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Part 3 Step 2: Data CollectionSeeking InformationThis is the data…

- - - - We would do a wet mount to check for white blood cells, trichomoniasis, clue cells and as the majority of Fitz-Hugh-Curtis Syndrome cases are caused by STIs, especially chlamydia & gonorrhea. We can consider a portion of the STI panel of $250. to start with (chlamydia & gonorrhea) and direct the patient to a free/low cost outpatient clinic for the HIV and other testing in the near future.
    - - We no longer think that a TVUS is necessary, as PID can be presumptively diagnosed with the constellation of her symptoms, a pelvic exam and a wet mount.
    - - We no longer think a CT scan is necessary, unless she has signs and symptoms indicating that she has a surgical emergency occurring, not just PID.
    - - We no longer think a laparoscopy is needed, as we can treat the patient for PID as indicated and monitor her closely for 72 hours: if she has un-resolving F/chills or cervical motion tenderness- then she will need laparoscopy and possible surgery.
- - - - epigastric pain/tenderness, guarding, and distention. (Osmosis from Elsevier, 2023)
      - Echymosis
        
        Grey-Turner’s sign: flank echymosis (Vege S., 2022)
        
        Cullen’s sign: periumbilical echymosis (Vege S., 2022)
        
        Fox sign: ingenial echymosis
        
        Bryant sign: scrotal echymosis
      - Palpable mass can indicate pancreatic pseudocyst (Osmosis from Elsevier, 2023)
      - Nausea/vomiting (Vege S., 2022)
      - Ascites (Osmosis from Elsevier, 2023)
    - - Tachycardia, hypotension, fever hypoxemia (Vege S., 2022)
        
        These can indicate a complication of acute pancreatitis from damaged blood vessels leading to hemorrhage then hypovolemic shock. (Osmosis from Elsevier, 2023)
    - - Jaundice: Indicates biliary obstruction (Osmosis from Elsevier, 2023)
    - - ARDS is associated with severe pancreatitis. (Osmosis from Elsevier, 2023)
    - - Tetany: resulting from hypocalcemia (Osmosis from Elsevier, 2023)
  - - - can be added on if other labs are elevated.
        
        Determine Cause
        
        Gallstone pancreatitis
        
        Elevated Total and direct bilirubin (Osmosis from Elsevier, 2023)
        
        Elevated LFTs (Osmosis from Elsevier, 2023)
        
        TRIGLYCERIDES
        
        Elevated triglycerides may indicate hypertriglyceridemia-induced pancreatitis (Osmosis from Elsevier, 2023)
      - acute pancreatitis can result in pt's conditions so this is a nessecary test
        
        Confirm diagnosis
        
        lipase (normal: 0-160 U/L)
        
        Lipase levels elevated 3 times above normal upper limit w/ or w/out amylase (Vege S., 2022)
        
        amylase (normal: 23-85U/L)
        
        Elevated 3 times above normal upper limit (Vege S., 2022)
    - - abd CT will show us why her abd is distended and allow us to visualze and r/o or confirm many ddx.
        
        abd CT scan w/ contrast
        
        Looking for necrosis, inflammation or blockages (Osmosis from Elsevier, 2023)
        
        Peripancreatic free fluid (Osmosis from Elsevier, 2023)
        
        Fat stranding (Osmosis from Elsevier, 2023)
        
        Pancreatic edema (Osmosis from Elsevier, 2023)
        
        Enlarged pancreatic duct (Osmosis from Elsevier, 2023)
      - CT would be more conclusize
        
        ultrasound
        
        To detect gal stones or sludge in gallbladder, biliary tree (Vege S., 2022)
    - - Endoscopic tests
        
        Endoscopic retrograde cholangiopancreatography (ERCP) (Osmosis from Elsevier, 2023)
        
        endoscopic ultrasound (EUS) (Osmosis from Elsevier, 2023)
  - - - Clinical presentation of epigastric abdominal pain (Osmosis from Elsevier, 2023)
      - Labs showing elevated lipase or amylase 3 times above upper normal limit (Osmosis from Elsevier, 2023)
      - Imaging evidence of pancreatitis (Osmosis from Elsevier, 2023)
- - - - Fatigue, Lightheadedness
      - Mood changes
      - Nasal Congestion
  - - - Human chorionic gonadotropin (hCG) - in blood or urine, detectable 8-10 days after ovulation at time of implantation. Levels double every 29-52 hours during the first 30 days and peak at 8-10 weeks.
        
        Cost Not Listed - Research showed the average out of pocket cost of a blood hCG test to be $50 - this is the most accurate for diagnosing pregnancy. Patient can follow up at low cost pregnancy clinics. Information can be provided by the hospital case manager or social worker.
      - Increased neutrophil count
    - - US
        4.5 - 5 weeks - Gestational sac
        5-6 weeks - yolk sac
        5.5-6 weeks - embryonic cardiac activity
        6-7 weeks - measurable embryo
        
        Cost Unknown - Not needed for diagnosis of pregnancy unless there is thought to be a complication. Offered at low income clinics like planned parenthood for an average of $100-150
- - - - Uncomfortable, with malaise, and altered sensorium- especially the latter should raise suspicion for calcium excess when combined with nausea and vomiting.
    - - No specific abnormalities but patients may have tachycardia due to dehydration. Blood pressure to be monitored due to kidney impairment, especially in patients taking diuretics (volume depletion) and ACEI/ARB/NSAIDS (GFR reduction)
    - - Routine abdominal exam. There are no specific findings for Milk Alkali Syndrome.
    - - Mental status exam with orientation, as patients classically/acutely present with confusion/impaired concentration, even psychosis.
  - - - NOTE: COST UNKNOWN We can hold off on this test, do the BMP first, hydrate the patient with IV fluids, attempt to normalize the calcium level with IV loop diuretic, and monitor the calcium level every 2-4 hours to see if it is normalizing. The patient would also be expected to return to normal sensorium if this was the correct diagnosis, which is one of exclusion. If she is not improving, more expensive testing would have to be performed to determine the cause of the hypercalcemia.
- - - - Instead we will perform a blood test. A blood sample analysis may reveal an active or previous H pylori infection
    - - https://www.youtube.com/watch?v=dViLAA43mzM
- - - - Rome IV criteria
        
        These occur 1 day per week in last 3 months and pt reports 2 of the following 3 (Fagel F et al., 2023)
        
        Abd pain related to defecation (Fagel F et al., 2023)
        
        Change in stool frequency (Fagel F et al., 2023)
        
        Change in stool form (Fagel F et al., 2023)
    - - R/O non-malignant GI conditions
        
        Labs
        
        Cbc: anemia, infection (Fagel F et al., 2023)
        
        ESR & CRP: inflammation (Fagel F et al., 2023)
        
        TSH: thyroid dysregulation (Fagel F et al., 2023)
        
        tTg-IgA: celiac disease (Fagel F et al., 2023)
        
        Fecal calprotectin: colonic inflammation (inflammatory bowel disease) (Fagel F et al., 2023)
- - - - Liver abscess culture
      - CBC with differential: identify anemia
      - Liver function tests: may find hypoalbuminemia and elevated alkaline phosphatase; transaminase and bilirubin may also be elevated
    - - Ultrasound: looking for hypoechoic or hyperechoic areas, gas may be present
        
        US - cost unknown - could be used for initial diagnosis if labs and physical assessment point to liver abscess. Could perform an US guided aspiration at the same time.
      - CT: showing distinguished mass, may show gas, double target sign (central fluid-filled lesion surrounded by high attenuation inner rim and low attenuation outer ring)
        
        Necessity Unknown- may be necessary for diagnosis if patient laboratory findings are suggestive of sepsis
    - - Technetium scan: can detect small lesions,
      - Gallium scan
      - Indium scan
- - - - Jaundice skin and sclera
      - Fatigue and weakness
      - Weight loss
      - Spiderlike blood vessels on the skin
      - Puritis
      - Edema of legs
    - - Presence of Hepatomegaly on exam
      - Presence of ascites
      - Dull aching pain in the RUQ of the abdomen
      - Abdominal assessment for presence of pain in the RUQ, hepatomegaly and ascites
    - - Mental confusion
  - - - AST - mild to moderate elevation, typically 2-5x the upper limit of normal (10-34 U/L)
      - ALT - mild to moderate elevation, typically 2-5x the upper limit of normal (10-130 U/L)
      - ALK - may be 2-3x the upper limit of normal (24-146 U/L)
      - Serum Albumin may be abnormal in patients who have developed cirrhosis (32-25 g/L)
      - Serum Bilirubin may be elevated in patient who have developed cirrhosis (3-22 mmol/L)
      - Serum Transferrin Saturation is elevated - 1.5x the upper limit of normal (215-380 mg/dl)
        
        Expensive and not difinitive NAFLD
      - Positive Serum Antibodies - a low titer may be present ANA (<1:320)
        
        While helpful is not difinitive of NAFLD and is expensive
      - CBC, CMP and Lipid Panel would cover the basics for identifying a liver concern for the least amount of money
    - - https://www.youtube.com/watch?v=XIvqfwBJIUQ
        
        Cost unknown - not needed for initial diagnosis of NAFLD
    - - CT - while helpful in diagnopsing NAFLD, is not necessary in initial diagnosis
    - - MRI is not necessary for diagnosis fo NAFLD
    - - Histologic findings - >5% steatotic hepatocytes in the liver tissue section
      - Biopsy, while the gold standard is not necessary for initial testing and treatment of NAFLD
    - - Test done lat later time - after diagnosis is made to determine the degree of fibrosis - not diagnostic
- - - - Percussion - hyperresonance or tympany
      - Palpation - palpable mass may indicate abscess, volvulus or tumor as source
  - - - https://www.youtube.com/watch?v=4su7Gj6wyLg
      - Instead, we will perform an X ray as this is much less expensive than an X-ray. We will discuss the importance of this test with the patient and will provide resources for financial assistance if possible.
    - - Metabolic Alkalosis - from severe vomiting
      - CBC - Leukocytosis with neutrophil predominance, or leftward shift, may indicate presence of obstruction. Anemia may point to etiology.
      - Electrolytes - BUN/Creat abnormalities may indicate presence and severity of hypovolemia and metabolic abnormalities such as hyponatremia and hypokalemia
      - Metabolic Acidosis - from bowel ischemia
      - Lactate - sensitive for mesenteric ischemia
      - Blood Cultures - bactermia and septicemia in presence of perforation
      - Procalcitonin - sensitive for detecting intestinal strangulation