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Can you see this patient?” a nurse says. “I put him in room 26. He’s in agony. He needs something for pain.” I take the chart and meet James Chin (patient’s name changed). He’s in a wheelchair, hunched over. His clenched fist is pushed into his gut and an empty vomit bag is lying across his lap. His triage note is detailed, so I already know his tale of woe. Beginning earlier in the day, James developed abdominal pain that radiated into his back. He’s in his early 60s, so the most important thing to consider is a ruptured abdominal aneurysm, but many of his details are reassuring. Firstly, this isn’t the first time James has had this pain. He’s had it several times—it began a few years earlier and initially attacks were two or three times a year. Now, the pain returns every few weeks and although he’s been investigated, no cause has been identified. He was even seen by a gastroenterologist a year earlier and had a normal upper endoscopy. Although most episodes resolve within a day, this one has lasted three days during which he hasn’t been able to eat, nor drink, and has had intermittent bouts of vomiting. James’s vital signs also don’t suggest a ruptured aneurysm. They’re normal: his temperature is 36 degrees, his blood pressure 140 over 90, his heart rate 80 and his oxygen saturation 100%. Read: Don't get them started: Canada's worst forms “I’ll get you something for pain in just a minute,” I say. “But tell me first, in your words, what’s going on." He repeats his story—recurrent episodes of abdominal pain, investigated yet unexplained. He stops and breathes heavily, panting before continuing. “They usually subside after 12 hours but this has been steady for three days.” He stops again, trying to catch his breath. “I just need something for pain to get me through this episode.” “I can control your pain,” I say. “But what happens after that? Do you have any further follow-up?" Well,” he says. “I was hoping to get another CT scan today. I had one a few weeks ago, but my family doctor didn’t order it with contrast for some reason." Read: Templates, patients and scribes Because his nurse had handed me the chart and asked me to see him immediately, I didn’t have a chance to look up James’s history on our EMR. “I’ll look at the CT report,” I say before taking the rest of his history. Other than the abdominal pain, James is relatively healthy. He has high blood pressure and type 2 diabetes—both controlled with oral medication. He isn’t on insulin, hasn’t ever had any surgery, hasn’t smoked in 20 years and doesn’t drink. He does use weed occasionally, and I wonder whether or not anyone has suggested cannabinoid hyperemesis syndrome as the cause for his pain. "One of the doctors had mentioned it,” he says, “but really, I rarely use it. Maybe just once or twice a week." A history of stones James groans in pain, and I leave to find his nurse. She’s standing just outside the door with morphine and gravol in hand. “Tell him I’ll be right back,” I say, as I log on to a computer and look at his recent scan. Minutes later, I’m back in the room. “You’re right, your CT scan was non-contrast—your doctor was looking for a kidney stone.” “Oh yeah,” he says, “I have a history of stones too, but they didn’t find anything." I examine him in the wheelchair as he’s too sore to move to the exam table. He’s pale and his lips and tongue are chapped. He looks sick. He’s tender everywhere and his abdominal muscles tighten when I palpate. “I’ll order the contrast CT scan,” I say. “But no guarantees that I’ll find any answers today.” “I just need something for pain today,” he says. “Just to get me through this episode. My family doctor is arranging another scope with a GI. This time upper and lower.” Read: Treating pediatric constipation: Here’s the poop “Did they only do the upper scope before?” “It was really only upper abdominal pain before. Pain in my upper gut radiating to the back." “Is that what it is again today?” “Mostly,” he says. “Sharp and going straight to my back. But I feel it all over my abdomen.” “You’ve never been told you have an aneurysm, have you?” “No,” he says. “Why? Do you think that’s what it is?” I look at his vital signs again. “No.” It’s unlikely, but when I fill in the CT requisition and write his history, I don’t forget to leave out rule-out AAA. Just as I’m about to leave the room, I remember to ask for a medication list. “I don’t have a list,” he says, pointing to a plastic bag on the floor beside him. “But all my pills are in there.” I take the bottles out and scribble quickly—he’s on Nexium for his stomach, Norvasc and Ramipril for his blood pressure and two medications for diabetes: Metformin and Jardiance. “Nothing else?” I say. “Just Tylenol for my pain,” he says. “But that’s not touching it.” “The pain meds should kick in soon,” I say. “We’re going to get some blood work, the CT scan and give you some I.V. fluids." ‘Your scan is normal’ It’s busy in the department and it’s five hours before the scan is complete. “Your scan, Mr. Chin,” I say, “is normal. No cause identified for your recurrent episodes of pain.” “I’m not surprised,” he says. “How’s your pain?” “Almost gone.” I look at his blood tests. “Do you feel well enough to go home?” "I do,” he says. “Can I get a prescription for a few tablets just in case my pain comes back?” His creatinine is slightly elevated at one-fifteen, likely due to dehydration, but the blood tests were drawn before he received I.V. fluids. Other than that, his white count is elevated slightly and his sodium is down a few points. “Do you think you can keep fluids down when you go home?” “I should be fine now,” he says. “And if I’m not, I’ll just come back." Read: Reasons for joy: A reminder of the 10 classic reasons it's great to be a doctor I’m ready to agree with him and write him a prescription. His CT is normal, his vital signs are normal, and his blood tests are OK. But he still looks sick. While his pain is controlled, his lips and tongue are still parched and although his respiratory rate is documented as normal, he pants between words. “I don’t know,” I say. “How would you feel about getting more hydration, and maybe staying overnight until things settle?” He sighs. “If you think I should, then I will.” “I think you should.” Minutes later, I’m describing his case to the admitting doctor—recurrent abdominal pain, blood tests more or less normal, normal CT scan. “He needs admission?” my colleague asks. “He doesn’t look well,” I say. “His vitals are normal but he’s dry as a bone. And that’s after two litres of fluid. If nothing else, he needs hydration overnight.” “OK.” The next day, I’m back in the ER and James is still in the ER here, this time lying in a monitored bed. I check the screen and again, and his vital signs are normal. I check his chart—and his admission diagnosis surprises me: diabetic ketoacidosis (DKA). Although it doesn’t explain his abdominal pain, it explains everything else—the dehydration, the rapid respiratory rate (his body’s way of blowing off the excess acid in his blood), the normal blood work. Had I considered the diagnosis at the outset, I would have ordered a blood gas, but I was focused on his abdominal pain. How long have you been on Jardiance?” I ask him, identifying the culprit-medication that causes acidosis—a severe complication of diabetes that until recently was almost exclusively associated with insulin. What makes this such a tough diagnosis is that while patients become dehydrated and acidotic, their glucose levels don’t skyrocket as they do when insulin causes this same, sometimes fatal condition. “Just a couple of weeks,” he says. “My doctor put me on it to help control my sugars.” “Well,” I say. “I’m happy I didn’t send you home.” I text the admitting doctor: Great call on the euglycemic DKA. I didn’t think of it, even though I knew he was on Jardiance. Text came back: I didn’t think of it either until I was dictating my note. Things didn’t sit well. I’m glad he’ll be OK. Had I sent him home, he may not have fared as well. I text him again: me too. Thx. Two weeks after discharge, he sees the GI specialist and is scoped again, up and down. No clear cause for his recurrent episodes of pain is found. Dr. Raj Waghmare is an ER physician in Newmarket, Ont.

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