doyoudig
Forum Guru
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Posts: 613
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19.
A 27-year-old primigravid woman at 29 weeks' gestation
comes to the
emergency department because of a 24-hour history of
increasingly severe
right-sided abdominal pain and no appetite. She has
vomited twice over
the past 4 hours. She has not had vaginal bleeding.
Her temperature
is 38.2 C (100.8 F). Examination shows exquisite
tenderness of the
right lateral flank and the fundus. There are no
peritoneal signs. Bowel
sounds are absent. The fetal heart rate is 144/min.
Laboratory
studies show:
Hematocrit 37%
Leukocyte count 16,000/mm3
Serum
Total bilirubin 1.1 mg/dL
Amylase 32 U/L
Lactate dehydrogenase 110 U/L
Urine WBC 3–5/hpf
Which of the following is the most likely diagnosis?
A
) Abruptio placentae
B
) Appendicitis
C
) Cholelithiasis
D
) Colitis
E
) Pyelonephritis
B or E, pls let me know what counts for or against E or B
thx
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| smal
Forum Guru
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i would go for appenditicis
due to the position change expected in pregnancy-hence the location of pain
hamburger sign
leukocytosis.
would've tought pyelonephritis in presence of sifnificant bactiuria
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| Justice
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B) Appendicitis Leukocyte count 16,000/mm3
for E) Pyelonephritis she should have more than Urine WBC 3–5/hpf
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| doc_clotaire
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B) 
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| Aashi
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Dicussed this q many times in this forum.chk out this link to view the discussion:-
http://www.prep4usmle.com/forum/thread/50634
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| zainee
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answer is B ,
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| hanialkhadher
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Would any body explain why not Abruptio placentae(Concealed type) ,
I find it difficult to explain the tender fondus and absent peritoneal signs by appendicitis.
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| Justice
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hanialkhadher wrote:
Would any body explain why not Abruptio placentae(Concealed type) ,
I find it difficult to explain the tender fondus and absent peritoneal signs by appendicitis.
Her temperature is 38.2 C (100.8 F). Examination shows exquisite tenderness of the right lateral flank...
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| hanialkhadher
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Temp is elevated in any collection of blood, like DVT, P.E.,M.I., Even atelectasis...
the patient has right lateral flank and the fundus.......!
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| eckimazuro
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Let me try to sort this out and explain why I think it is B-appendicitis:
A - Abruptio placentae presents in 80% of cases with vaginal bleeding. Although there is fundal tenderness, a sign of AP, neither the hematocrit dropped sufficiently for 24-hour-symptoms, nor is the fetus showing enough distress for this diagnosis to be likely.
C- Cholelithiasis is associated with an elevation of amylase to a large degree in a third of cases. Additionally, even though it can occasionally mimic appendicitis, there is normally no fever. Plus, often there is a history of previous episodes, not given here.
D- Even though there are absent bowel sounds, there are not enough signs (diarrhea or constipation) mentioned to warrent this diagnosis.
E - Pyelonephritis: Although it is conceivable that pyelonephritis may exist without WBC´s in the urine, this is very rare. Over 90% have WBC´s and/or WBC casts in their UA.
So why do I think it is appendicitis? Well, for the first part this is a rather young woman in her third trimester, which means that the appendix has shifted from a lower-right-quadrant position to a higher, periumbilical or even upper-right-quadrant position. This could cause "right lateral flank pain". Additionally, it would explain why bowel sounds are absent (reactive inflammation) and also explain why the patient is anorexic and nauseous/vomiting, what happens frequently with appendicitis, even during pregnancy.
Treatment? Surgery.
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