24
Vol. 66, No. 1 2015
Northeast Florida Medicine
CME
Case Two:
This case involves a patient who had been under the care
of the same primary care physician for nine years. He com-
plained intermittently of back problems and fatigue. He was
prescribed B12 injections, multivitamins, iron and folic acid
during the ensuing years.
At the age of 43, the patient presented with complaints of
rectal bleeding and had hemoglobin of 14.6. His physician
ordered a barium enema and found diverticular disease. At
a follow-up office visit two weeks later, the patient again
reported rectal bleeding. A high fiber diet and Cipro were
recommended. No rectal exam is recorded at either of these
office visits. Nearly 22 months later, the patient returned to
the office. CBC revealed hemoglobin of 10.7, although he
reported having had no rectal bleeding for a year. Again no
rectal exam recorded.
The next visit was seven months later, about 18 months
after anemia was first confirmed and 3.5 years after the initial
complaint of rectal bleeding. A rectal exam was done, con-
firming blood and the presence of “an internal hemorrhoid.”
The colonoscopy performed four weeks later revealed a “lob-
ulated, ulcerated mass at two to five cm from the anal verge.”
A small polyp was removed 20 cm from the anus. Biopsies of
the smaller polyp were non-diagnostic at pathologic exam,
but pathology confirmed the rectal mass as adenocarcinoma.
Referral was made to a colorectal surgeon who ordered
an abdominal and pelvic CT scan. The CT was negative for
metastatic disease. Also, the Chest x-ray was normal. The
surgeon recommended neoadjuvant chemo-radiation which
was completed without incident.
Five months later the surgeon performed a recto-lower sig-
moid resection and sigmoid colostomy.The resected specimen
revealed adenocarcinoma extending into the perirectal tissues
with two nodes revealing malignancy. Following the surgery,
adjuvant 5FU was prescribed and given for approximately
four months.
Fivemonths after completionof the adjuvant chemotherapy,
and nowone year after surgical resection, a pulmonary nodule
showed on PET scan and was biopsied. The biopsy report
was positive for malignancy. An outside expert confirmed
the tissue was most consistent with metastatic disease from
the primary rectal carcinoma. Also at this time, the patient
developed cardiomyopathywith rather severe congestive heart
failure and atrial fibrillation.
The patient died approximately 1.5 years following his
diagnosis. The lawsuit subsequently filed alleged delay in
the diagnosis of rectal cancer by the primary care physi-
cian. After months of negotiation, they settled the case for
a large amount. The errors which led to this outcome are
clear in retrospect.
Abdominal Condition Diagnosis
Acute abdominal pain is oneof themost common symptoms
bringing patients to the emergency department. Appendicitis
can be easily missed if the clinical presentation isn’t classic,
as seen in almost half the cases. While overall mortality for
appendicitis is low (0.2 deaths per 100,000 cases), delay can
lead to perforation and an increased risk of death.
20
When
evaluating a patient with abdominal pain, an organized and
evidence-based approach should be utilized.
Acute abdominal pain of less than one to two weeks du-
ration accounts for up to 10 percent of admissions to the
ED.
21
Of those, 20 to 40 percent are admitted to the hospital
for investigation and symptom management. The reason for
the acute pain remains undetermined in approximately half
of these patients. The spectrum of diseases that present as
abdominal pain ranges from life-threatening to benign, and
often the diagnosis can’t be established in a single encounter.
It may be most prudent to exclude life-threatening etiologies
than to make a specific diagnosis.
A focused assessment is critical, related to the characteristics
of the pain, (location, quality, severity, onset pattern, radi-
ation and aggravating/relieving factors) presence or absence
of associated symptoms that are systemic, and those that are
organ-specific (e.g. nausea and vomiting or vaginal bleeding)
must be assessed. A general physical examination is essential,
as is noting vital signs blood pressure, heart rate, respiratory
rate, temperature andO2 saturation.The examshould include
inspection, auscultation, percussion and palpation of the
abdomen and external genitalia. A speculum and bimanual
pelvic examination may be indicated.
22
There are some myths related to the examination. First, is
that rebound tenderness is a good indicator of peritonitis.
Second, that all patients with abdominal pain should undergo
a digital rectal examination. Third, that administration of
opioid analgesics contaminates the examination. Trials con-
sistently demonstrate that giving morphine doesn’t alter the
physical exam, and in one study at Brigham and Women’s
Hospital inBoston, administration of intravenousmorphine
actually enhanced diagnostic accuracy.
21,22,23,24
The fourth is
that the White Blood Count (WBC) is an excellent indi-
cator for diagnosis of the acute abdomen. Plain abdominal
x-rays also have limited use. A clear indication, though, is
a suspected bowel obstruction.
21
Urinalysis is cheap, simple and readily available. Either the
dipstick test or routine analysis withmicroscopy exhibits high
yield when results fit with the clinical scenario. A screening
urine pregnancy test is recommended for all women of
child-bearing potential.
The two features that have the highest positive impact
on correct diagnosis are pain in the Right Lower Quadrant
