A 75-year-old man presents to urgent care with severe abdominal pain that began more than 8 hours ago. He is holding his stomach in agony and can barely ambulate. He describes low-grade fever, chills, and one episode of nausea and vomiting that occurred when the pain began. He took ibuprofen at home for his pain, with minimal effect. He denies urinary symptoms, back pain, diarrhea, or rectal bleeding. He has a history of diverticulosis, hypertension, and chronic kidney disease (stage 3).
On physical examination, his vital signs are: temperature, 101˚F; heart rate, 102 beats/min; blood pressure, 138/80 mm Hg; respiratory rate, 18 breaths/min; and SpO2, 97% on room air. He has marked tenderness in the lower quadrants of his abdomen with mild guarding, no rebound, and decreased bowel sounds. He has no palpable masses and no costovertebral angle tenderness. The CBC that you ordered indicates mild leukocytosis; his baseline creatinine is elevated, which is consistent with known chronic kidney disease. His urinalysis is unremarkable. Since your urgent care clinic has the capability, you order CT imaging with IV contrast, which reveals segmental colonic wall thickening with pericolic fat stranding in the sigmoid colon and a 4-cm pericolic collection with rim enhancement that is consistent with a pericolic abscess. Imaging does not show free air or evidence of perforation.
Which of the following is the most appropriate next step in managing this patient?
- Refer him to the emergency department for IV antibiotics, pain control, and specialty consultation.
- Give him a dose of ceftriaxone 1000mg IM and observe him for 3 hours in the clinic.
- Prescribe oral antibiotics and discharge home.
- Discharge him home with over-the-counter acetaminophen for pain, a clear liquid diet for 2 days, and instructions to schedule a follow-up appointment with his gastroenterologist.
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Correct Answer: d. Discharge this patient home with over-the-counter acetaminophen for pain, a clear liquid diet for 2 days, and instructions to schedule a follow-up appointment with her gastroenterologist.
You conducted a careful and thorough physical examination to determine the cause of this patient’s abdominal pain. Her symptoms were suggestive of an uncomplicated diverticulitis flare. Given her stable vital signs, absence of peritoneal signs, and relatively mild symptoms, you followed current evidence and guidelines that support not prescribing antibiotics for select patients with uncomplicated diverticulitis who are otherwise healthy and immunocompetent.
Your discharge instructions also included explicit return precautions should her symptoms worsen or fail to improve in the next 48 to 72 hours. You informed your patient that the clear liquid diet and analgesic will provide relief of her symptoms in the short term; however, you reminded her that improving her diet to include more fiber and a probiotic, being more active, and drinking more water will improve her long-term outcome.
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Tracey Davidoff, MD, FACP, FCUCM, has practiced Urgent Care Medicine for more than 15 years. She is Board Certified in Internal Medicine. Dr. Davidoff is a member of the Board of Directors of the Urgent Care Association and serves as Co-Editor-in-Chief of the College of Urgent Care Medicine’s “Urgent Caring” publication. She is also the Vice President of the Southeast Regional Urgent Care Association and a member of the editorial board of the Journal of Urgent Care Medicine. At EB Medicine, Dr Davidoff is Editor-In-Chief of Evidence-Based Urgent Care, and co-host of the Urgentology podcast.
