Re: F/U on TOAs with IUD in place
From: Efrain Ramirez MD (eramirez@icepr.com)
Fri May 29 13:07:56 1998
Give us more feedback!!
At Tue, 26 May 1998, Caryn Rybs wrote:
>
>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 ...)
--
Efrain Ramirez MD FACOG
