FROM THE BLOGOSPHERE
KEEP YOUR Differential Broad
Patrick Barrett, MD
I
had a case in our
department that I
won’t forget for a
while. It remind-
ed me to keep my
differential broad even
if the suspected diag-
nosis seems blatantly
obvious. An early 40’s female presented to
our ER about 5 days after an MVC in which
she was the restrained driver, where the
car rolled onto its side going about 40s-50s
MPH. She lost consciousness, and airbags
deployed. Paramedics arrived on scene after
a while when she was up and walking, and
she refused to be taken to the ER. Over the
following 5 days, she had near constant neck
pain as well as a worsening headache and
worsening abdominal and rib pain on the
lower left side.
She presented to our ER in a hallway bed,
where her initial HR was in the mid 80s,
but BP was 80s/40s on multiple checks. O2
sat and temperature were normal. Mental
status was normal, and there were no phys-
ical signs of trauma on her body. She had
tenderness to the L lower and lateral ribs, as
well as LUQ/LMQ abdominal tenderness,
and lower midline C-spine tenderness. I
quickly had her placed in a cervical collar,
and brought the ultrasound to bedside and
performed a FAST (Focused Assessment
with Sonography in Trauma), which was
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LOUISVILLE MEDICINE
negative, to my surprise. I ordered fluid
boluses, trauma labs, type and crossmatch,
and planned to send her for a man scan, but
her kidney function showed an AKI and
therefore had to wait for one fluid bolus
before she could go to the scanner. BP slowly
started to trend upwards, but not reaching
over mid 90s systolic before she went to
the scanner. Of note, she did have a slightly
elevated white count in the mid-to-upper
teens. My differential? Trauma, trauma,
trauma. She has to be bleeding somewhere,
she may have a fractured C-spine, intracra-
nial injury, intraabdominal injury, likely
splenic laceration - My FAST just must not
have picked it up.
Given the history and clinical circum-
stance, I don’t think I was badly wrong for
not having anything else on my differential
for this hypotensive patient with concerning
physical exam findings 5 days out from a
serious car accident. But once her man scan
was done, I looked though the imaging and
noticed her right kidney was heterogenous
with contrast enhancement with stranding
around it. She had no fluid in her pelvis,
and the rest of the man scan was entirely
negative. Radiology soon called and said she
had the “worst case of pyelonephritis I think
I’ve ever seen.” A urine sample was finally
collected after the scan resulted, which was
(no longer to my surprise) infected. When
I asked the patient, she denied any dysuria
or frequency, but said her urine had been
“green” this morning. She never had any
suprapubic pain.
That is the story of how I admitted a pa-
tient to medicine for pyelonephritis after
getting a man scan and diagnosing it on CT.
I don’t think I’ll be changing the top item
on my differential, but I think I will keep
other causes of hypotension and shock on
my differential until they are ruled out in
cases of delayed trauma presentation, such
as this one.
Patrick Barrett is a resident at the Univer-
sity of Louisville Department of Emergency
Medicine.
This blog entry was featured on Room 9
Blogs, a blog for ER Residents. You can view
other entries at www.room9er.com