. #scenario ask Which practice setting would you like? 1. You are a family practitioner in an isolated rural community with a 30-bed hospital. There is a general surgeon on staff who is usually available, but all other specialists are 100 miles away. Your practice includes routine and complicated obstetrics, ICU/CCU, and general surgery. 2. You are a family practitioner who hospitalizes patients in a new 100- bed suburban hospital. Most major medical specialties are represented on staff but the consultants are not always immediately available. Your practice includes routine and some complicated obstetrics, ICU/CCU care, but not surgery. #case start Brief Case Presentation: You and your spouse are having dinner with friends. Just as the main course is served, the hospital calls to tell you that Mary Jones has brought her 16- year-old daughter, Sue, to the emergency room with abdominal pain of two hours' duration. # The family is well known to you. The mother is very high strung with a tendency to worry; you thus elect to see the patient yourself. You arrive a few minutes later and learn that Sue was enjoying a hamburger and fries at Dons Drive Inn with her boyfriend when she had the sudden onset of lower abdominal pain, which has not improved. Shortly after the onset of pain she had a very loose stool. Her last menstrual period was 2 and 1/2 weeks earlier. When you ask her in private if there is any possibility that she might be pregnant, Sue replies "No." # The emergency room nurse has already taken her vital signs. They are blood pressure 128/78 mmHg, pulse 80/min and regular, respiration 20/min, and temperature 99 F. (37.2 C.). #start ask Patient's first visit.... What do you wish to do next? 1. Further history 2. Physical exam 3. Lab - routine 4. Lab - nonroutine 5. Lab - microbiology 6. Diagnostic procedures 7. Radiology/imaging 8. Treatment/disposition # 8 1 2 # question -99 start hx question -99 start detailed px say 0 0 here 1 say 0 0 here 1 say -1 0 here 1 say -1 0 here 2 say -1 0 here 2 say 0 0 here 3 # At least a minimal history and a physical exam should be done before ordering tests. # Without having done at least a minimal history and a physical exam, it is inappropriate to do tests or procedures. # Without having done at least a minimal history and a physical exam, it is inappropriate to undertake treatment. #start hx Further History (HX). What do you wish to learn? 1. Skin 12. Travel 2. HEENT 13. Smoking/drugs/ 3. Cardiorespiratory alcohol 4. Gastrointestinal 14. Current 5. Genitourinary medications 6. Musculoskeletal 15. Psychosocial 7. Neurological history 8. Past episodes 16. Sexual history 9. Past medical HX 10. Family history 17. finished with 11. Allergies/drug history reactions # many textforeach endhold ifall 17 17 last 17 # data 0 1 data 1 1 data 1 3 data 1 1 data 2 3 data 0 2 data 0 2 data 1 1 data 1 2 data 2 1 data 1 1 data 0 1 data 1 1 data 1 1 data 1 3 data 2 2 finished # HX--SKIN: Normal. # HX--HEENT: Negative. # HX--CARDIORESPIRATORY: Heart murmur early childhood. Not heard since aged 8 years. No history of rheumatic fever. # HX--GASTROINTESTINAL: Mild nausea for previous hour. # HX--GENITOURINARY: Very regular menses since aged 13 years. Prior menses 2 and 1/2 weeks ago was abnormal; on time but very light. Itchy vaginal discharge past week. # HX--MUSCULOSKELETAL: Easily fatigued past month. # HX--NEUROLOGICAL: Negative. # HX--PAST EPISODES: None. # HX--PAST MEDICAL HISTORY: Hospitalized aged 8 years for ruptured appendix. Diagnosis initially missed. Had surgery on 4th day with postoperative course complicated by wound infection, etc. Prolonged painful experience that left patient with mistrust of physicians and hospitals. # HX--FAMILY HISTORY: Normal. # HX--ALLERGIES/DRUG REACTIONS: None. # HX--TRAVEL: No travel outside USA. # HX--SMOKING/ALCOHOL/DRUGS: Has had occasional cigarette and beer at parties, unknown to parents. No drug usage. # HX--CURRENT MEDICATIONS: None. # HX--PSYCHOSOCIAL HISTORY: Oldest daughter with 1 younger sibling. Good student, active in sports, extracurricular activities, and religious youth group. # HX--SEXUAL HISTORY: Has been having occasional intercourse with boy friend for past 6 months. Using withdrawal to prevent pregnancy. #start detailed px Detailed Specific Physical Examination of Area or System: 1. Vital signs 8. Genitourinary 2. Skin 9. Musculoskeletal 3. HEENT 10. Mental status 4. Neck 11. Neurologic 5. Cardiovascular 12. Rectal 6. Respiratory 13. finished with 7. Abdomen exam # many textforeach endhold donedo: 3 ifall 13 13 last 13 # special 41 special 42 data 1 2 data 0 1 special 45 data 1 1 special 47 data 2 10 data 0 3 data 0 1 data 0 5 data 2 3 finished # PX--VITAL SIGNS: Blood pressure 128/78 mmHg, pulse 80/min and regular, respiration 20/min, and temperature 99 F. (37.2 C.). # PX--SKIN: Warm. Good color. No rashes. # PX--HEENT: Normal. # PX--NECK: Normal. # PX--CARDIOVASCULAR: Blood pressure 128/78 mmHg, pulse 80/min and regular, grade 2/6 midsystolic murmur at lower left sternal border without radiation. # PX--RESPIRATORY: Normal. # PX--ABDOMEN: Large lower midline scar, very uncosmetic, well healed. Diminished but present bowel sounds. 2+ right lower quadrant, left lower quadrant and superpubic tenderness. Much voluntary guarding in both lower quadrants. No apparent rebound. # PX--GENITOURINARY: Has never had pelvic exam. Very apprehensive. External genitalia inflamed and tender. Patient unable to relax and tends to scoot up the table with each movement. Speculum exam reveals white curdy discharge. Cervix shows moderate ectropion. Because of discomfort, patient refuses to allow you to proceed with the exam. # PX--MUSCULOSKELETAL: Normal. # PX--MENTAL STATUS: Normal. # PX--NEUROLOGIC: Normal. # PX--RECTAL: Retroverted but not fixed uterus. Appears slightly enlarged. Moderate to marked tenderness in right adnexa, but inconclusive exam. Soft brown stool in rectum (guaiac negative). #changed px PX--VITAL SIGNS: Blood pressure 90/50 mmHg, pulse 110/min and regular, respiration 30/min, and temperature 99 F. (37.2 C.). # PX--VITAL SIGNS: Blood pressure 80/40 mmHg, pulse 150/min and regular, respiration 30/min and shallow, and temperature 99 F. (37.2 C.). # PX--SKIN: Skin cold and clammy. # PX--CARDIOVASCULAR: Blood pressure 90/50 mmHg, pulse 110/min and regular, grade 2/6 midsystolic murmur at lower left sternal border without radiation. # PX--CARDIOVASCULAR: Blood pressure 80/40 mmHg, pulse 150/min and regular, grade 2/6 midsystolic murmur at lower left sternal border without radiation. # PX--ABDOMEN: Large lower midline scar, very uncosmetic, well healed. Absent bowel sounds. Diffuse abdominal tenderness, 2+ right upper quadrant, left upper quadrant, 4+ right lower quadrant, left lower quadrant. Marked rebound and guarding. #start 2 ask Patient's first visit.... What do you wish to do next? 1. Further history 2. Repeat physical exam 3. Lab - routine 4. Lab - nonroutine 5. Lab - microbiology 6. Diagnostic procedures 7. Radiology/imaging 8. Treatment/disposition # 8 8 # question -99 start hx question -99 start detailed px question -99 start lab-routine question -99 start lab-nonroutine question -99 start lab-micro question -99 start procedures special 67 say 0 0 0 0 #start lab-routine Routine Laboratory Tests (you can order tests simultaneously or separately, but each separate blood draw takes time). 1. Urinalysis 10. Thyroid 2. Complete blood (T3, T4) count (CBC) 11. Uric acid 3. CBC with smear 12. Creatinine 4. Hematocrit 13. VDRL 5. Sedimentation rate 14. PPD (TB skin) 6. PT, PTT 15. Gravindex 7. SMA-6 (urea, elec- (urine preg.) trolytes, glucose) 16. Stool guaiac 8. Liver function 17. Blood type and (bilirubin, SGOT, crossmatch LDH, Alk. Phos.) (hold 2 units) 9. Arterial blood 18. finished with gases routine labs # many textforeach endhold donedo: 1 ifall 18 18 last 18 # data 1 5 delay 2 0 30 tell delay 2 0 45 tell data 2 3 delay 0 0 60 tell delay 1 0 30 tell delay 0 0 30 tell delay -1 0 1440 tell delay -1 5 15 tell delay -1 0 1440 tell delay -1 0 1440 tell delay -1 0 1440 tell delay -1 0 2880 tell delay -1 3 2880 tell delay 2 5 5 tell data 0 2 special 51 finished # LAB--URINALYSIS: Contains some hyphae. # LAB--COMPLETE BLOOD COUNT (CBC): Normal. Hematocrit 40%. # LAB--CBC WITH PERIPHERAL SMEAR: Hematocrit 40%. Hemoglobin 13.1, normal indices. White blood count 8,000/cu mm. Normal differential, platelets normal. # LAB--HEMATOCRIT: 40%. # LAB--SEDIMENTATION RATE: Normal. # LAB--PT, PTT: Normal. # LAB--SMA-6: Normal. # LAB--LIVER FUNCTION: Normal. # LAB--ARTERIAL BLOOD GASES: Normal. # LAB--THYROID FUNCTION: Normal. # LAB--URIC ACID: Normal. # LAB--CREATININE: Normal. # LAB--VDRL: Negative. # LAB--PPD: Negative. # LAB--GRAVINDEX: Negative (2-minute latex slide test). Sensitex urine pregnancy test not available (supplies of this more sensitive test have been ordered, but are not yet available). The 2-minute urine latex slide tests for human chorionic gonadotropin (HCG) detect levels of HCG at 2300 +/- 1000 mIU/mL and therefore have an estimated false-negative rate of 50%. The tube-type tests on urine are more sensitive (can detect 500-1200 mIU/mL), but take 1 1/2 to 2 hours to perform and still have a 15% to 35% false- negative rate. # LAB--STOOL GUAIAC: Negative. #blood LAB--BLOODTYPE AND CROSSMATCH: 2 units available. Blood type O negative. # LAB--BLOODTYPE AND CROSSMATCH: Blood will be available in 20 minutes. #start lab-nonroutine Lab Tests - Nonroutine (you can order tests simultaneously or separately, but remember that each blood draw takes time). 1. Iron and iron-binding FE/TIBC 2. Serum amylase 3. Albumin/globulin 4. Calcium, phosphate 5. Acid phosphatase 6. Antinuclear antibodies, rheumatoid factor 7. Monospot/heterophile 8. Folate and B12 9. Cholesterol 10. Serum pregnancy 11. finished with nonroutine labs # many textforeach endhold donedo: 2 ifall 11 11 last 10 last 11 # delay -2 0 1440 tell delay -2 0 1440 tell say -2 0 say -2 0 say -2 0 say -2 0 say -2 0 say -2 0 say -2 0 special 20 finished # LAB--IRON AND IRON-BINDING FE/TIBC: You just spent $45 on an unnecessary test. The test was normal. # LAB--SERUM AMYLASE: Do you think this is pancreatitis? The test was normal. # LAB--ALBUMIN/GLOBULIN: Unnecessary. # LAB--CALCIUM, PHOSPATE: Unnecessary. # LAB--ACID PHOSPHATASE: What on earth for? # LAB--ANTINUCLEAR ANTIBODIES: Do you have a financial interest in the laboratory? # LAB--MONOSPOT/HETEROPHILE: Why this? # LAB--FOLATE AND B12: Not appropriate in this case. No wonder medical costs are escalating so fast. # LAB--CHOLESTEROL: Not indicated. # LAB--SERUM PREGNANCY: Are you suspicious that the urine pregnancy test was falsely negative? Good idea, but this test costs an additional $20, and, more importantly, is unavailable at this hospital. Since you say that you really want this test, the laboratory technician will send out the sample on the bus in the morning, and you will have the result 36 hours from now. #serum ask A serum pregnancy will be available in 2 hours. You will now ... 1. Continue your evaluation/management while waiting for the result. 2. Go back to dinner while awaiting result. 3. Cancel order for test. # endhold 3 # delay 1 3 120 tell here 1 data -1 120 here 1 finished #serum LAB--SERUM PREGNANCY: The test is positive--1000 mIU/mg. There are two types. The radioreceptor assay (RRA) for HCG can be falsely positive (albeit rarely) secondary to increased luteinizing hormone, but one series (Berry CM, et al: The radio- receptor assay for HCG. Obstet Gynecol 54:43, 1979) was 94% sensitive for ectopic pregnancy. The most sophisticated test available is the radioimmunoassay for detection of the serum beta-subunit of HCG. It can detect HCG at 5mIU/mL and is essentially 100% sensitive for pregnancy of any type beyond 9 to 12 days after conception. #start lab-micro Microbiology laboratory tests form. What tests do you order? 1. Gram stain of cervical smear 2. Throat culture 3. Urine culture 4. Sputum culture 5. Blood culture 6. Stool culture 7. Wound or lesion culture 8. Acid fast - tuberculosis 9. Fungal culture 10. Endocervical culture 11. Stool ova and parasites 12. Potassium hydroxide/saline smear 13. finished with microbiology # many textforeach endhold ifall 13 13 last 13 # data 0 10 say -2 2 say -2 5 say -2 3 say -2 5 delay -2 3 1440 tell say -99 0 say -2 3 say -2 1 delay 1 1 1440 tell delay -1 3 1440 tell data 0 4 finished # LAB--GRAM STAIN: Normal flora -- some gram-negative diplococci seen, but none are intracellular. # LAB--THROAT CULTURE: Not indicated. # LAB--URINE CULTURE: Not indicated. # LAB--SPUTUM CULTURE: Patient cannot produce a specimen. # LAB--BLOOD CULTURE: Not indicated at this point. # LAB--STOOL CULTURE: Results negative. # LAB--WOUND OR LESION CULTURE: Not indicated. # LAB--ACID FAST - TUBERCULOSIS: Patient unable to produce sputum. # LAB--FUNGAL CULTURE (vaginal discharge): This totally unnecessary test was fortunately lost and never completed. # LAB--ENDOCERVICAL CULTURE: Yeast species. # LAB--STOOL OVA AND PARASITES: Negative. # LAB--POTASSIUM HYDROXIDE/SALINE SMEAR: Positive for yeast: negative for trichomoniasis. #start procedures Diagnostic procedures. Which do you do? (If you are an urban-based physician, you may wish to get a consult as this time. However, for the purposes of this simulation you should continue with the most appropriate work-up.) 1. Paracentesis 2. Culdocentesis 3. Lumbar puncture 4. Thoracentesis 5. Laparoscopy 6. finished # many textforeach endhold ifall 6 6 last 6 # data 0 15 special 70 data -2 45 say -2 0 special 25 finished # PARACENTESIS: Using an 18-gauge needle you tap both lower quadrants and get no return of blood or fluid. #culdo CULDOCENTESIS: You use 18-gauge spinal needle with considerable difficulty because of patient's inability to relax and continuing pain. Two cc of apparently nonclotting blood is retrieved before needle is dislodged as patient moves on table. She refuses to let you try again. # LUMBAR PUCTURE: Using a 22-gauge spinal needle you obtain 4 cc of clear fluid, which is sent to the laboratory. # THORACENTESIS: Not indicated. #laparoscopy LAPAROSCOPY: Unsuccessful because of multiple adhesions from ruptured appendix. # LAPAROSCOPY: You take the patient to the operating room for this procedure. As you are about to start, the nurse in charge of the operating room informs you that you do not have privileges for this procedure and asks you to wait for someone who does. As you are waiting for the obstetrics and gynecology consultant, the patient goes into shock and arrests. #culdo teach ask Are you interested in a brief digression on culdocentesis technique? (Y or N) #culdo teach After careful pelvic examination to exclude conditions that would contraindicate culdocentesis (ie, a fixed mass in the cul-de-sac or a fixed retroverted uterus), a speculum is placed in the vagina and the vagina and cervix are prepped with povidone- iodine. A tenaculum is applied to the posterior or anterior lip of the cervix. Cramping can usually be minimized at this point if the tenaculum is closed slowly over about 15 seconds. # 2-3 cc of air are drawn into a 10-cc 3-finger control syringe fitted with an 18-gauge spinal needle. The vaginal mucosa is entered in the midline 1 cm below its posterior reflection. (In this author's experience, local anesthetic to vaginal mucosa is worthwhile. Some texts disagree on the grounds that the anesthetic may be confused with peritoneal fluid.) The needle should be directed horizontally and advanced 3-4 cm through the mucosa. After aspirating to make sure the needle is not in a vessel, the 2-3 cc of air is injected. Resistance indicates that the needle has entered solid tissue and should be redirected. If air passes easily then an aspiration is performed. # Procedure is complete after aspiration of fluid or after 3 negative taps. A positive tap is nonclotting blood. Clotting blood is nondiagnostic. Peritoneal fluid (straw colored) effectively eliminates any likelihood of intraperitoneal bleeding. Reference: Eisinger SH: Culdocentesis. J Fam Pract, 13:95, 1981. #start xray Radiological Studies/Imaging What do you wish to order? 1. Chest (posteroanterior and lateral) 2. Abdomen (kidney, ureter, bladder) 3. Upper Gastrointestinal (GI) 4. Barium enema 5. Intravenous pyelogram (IVP) 6. Abdominal ultrasound 7. Specific bones 8. Skull films 9. Sinus films 10. Cervical spine 11. Computed tomographic(CT) scan - Head 12. Computed tomographic(CT) scan - Body 13. finished with radiology/imaging # many textforeach endhold 13 first 11 12 last 13 # say -2 30 special 62 say -2 120 say -2 120 say -2 120 special 26 say -2 60 say -2 60 say -2 60 say -2 60 special 11 special 12 finished # XRAY--CHEST POSTEROANTERIOR AND LATERAL: Ordered. Unnecessary. # XRAY--ABDOMEN (KIDNEY,URETER,BLADDER): Ordered. # XRAY--UPPER GASTROINTESTINAL: Ordered. Not indicated. # XRAY--BARIUM ENEMA: Ordered. Not indicated. # XRAY--INTRAVENOUS PYELOGRAM: Ordered. Not indicated. # XRAY--ABDOMINAL ULTRASOUND: The ultrasound machine was sent out this morning for repairs; it is not expected back for one week. The loaner promised by the company has inexplicably failed to arrive. # XRAY--SPECIFIC BONES: Ordered. Not indicated. # XRAY--SKULL FILMS: Ordered. Not indicated. # XRAY--SINUS FILMS: Ordered. Not indicated. # XRAY--CERVICAL SPINE: Ordered. Not indicated. # CT SCAN--HEAD: The machine is over 100 miles away. Do you still wish to have this done now? # CT SCAN--BODY: The machine is over 100 miles away. Do you still wish to have this done now? #kub XRAY--ABDOMEN (KIDNEY,URETER,BLADDER): Slightly dilated loops of bowel. No air fluid levels seen. #round 2 images ULTRASOUND: Shows slightly enlarged uterus. No gestational sack. Adnexa obscured by bowel gas pattern. # CT SCAN - HEAD: Not indicated. Machine down. # CT SCAN - BODY: The machine is down. #ct kill You receive a call three hours later informing you that your patient died en route to the CT scan and could not be resuscitated. #xray shock SHOCK IN X-RAY: X-ray technician calls to say that the patient appears "shocky." The patient is rushed back to you (interrupting the filming)--reaches the emergency room and is found to be in shock. Blood pressure 80/40 mmHg, pulse 150/min, respiration 30/min and shallow, skin cold and clammy. Perhaps some sort of immediate action is indicated. # RADIOLOGY/IMAGING: Nurse says, "Doctor, the patient's blood pressure is falling. I would prefer not to move her." Choose another option. #time shock SHOCK: While away momentarily you receive an emergency page; when you arrive at the patient's bedside you find her in shock. Vital signs blood pressure 80/40 mmHg, pulse 150/min, respiration 30/min and shallow. Skin cold and clammy. Perhaps some sort of immediate action is indicated. #time arrest While handling an outside telephone call you hear a page for Code Red (cardiac arrest); on arrival at the designated location, you find that your patient has had a cardiac arrest. The nurse reports that the patient's blood pressure was falling rapidly, and as she started to summon help the patient arrested. #tsk Your previous decision has led to an unexpected and undesirable outcome. However, since this is a computer simulation, it is possible to return to the previous decision point and allow you to try another option. #prov diag At this point, what is your provisional differential diagnosis of this patient? [Your diagnosis will be compared with the author's diagnosis later. It will be interesting to see the comparison.] #specific act Specific Treatment/Disposition 1. Intravenous fluids 2. Insert Foley catheter 3. Admit to intensive care unit with intravenous antibiotics 4. Admit to hospital with intravenous antibiotics 5. Admit to hospital for observation 6. Send home on clear liquids 7. Send home on amoxicillin 500 mg qid. 8. Transfuse 2 units whole blood 9. Cardiac monitor 10. Take patient to surgery 11. Wait one hour for test results 12. Do further workup 13. finished # 13 10 # special 1 data -1 5 here 3 special 3 special 4 special 5 special 6 special 7 special 8 data 1 5 find 0 monitor special 10 say -1 60 find 0 hour question -99 specific data special 13 #iv INTRAVENOUS FLUIDS: Good idea. Patient may indeed have acute intra-abdominal problem. # INTRAVENOUS FLUIDS: Blood pressure rises to 90/50 mmHg with maximal flow. Additional intravenous started with large bore needle. #foley INSERT FOLEY CATHETER: 50 cc of clear urine recovered. #admits ADMIT TO INTENSIVE CARE UNIT (ICU): Patient admitted to ICU. Shortly thereafter nurse reports that patient is complaining of increasing abdominal pain and left shoulder pain. The shoulder pain was relieved by sitting up but this made her extremely dizzy. Blood presure 90/50 mmHg, pulse 140/min and regular lying down, and blood pressure 80/40 mmHg, pulse 150/min sitting. # ADMIT TO HOSPITAL W/ IV ANTIBIOTICS: Patient admitted to hospital. Shortly thereafter nurse reports that patient is complaining of increasing abdominal pain and left shoulder pain. The shoulder pain was relieved by sitting up but this made her extremely dizzy. Blood presure 90/50 mmHg, pulse 140/min and regular lying down, and blood pressure 80/40 mmHg, pulse 150/min sitting. # ADMIT TO HOSPITAL FOR OBSERVATION Patient admitted to hospital. Shortly thereafter nurse reports that patient is complaining of increasing abdominal pain and left shoulder pain. The shoulder pain was relieved by sitting up but this made her extremely dizzy. Blood presure 90/50 mmHg, pulse 140/min and regular lying down, and blood pressure 80/40 mmHg, pulse 150/min sitting. # ADMIT--No. Patient is in shock and cannot be moved at this time. Life support measures should be instituted immediately. Choose another option. # Patient Admitted. What do you want to do now? #home SEND HOME: On the way home the patient complains of increasing lower abdominal pain, left shoulder pain, and then passes out. Her mother rushes her back to the emergency room, where she is found to be in deep shock. As you arrive she has a cardiac arrest. # SEND HOME ON AMOXICILLIN 500: On the way home the patient complains of increasing lower abdominal pain, left shoulder pain, and then passes out. Her mother rushes her back to the emergency room where she is found to be in deep shock. As you arrive she has a cardiac arrest. #transfuse TRANSFUSE 2 UNITS: Patient stabilizes and blood pressure rises. # TRANSFUSE 2 UNITS: Blood previously ordered not quite ready yet. # TYPE, CROSSMATCH, AND TRANSFUSE 2 UNITS: Blood ordered. Emergency cross match done and blood will be ready for transfusion in 20 minutes. # TYPE, CROSSMATCH, AND TRANSFUSE 2 UNITS: Although patient may have acute intra-abdominal problem, is blood transfusion really indicated at this time? Type and crossmatch is reasonable, and 2 units are ordered, but not given. # Intravenous fluids may be a more appropriate first step. #monitor CARDIAC MONITOR: Installed. #hour One hour has passed. #unready SURGERY PREMATURE: You do not have enough information to justify undertaking a surgical procedure at this point. # SURGERY: You should deal with the patient's shock before going into surgery. #quits SURGERY NOT SELECTED: This patient has increasing abdominal pain and shoulder pain, and has been in shock. A strong possible cause is intra-abdominal hemorrhage. Surgery is indicated. #specific data For further workup of this patient, what would you do now? 1. Consultation 2. Repeat physical exam 3. Lab - routine 4. Lab - nonroutine 5. Lab - microbiology 6. Radiology/imaging 7. Diagnostic procedures (including culdocentesis) 8. Workup finished, go to Treatment/Disposition # 8 8 # special 21 question -99 start detailed px question -99 start lab-routine question -99 start lab-nonroutine question -99 start lab-micro special 66 question -99 start procedures finished #consult Consultation 1. Cardiology 2. Pulmonary 3. Gastroenterology 4. Neurology 5. Surgery 6. Psychiatry 7. Obstetrics and gynecology 8. Pediatrics 9. Other family physician 10. finished # many textforeach endhold ifall 10 10 last 10 # say -1 10 summary find 0 con-2 say -2 10 summary find 1 con-2 say -2 10 summary find 2 con-2 say -2 10 say 0 5 summary find 3 con-2 say -2 10 say 0 10 summary find 4 con-2 say -2 10 say 2 2 finished # CONSULT--CARDIOLOGY: Unnecessary. Murmur is prolapsing mitral leaflet. # CONSULT--PULMONARY: You are wasting valuable time. # CONSULT--GASTROENTEROLOGY: You are wasting valuable time. # CONSULT--NEUROLOGY: You are wasting valuable time. # CONSULT--SURGERY: The surgeon is in San Francisco attending a convention. # CONSULT--PSYCHIATRY: You are wasting valuable time. # CONSULT--OBSTETRICS AND GYNECOLOGY: While you are discussing this case with a consultant over 100 miles away, your patient's condition is deteriorating. You would be better off to stop talking and to start doing something. # CONSULT--PEDIATRICS: You are wasting valuable time. # CONSULT--OTHER FAMILY PHYSICIAN: Is immediately available should surgical assistant be necessary. #con-2 CONSULT--PULMONARY: This consultation is not indicated and wastes valuable time in this acute case. # CONSULT--GASTROENTEROLOGY: This consultation is not indicated and wastes valuable time in this acute case. # CONSULT--NEUROLOGY: This consultation is not indicated and wastes valuable time in this acute case. # CONSULT--PSYCHIATRY: This consultation is not indicated and wastes valuable time in this acute case. # CONSULT--PEDIATRICS: This consultation is not indicated and wastes valuable time in this acute case. #consult2 Consultation 1. Cardiology 2. Pulmonary 3. Gastroenterology 4. Neurology 5. Surgery 6. Psychiatry 7. Obstetrics and gynecology 8. Pediatrics 9. finished # many textforeach endhold ifall 9 9 last 9 # data -1 45 summary find 0 con-2 say -2 45 summary find 1 con-2 say -2 30 summary find 2 con-2 say -2 60 data 2 15 summary find 3 con-2 say -2 60 data 2 15 summary find 4 con-2 say -2 60 finished # CONSULT--CARDIOLOGY: Unnecessary. Murmur is prolapsing mitral leaflet. # CONSULT--PULMONARY: You are wasting valuable time. # CONSULT--GASTROENTEROLOGY: You are wasting valuable time. # CONSULT--NEUROLOGY: You are wasting valuable time. # CONSULT--SURGERY: General surgeon, who happens to be in emergency room at the time, reviews the history and accumulated lab data. He re-examines the patient, who now has developed a surgical abdomen and postural hypotension. He asks you to order a 14-gauge intravenous and blood for emergency type and crossmatch, and recommends immediate laparotomy. You concur. # CONSULT--PSYCHIATRY: You are wasting valuable time. # CONSULT--OBSTETRICS AND GYNECOLOGY: After some delay, you reach the consultant by telephone. He has just finished a delivery at another hospital. He recommends an ultrasound and culdocentesis and says he will be there in 30 minutes. # CONSULT--PEDIATRICS: You are wasting valuable time. #revive RESUSCITATE: Heart and breathing restarted. Intravenous fluids restore patient's volume and blood pressure rises to 80/50 mmHg, pulse 110/min, sinus rhythm. Patient regains consciousness. #arrest ask What is the most likely reason for the patient's shock and arrest? 1. Pulmonary embolus 2. Cardiogenic shock 3. Intra-abdominal bleeding 4. Septic shock # textforeach endhold tries: 2 4 3 # summary here 1 say -2 0 summary here 2 say -2 0 special 80 say -1 0 # PULMONARY EMBOLUS: A pulmonary embolus is unlikely in a patient this young with no added risk factors such as use of oral contraceptives. What about the lower abdominal pain? A ruptured ectopic pregnancy should be ruled out. # CARDIOGENIC SHOCK: Unlikely in a young female patient. Other possibilities should be considered first. # INTRA-ABDOMINAL BLEEDING: YES! A culdocentesis would have been most useful earlier in the workup. However it is only contributory if positive. A dry tap does not exclude the diagnosis. # SEPTIC SHOCK: Although patient may have pelvic infection with septic shock, this is unlikely in view of absence of fever and normal white blood count. A ruptured ectopic pregnancy should be excluded and a culdocentesis performed. # INTRA-ABDOMINAL BLEEDING: YES! A culdocentesis is only contributory if positive. A dry tap does not exclude the diagnosis. In this case it was equivocal. #urban anesthetic TAKE PATIENT TO SURGERY: Since you are not a rural physician, you are unlikely to give your own anesthetic. However it may be interesting for you to review some important principles in giving anesthesia in this emergency situation. #anesthetic TAKE PATIENT TO SURGERY: You will be ready to operate in 20 minutes with a crash general or 40 minutes with an epidural. Which do you prefer? 1. Anesthetic - crash general 2. Anesthetic - epidural # 2 1 or 2 # special 98 special 99 # ANESTHETIC--EPIDURAL: An epidural anesthesia is appropriate only if the patient has not been in shock and time is available. In this case, a crash general with appropriate precautions is preferred. # ANESTHETIC--EPIDURAL: Epidural anesthesia is appropriate only if the patient has not been in shock and time is available. The patient is probably hypovolemic, and an epidural could lead to further hypotension. A crash general with appropriate precautions is preferred. # ANESTHETIC--CRASH GENERAL: In administering a crash general to this patient, are any special precautions necessary? (Y or N) # ANESTHETIC--CRASH GENERAL: Patient vomits on table and aspirates (remember, she had burgers and fries for dinner shortly before coming in to see you), then arrests and cannot be resuscitated. You should have taken precautions. # ANESTHETIC--CRASH GENERAL: YES! Patient had burger and fries for dinner shortly before coming to see you, thus intubation is indicated. #general precautions Should the patient be given oxygen for five minutes prior to the anesthesia (Y or N)? # YES. It is desirable to oxygenate the patient, since it may take time to place the tube. # Should the patient be bagged prior to the placement of the tube (Y or N)? # NO. The patient should not be bagged prior to the placement of the tube, since this could stimulate vomiting. # Should pentothal and succinyl choline be administered (Y or N)? # YES. Pentothal and succinyl choline should be administered. These are the preferrred agents to use for induction and inubation. # Should a cuffed endotracheal tube be used (Y or N)? # YES. The cuffed endotracheal tube should be placed with speed. # Would an assistant be helpful (Y or N)? # YES. An assistant should apply cricoid pressure to close the esophagus. #more precautions Other precautions for the crash general include: ** Suction should be available. ** During extubation the patient should be in a head-down position and suction available. #work diag At this point, what is your working (differential) diagnosis of this patient? #surgery pick Surgical Intervention 1. Laparoscopy 2. Laparotomy 3. Cesarean section 4. Hysterectomy 5. Tracheostomy # endhold notdonetext 5 2 # data -1 30 here 1 special 100 special 33 special 34 special 35 # SURGERY--LAPAROSCOPY: Unsuccessful because of multiple adhesions from old ruptured appendix. # SURGERY--LAPAROTOMY: Patient is moved rapidly to operating room. The anesthetic is administered by the nurse anesthetist without a hitch, and your partner arrives to be the surgical assistant. A ruptured right-sided ectopic pregnancy is found. # SURGERY--CESAREAN SECTION: The patient dies during this totally inappropriate procedure. You are sued penniless and turn to alcohol. You die alone and forgotten, abandoned by your family, 15 years later of bleeding esophageal varices. # SURGERY--HYSTERECTOMY: The patient dies during this totally inappropriate procedure. You are sued penniless and turn to alcohol. You die alone and forgotten, abandoned by your family, 15 years later of bleeding esophageal varices. # SURGERY--TRACHEOSTOMY: The patient dies during this totally inappropriate procedure. You are sued penniless and turn to alcohol. You die alone and forgotten, abandoned by your family, 15 years later of bleeding esophageal varices. #surgery2 Surgical Intervention 1. Laparoscopy 2. Laparotomy 3. Cesarean section 4. Hysterectomy # textforeach endhold notdonetext 4 2 # data -1 10 special 100 say -2 0 say -2 0 # SURGERY--LAPAROSCOPY: Consultant decides against this because of urgency of situation and history of prior ruptured appendix. # SURGERY--LAPAROTOMY: The patient is moved rapidly to operating room. Appropriate anesthesia is chosen by the surgeon and anesthesiologist because of recent burger and fries. The abdomen is entered through the old lower midline scar. A ruptured right-sided ectopic pregnancy is found. # SURGERY--CESAREAN SECTION: Not appropriate. # SURGERY--HYSTERECTOMY: Not appropriate. #surgery how Definitive management--What surgery(s) would you perform? 1. Resect entire right tube 2. Preserve maximal amount of tube 3. Attempt tuboplasty # textforeach endhold 3 2 # say 1 0 say 2 0 say -1 0 # RESECT ENTIRE RIGHT TUBE: The is a solid traditional approach. However, the patient has multiple adhesions in the pelvis and a left hydrosalpinx. Her fertility is compromised. Try option #2. # PRESERVE MAXIMAL AMOUNT OF TUBE: Preserving as much tubal structure as possible consistant with hemostasis may allow a successful tuboplasty in the future. This would be particularly important in this case because Sue's left tube is a hydrosalpinx with a clubbed end. # ATTEMPT TUBOPLASTY: It is more likely that tuboplasty will be successful if done at a later date using microsurgical technique. #rhogam Do you wish to order Rhogam on this patient? 1. Yes, order Rhogam 2. No, do not order 3. Not sure # endhold 3 # say 2 0 here 1 summary here 2 say -2 0 here 2 say -1 0 here 1 # RHOGAM: Since patient is Rh negative, Rhogam is definitely indicated, as it would be for spontaneous or therapeutic abortion. # NO RHOGAM: WRONG! Since patient is Rh negative, Rhogam is definitely indicated, as it would be for spontaneous or therapeutic abortion. #problem lists After initial data gathering: After decision to undertake management: # 1. Tubal pregnancy with rupture 2. Ruptured corpus luteum cyst 3. Torsion of ovary or ovarian cyst 4. Incidental yeast vaginitis # 1. Ruptured ectopic pregnancy 2. Ruptured corpus luteum cyst with hemorrhage #teach TEACHING POINTS As has been pointed out in a recent article in the Journal of Family Practice, (Quan M, Rodney W, Puffer J: Ectopic pregnancy. J Fam Pract 14:561 1982), the most consistent presenting symptom of ectopic pregnancy is abdominal pain. Abnormal vaginal bleeding is present in only 55% to 74% depending on what series is reviewed. Amenorrhea or delayed menses may be present in 68% to 83%, but is by no means consistent. # A sexual history may not always elicit the information desired. Sue was not lying when she said that it wasn't possible for her to be pregnant-- she was just indulging in a form of denial based either on erroneous information or magical thinking-- quite common among sexually active teenagers. # On physical examination adnexal tenderness was the most common finding present in 72% to 96% of cases in the aforementioned review, but a palpable mass or fullness was found in only 49% to 76% of patients. In rare cases the patient's ectopic pregnancy can rupture during the pelvic exam -- an uncommon event, but one which can definitely occur -- hence the importance of gentleness here. # Pregnancy testing is obviously an important factor whenever this diagnosis is entertained. Urine pregnancy tests have a false negative rate of 15% to 50% depending on the test used. Serum pregnancy tests offer a considerable improvement in accuracy but are less widely available in-house. It is rarely available to the rural practitioner without a 1 to 2 day delay to transport the specimen. # Pelvic ultrasound is most often useful in establishing early intra- uterine pregnancy -- thereby excluding an ectopic pregnancy. # Finally, the long-term outlook regarding future pregnancy is substantially altered by ectopic pregnancy. To quote Quan et al directly: "An estimated 38 to 70 per cent of patients will be involuntarily sterile following an ectopic pregnancy and only 33 per cent can ever be expected to deliver a normal child. It is hoped that through earlier diagnosis prior to rupture of the ectopic gestation, the use of more conservative, less ablative surgical procedures, and the use of currently available improved techniques for tubal reconstructive surgery, these grim figures can be improved upon." # Sue recovered from her surgery uneventfully. Extensive family counseling is necessary to help deal with the obvious fact of her sexual activity. You pave the way as well for access to information about birth control at such times that Sue chooses to be sexually active again. # This case also illustrates how a ruptured appendix in childhood can have disasterous sequelae years later in terms of the need for repeat surgery and loss of fertility. #references References: Berry CM, et al: The Radioreceptor Assay for HCG. Obstet Gynecol 54:43, 1979. Eisinger SH: Culdocentesis. J Fam Pract 13 (1):95, 1981. Quan M, Rodney W, Puffer J: Ectopic pregnancy. J Fam Pract 14:561, 1982. #dirge 4 100 4 75 4 25 4 100 7 75 6 25 6 75 4 25 4 75 3 25 4 200 #hurrah 8 50 13 50 17 50 20 100 17 50 20 200 #uh-oh 15 100 9 100 15 100 9 100 15 100 9 100 #code The tutorial "password" for this case is HURRY This word will allow you to access the teaching material in this case at any time without having to work through the case. You can then use this program as a reference. Write this password on the dust jacket of the floppy disk in the space provided on the back. You may also wish to run the case again and try additional options to review all the teaching points contained in the text. # CREDIT In order to receive two hours of AMA category 1 continuing medical education credit and documentation for AAFP prescribed credit, please fill out the attached self-addressed registration card. Be certain to complete all the items before mailing to ensure proper credit. We would appreciate your evaluation of this simulation on the same card. Include the "completion code" given below. A computer printout documenting your participation will be sent to you from the University of Washington Office of Continuing Medical Education. Your "completion code" is: #scoring Your scores were categorized as follows: (essential) (desirable) (neutral) (not indicated or unnecessary) (inappropriate and wasteful, or potentially harmful) (fatal or near-fatal outcome) Your overall performance index is: # The following items you selected were considered inappropriate and wasteful, or potentially harmful (scored -2): # An average overall performance index for this case obtained from a test panel of family practice residents and practicing community physicians was: 125. #version Text version 1.0 6/11/84 IBM/TURBO #timelines <<Results obtained: >> <<Items after shock: >> <<Items after arrest: >> #