Unusual Presentations

A 45 year old hispanic female reports to the ER complaining of right sided abdominal pain. This is her third visit to the ER. The first visit was by ambulance one month previously, and she was discharged after observation and treatment for nausea and constipation. Labs were insignificant except for a UDS of methamphetamines and opiates. The second visit occurred two days later, with treatment of nausea and discharge. This is her third visit, she reports nausea, constipation and abdominal pain. Physical exam shows minimally distended abdomen that was tender to palpation. Labs were ordered, as was an abdominal CT. Labs were essentially negative, including the HCG. However, patient did have cholelithiasis and nephrolithiasis. At this time, patient is discharged with pain medicine and follow up.
Now she is in your ER the next day complaining of right sided abdominal pain. She has a history of diabetes and hypertension. She has had one laparotomy and an appendectomy. She denies taking any medication but the pain medication given. Vital signs are stable. Abdomen is diffusely tender, worse over the right lower and upper quadrant. What do you do?

Patient was discharged with follow-up, and returned the next day. At this time, she was admitted for pain control then discharged. She returned once more and expired.

I'm sure most people have heard the story of Edith Rodriguez and King-Harbor. I present this, not to discuss the many socio-economic factors involved, but to highlight the medical pathology. The autopsy report is at: http://www.latimes.com/media/acrobat/2007-06/30524153.PDF
According to the autopsy, the patient's death was caused by a ruptured colonic diverticulis. This is an interesting presentation, considering the patient seemed to only complain of right sided pain, and most cases of diverticulits result in left sided pain. Also, the case is a classic example of not "marrying a diagnosis." The patient did have another cause for her pain- multiple gallstones. The CT, a major tool for evaluating the abdomen, also seemed to be otherwise negative from the report, so how should further evaluation proceed? On ER visits and during the admission, should she be expectantly managed with serial exams, or would an ex lap have been appropriate? Assuming the exam did not show an acute abdomen, would surgery have been recommended, or would medical management with pain medicine and a surgical follow up have been more appropriate. Did the patient continue to not exhibit a classic acute abdomen? Were there signs of infection that we would have expected with diverticulitis?

We do not have information other than the autopsy and news reports, and cases are easier to examine in hindsight. However, often in medicine, the way to learn is from your mistakes. Right sided pain due to diverticulitis is an unusual presentation, and it is also wise to note that diverticulitis can lead to bowel perforations and can be fatal.