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F/U on TOAs with IUD in placeFrom: Caryn Rybs (CarynRybs@aol.com)Tue May 26 21:44:56 1998
Thanks for all of the responses to my post... My patient continues to spike fevers as high as 102.7 today just a few hours ago. She actually looks well for that high of a spike maintaining her BP, pulse is in the 110s and U.O is good. Exam is still not all that impressive- just mild tenderness, no peritoneal signs. Forgot to mention originally that she is pretty obese, about 300#, so not surprised the admitting resident-2nd year night float- couldn't feel her masses. The IUD by sono looked like a Copper T380 and we got a flat plate as suggested by my attending to further eval it. It's deviated to the left, almost at a 45 degree angle to the uterine long axis... Nevertheless, we did try to remove her IUD today using a cytobrush, hook and some forceps without success! Made her NPO after midnight hoping we can take her to the OR for a full sweep tomorrow, but we'll see... I don't get the sense that anyone is too excited about operating on her except me- the least experienced on the team I might add... I should probably learn from their hesitation... I did switch her antibiotics over to Amp/Gent and Flagyl instead of Clindamycin today since my chief approved (The covering senior resident yesterday disagreed with me despite my concern over C diff possibility given the diarrhea) The toxin and cx are still pending. Blood and cervical cx are neg so far... The other worrisome thing with this patient is that last night she started talking to herself and became very agitated, had an incontinent episode in the bed, after which she took off all of her clothing as well as bedding and was uncontrollable... The cross-cover who admitted her now elicited a hx of her taking haldol and cogentin before even though the pt denies a psychiatric past. She got Haldol 5 mg total last night and this AM was still snowed. Psych saw her but says she is too sedated to get a hx from her yet... The patient is certainly very odd to say the least and I have strong suspicions that she has more than one DSM-IV diagnosis, especially psychosis... So the plan from my staff today is "more time and if no response, IR to eval and possible surgery"... Reminds me of my night float a few months back when the Gyn service had 4 patients with TOAs on their ward for about a week and I knew that I was going to be up all night seeing their q 4 hr fever spikes until they got drained or operated on and got better... By the way, I think I mentioned that the patient declined i.e.refused HIV testing... We need informed consent to order this in California... Do some of you order without or against your patient's wishes? One last bit, I was called this afternoon to see this patient in the ER who also had an IUD in for 8 years, came in for anemia sxs with heavy VB x 3 weeks and foul vaginal discharge. Orthostatic with Hb of 8. Exam showed this 6 cm necrotic foul smelling complex mass in her vagina (couldn't see a cervix but could palpate it so the mass seemed to be protruding through her os) that was literally covered with this nasty black tar-like paste and fibrinous material which smelled like stool. (I was just praying this wasn't bowel I was looking at but no RF for a fistula) The IUD was imbedded within this presumed necrotic prolapsed fibroid and I retrieved that and cx'd it and bx'd the mass... Not bleeding now. No h/o fibroids... Uterus small. Febrile to 101.7. Admitted her for blood transfusion and started Gent/Clinda and scheduled her for the OR in am but my chief wants to wait for the bx results before operating... We do see some interesting things I must say... Just glad I'm at home because I'm sure the night float will be called soon enough on their fevers :-) Caryn Rybczynski (known in my program and by my patients as Dr. Rybs ...)
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