CPC Case: The Diagnostic Crisis

Patient Profile

This section establishes the baseline for a 30-year-old female presenting with right lower quadrant pain. Understanding her background is critical: note her young age contrasted with a significant history of poorly controlled hypertension.

Patient Demographics

30-Year-Old Female

Nationality Filipino
Parity Nulliparous
Habits Non-smoker/drinker

Medical History

Hypertension (2020)

Poorly controlled on 3 medications. History of "Hypertensive Emergency" 2 years prior.

Family History

Significant history of hypertension (Parents to Grandparents).

Chief Complaint

Right Lower Quadrant (RLQ) Pain (Onset: 2 days prior to admission).

Review of Systems & Physical Exam

Weight Loss

10% loss reported

Fever

Temp 38°C at ER

Abdominal Pain

RLQ, Direct/Rebound Tenderness

Headache

Review of Systems (+)

Palpitations

Review of Systems (+)

Jaundice

Negative

Vomiting

Negative

Myopathy

Proximal/Distal (-)

Clinical Course Timeline

Trace the patient's short journey from admission to the fatal event. Note the stability in the wards contrasted with the sudden collapse during induction.

Day 0

Admission

Patient admitted for workup of RLQ pain. Initial impression: Appendicitis vs. other acute abdomen. Vital signs elevated (BP 160/90) but patient stable.

Day 1-3

Ward Course

"Unremarkable course in the wards." Patient was prepped for surgery (Appendectomy).

Day 3 - Pre-Op Area

The Induction Crisis

Upon anesthesia induction, patient became diaphoretic. Sudden hemodynamic instability.

BP Spike: 240/120 mmHg
HR Spike: 180 bpm (Irregular)
Desaturation: 85%

Post-Crisis

ICU & Outcome

Operation deferred. Admitted to ICU. Started on Nicardipine drip. Intubated. Patient became unresponsive. ACLS unsuccessful. Patient pronounced dead. Autopsy requested.

The Anesthesia Crisis

Interact with the monitor below to visualize the physiological storm that occurred during induction. This sudden shift is the key diagnostic clue.

Simulate Patient State

Hemodynamic Monitor

STABLE

Diagnostic Evidence

Review the objective data gathered upon admission and during the ICU workup.

Hematology Trend (Admission vs ICU)

Note the drop in Hgb/Hct (Hemoconcentration resolution or blood loss?) and slight rise in WBC.

Electrolytes & Chemistry

Parameter	Admission	ICU Workup	Change
Sodium (Na)	148 mmol/L	139 mmol/L	Normalized
Potassium (K)	3.4 mmol/L	3.9 mmol/L	↑ Slight
Creatinine	1.9 mg/dL	-	Elevated

Urinalysis (Admission)

Specific Gravity 1.005

Pus Cells 3-5 /hpf

RBC 0-2

Protein/Glucose Negative

Case Analysis: The Diagnostic Dilemma

The patient presented with abdominal pain, but died of a hypertensive crisis. Connect the clues to formulate your differential.

1. Identify the Pattern

Click the findings present in this case:

2. Formulate Differential

Trigger Event: Anesthesia Induction

Induction agents or physical stress can precipitate massive catecholamine release in certain tumors.

Diagnostic Consideration: Pheochromocytoma

Why? Young hypertensive, paroxysms (headache/palpitations), precipitated by anesthesia, "Classic Triad".

RLQ Pain? Could be mass effect from a large adrenal tumor or concurrent appendicitis.

Diagnostic Consideration: Thyroid Storm

Why? Fever, Tachycardia, weight loss.

Why unlikely? BP usually has wide pulse pressure, not predominantly diastolic hypertension. No goiter mentioned.

Diagnostic Consideration: Malignant Hyperthermia

Why? Occurred at induction, fever, muscle rigidity (though not explicitly stated, myopathy was negative).

Caveat: Usually presents with CO2 retention first. BP spike less characteristic than temp spike.

Case material derived from 8th CPC-MD3 Student Copy. Autopsy results pending clinical correlation.

CPC Case: MD3