Wisconsin – Emergency Medicine – Fever, Elevated WBC, And Abdominal Pain Diagnosed As Possible Mittelschmerz

On 7/8/1999, a 13-year-old patient presented to an urgent care clinic at a hospital complaining of back pain, right lower quadrant abdominal pain, and with a fever of 101 degrees.  The patient was five feet tall and weighed 265 pounds.  The nurse’s examination notes state that the patient’s abdomen was round and firm, and that it was soft.  A family practitioner assessed the patient’s abdomen as soft with positive bowel sounds and lower right quadrant tenderness.  The family practitioner noted in the patient’s chart that her pulse rate was 120 per minute, and that her respirations were 32 per minute.

The family practitioner ordered laboratory analysis of a blood sample.  In his documentation, the family practitioner stated “[w]hite count is bizarre with a 5700 white count, 24 neutrophils, 32 bands.  Reactive lymphs are increased.”  The family practitioner ordered two radiographs, a flat plate, and an upright, which he read as “basically unremarkable”.  Three radiographs were taken of the patient. The family practitioner did not learn that the third x-ray film had been taken until sometime after that day.

The x-ray films taken of the patient were read the next day by a radiologist, who noted free air in the abdomen.  The radiologist noted the following in his report: “Impression: Findings consistent with free air under both diaphragms with several associated slightly distended loops of small bowel.  These findings were called immediately to the Treatment Center and discussed with [a physician].”

The family practitioner prescribed Toradol 60 mg IM, for pain, and assessed the patient’s condition as “Probable Mittelschmerz.”  Mittelschmerz is a condition of pain on ovulation; it lasts approximately six to eight hours, and is not accompanied by any notable fever, or by rapid pulse or respirations, or an increase in immature white blood cells in circulation.  The patient’s temperature, band count, pulse rate, and respiration rate were all significantly elevated.  An internal pelvic examination, pelvic ultrasound, or CAT scan was not performed when the patient presented at urgent care.

Prior to releasing the patient to go home, the family practitioner consulted with a surgeon regarding the patient’s symptoms and health status.  The family practitioner did not determine that the patient had free air in her abdomen and, therefore, did not inform the surgeon of its presence.  The family practitioner did not ask surgeon to come to the hospital to examine the patient, or to come to the hospital to examine the radiographs of the patient.  A minimally competent family practice physician would call a surgeon to the hospital to examine the patient and keep the patient in the hospital under close observation when free air is observed in an abdominal radiograph.

The family practitioner released the patient to go home with her mother, with instructions to contact the surgeon if her condition got worse overnight; finish taking her Macrobid; to consume “clear liquids tonight only”; to return to the clinic the following morning to undergo another complete blood count (CBC), and, if not better, to see the surgeon the following day.  The family practitioner also prescribed Naprosyn 500 bid for pain.

The family practitioner’s decision to send the patient home with a diagnosis of Mittelschmerz exposed her to the grave risk of an untreated surgical emergency, when the minimally competent physician would have begun prompt medical intervention and preparations for surgery.

The family practitioner noted the following in the patient’s chart:

SUBJECTIVE: This is a 13-year-old white female, very heavy 265 pounds with temperature 101 today.  Seen and put on Microbid and Pyridium Saturday for UTI.  Continues to have back pain and fever, right lower quadrant pain today, mucousy stool, usually is soft, a little harder today.

OBJECTIVE: Temperature 101, went down with Tylenol.  Pulse 120, respiratory rate 32.  Head: Normocephalic, atraumatic.  Eyes: PERRLA.  Tympanic membranes intact. Abdomen is soft.  Positive bowel sounds.  Right lower quadrant tenderness. She is two weeks post-period.  White count is bizarre with a 5700 white count, 24 neutrophils, 32 bands.  Reactive lymphs are increased.  Flat plate and upright are basically unremarkable.

ASSESSMENT: Probable mittelschmerz. She got excellent relief with Toradol in the treatment center and was able to hold down some Sprite.

PLAN: Naprosyn 500 bid, finish her Macrobid.  Clear liquids tonight only.  If any worsening tomorrow, mom is a nurse on 2 South, she will see [the surgeon] in the morning. I discussed the case with him and he said to watch it tonight and he will deal with it tomorrow if there is any increase in pain.

While at home, the patient vomited throughout the night and aspirated.  She was brought to the urgent care clinic the next morning, with cold and mottled skin, shallow panting respirations, and mental confusion.  She required resuscitation in the urgent care, and was taken directly to the operating room. The surgeon’s impression was: “septic shock, probably due to perforated viscus”.

The operation disclosed a tubo-ovarian abscess with large quantities of pus in the intraperitoneal cavity. The patient suffered two cardiac arrests during the operation, from which she was resuscitated, and two episodes of bradycardia, with resuscitation. She was taken to the intensive care unit with adult respiratory distress syndrome, renal failure, hemodynamic instability, and died early the next morning from cardiac arrest with ventricular fibrillation that could not be corrected.

The patient’s discharge summary report dictated after the operation stated the following regarding the patient’s diagnosis: Preoperative diagnosis: ABD Pain.  Final Diagnosis: 1) marked chronic salpingitis with fibrosis; 2) ovarian abscesses with acute fibrinopurulent peritonitis change.

The Board ordered the family practitioner pay the costs of the proceeding, be reprimanded, and complete 24 hours of continuing education in abdominal diagnosis, evaluation and management, including pediatric or adolescent patients.

State: Wisconsin

Date: August 2005

Specialty: Emergency Medicine, Family Medicine, Gynecology, Internal Medicine, Pediatrics

Symptom: Fever, Nausea Or Vomiting, Abdominal Pain, Back Pain

Diagnosis: Acute Abdomen, Sepsis

Medical Error: Diagnostic error

Significant Outcome: Death, Hospital Bounce Back

Case Rating: 5

Link to Original Case File: Download PDF

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