# Abdominal pain



## Clare (Mar 3, 2013)

You are sent to a 37 year old Asian female who is complaining of abdominal pain.  The call has been categorised as "urgent/potentially serious".  

O/A she is sitting up on the master bed with her husband and doesn't look sick (passes the "end-of-the-bed-oscopy")

C/O 4/24 generalised abdominal pain in all quadrants and some nausea but no vomiting 

Previous history NAD, smoker (but trying to quit), gynae history is G1 P1, vaginal birth, menstural NAD - last +/- 3/52 ago, IUD

O/E ABC OK, BP 140/100 PR 80 RR 12 SpO2 99% RA T 37.5 ECG SR 

Abdo generalised tenderness, no distention, no guarding, no organomegaly, bowel sounds present, no discolouration (Greys sign), some mild pain upon percussion.  

GUI, CVS, Resp NAD, pedal pulses present, some light vaginal discharge but this is said to not be anything different from her normal period.

The patient states the pain is (again) generalised to all quadrants, it is not a tearing pain, does not radiate to the back, is 3/10, does not get worse or better with movement or rest and is not cardiac pain.

Most recent meal was this morning and before that the family ate at a Mexican restaurant the previous evening where she had chicken enchiladas.

Questions 

(1) Do you see any "red flags" in the information presented? What? Why?
(2) What is your provisional diagnosis? 
(3) Can this patient be safely left at home? Why or why not?

This is my first time doing this so I hope I have given you the information you need, if anything is missing please ask.


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## Milla3P (Mar 3, 2013)

The IUD, depending on how long it's been in, could be. I've run into a few that we're overdue for removal/replacement that have caused similar situations. 

She should be seen eventually but doesn't sound super emergent...


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## Clare (Mar 3, 2013)

Milla3P said:


> The IUD, depending on how long it's been in, could be. I've run into a few that we're overdue for removal/replacement that have caused similar situations.
> 
> She should be seen eventually but doesn't sound super emergent...



So are you thinking it has become infected or something?

If she needs to be seen "eventually" would you say she is safe to be left at home and seen say, the next day when her GP can see her, or does she require immediate referral to ED where she can be seen by a Gynae/Gynae Registrar?


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## VFlutter (Mar 3, 2013)

My Ddx is pelvic inflammatory disease vs Gastroenteritis. 

I would personally transport but I would entertain an argument to allow her to follow up with her PCP the next day. I would feel more comfortable getting diagnostics and starting antibiotics sooner than later. There a few zebras that present with similar symptoms. 

When did this all start? Before or after the meal. 

History of STDs or painful intercourse? 

The IUD is a red flag. Hopefully it didn't perforate the uterus


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## Clare (Mar 3, 2013)

It started after her meal; she ate last night at 6 pm and it started 4 hours ago; lets say it is the following afternoon so 18 hours ago?

No history of painful intercourse, there might, might have been an STD 20 years ago but that's a bit difficult to elicit.

The IUD went in after her child was born 2 years ago so is not due for replacement.


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## Veneficus (Mar 3, 2013)

Clare said:


> You are sent to a* 37 year old Asian female *who is complaining of abdominal pain.  The call has been categorised as "urgent/potentially serious".



This is way too young for her BP, and considering that she is asian, the HR of 80 is probably relatively tachy.  



Clare said:


> O/A she is sitting up on the master bed with her husband and *doesn't look sick *(passes the "end-of-the-bed-oscopy")



Asian women hardly ever look sick or pregnant.



Clare said:


> C/O 4/24 generalised abdominal pain in all quadrants and some nausea but no vomiting")



Sounds more GI, but still possibly early sepsis or endomitriosis or endomitritis. Leaning towards GI. 



Clare said:


> Previous history NAD



This makes the BP more concerning.



Clare said:


> smoker (but trying to quit),



Cmon, you did such a good job with this compared to what we normally see here and you don't have a pack/year assessment?



Clare said:


> gynae history is G1 P1, vaginal birth, menstural NAD - last +/- 3/52 ago, IUD



The IUD is nagging won't let me write off inflammation of gyn origin. 



Clare said:


> O/E ABC OK, BP 140/100 PR 80 RR 12 SpO2 99% RA T 37.5 ECG SR



That is a red flag.



Clare said:


> Abdo generalised tenderness, no distention, no guarding, no organomegaly, bowel sounds present, no discolouration (Greys sign), some mild pain upon percussion.



This is another red flag, it is indicative of viceral pain, and not peritoneal distension, pointing to specific organ pathology.

Pain on percussion where?

If she is of slight build did you try palpating ovaries, uterus, or renal stones transabdominally?  



Clare said:


> GUI, CVS, Resp NAD, pedal pulses present, some light vaginal discharge but this is said to not be anything different from her normal period.



Not surprising, but with smoking history, abd arterial or portal occlusion cannot be rules out.



Clare said:


> The patient states the pain is (again) generalised to all quadrants, it is not a tearing pain, does not radiate to the back, is 3/10, does not get worse or better with movement or rest and is not cardiac pain.



Not surprised by this either. With smoking but no history of HTN, she has a slight aneurysm risk, but not outrageously high. Is she obese?



Clare said:


> Most recent meal was this morning and before that the family ate at a Mexican restaurant the previous evening where she had chicken enchiladas..



Sounds better than what I had, also points to GI. Any reports of dark stool or other symptoms of peptic/duodenal ulceration?

Questions 



Clare said:


> (1) Do you see any "red flags" in the information presented? What? Why?



viceral pain and eleveated BP and relative tachy HR.

Wouldn't call the IUD a red flag, but it is sort of nagging.



Clare said:


> (2) What is your provisional diagnosis?



Too many to list, but GI, Gyn, and accessory GI are all systems on my list. Vascular issue possible, but not jumping right out now.  



Clare said:


> (3) Can this patient be safely left at home? Why or why not?



I wouldn't A couple of red flags, too many unanswered questions for my liking, and intuition something is wrong. Maybe doesn't need "emergency work up" but I would like to see some diagnostics. At least an trans abd ultrasound. 



Clare said:


> (This is my first time doing this so I hope I have given you the information you need, if anything is missing please ask.



You will never include all the info I need, my physical exam skills are very advanced and I can get a lot from it that is often unnoticed by most, but this has been better than 90% of what I have seen here in the past.


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## Clare (Mar 3, 2013)

Veneficus said:


> This is way too young for her BP, and considering that she is asian, the HR of 80 is probably relatively tachy.



Could it be she is just a bit upset and feeling sick and stressed out enough to have called ambulance?

When I went in for surgery they said my BP was 150 before I was anaesthetised and I am like no way ... but apparently so!



Veneficus said:


> Asian women hardly ever look sick or pregnant.



True 



Veneficus said:


> Sounds more GI, but still possibly early sepsis or endomitriosis or endomitritis. Leaning towards GI.



It sounds very GI but also very potentially gynae



Veneficus said:


> [Previous history NAD] makes the BP more concerning.



True, but as with the above could the BP and tachycardia be transient signs of anxiety?



Veneficus said:


> Cmon, you did such a good job with this compared to what we normally see here and you don't have a pack/year assessment?



I could do a pack/day or pack/week assessment but I have no idea how many fags are even in a pack so um yeah ... all I know is smoking is bad, do you really need to know any more?



Veneficus said:


> The IUD is nagging won't let me write off inflammation of gyn origin.



It is concerning yes 



Veneficus said:


> Pain on percussion where?



Wherever is percussed



Veneficus said:


> If she is of slight build did you try palpating ovaries, uterus, or renal stones transabdominally?



Erm ... not sure how to do that?



Veneficus said:


> Is she obese?



No



Veneficus said:


> Any reports of dark stool or other symptoms of peptic/duodenal ulceration?



No



Veneficus said:


> viceral pain and eleveated BP and relative tachy HR.



What if in the 20 minutes you are at the scene the BP and HR go down because she is a bit calmer now?



Veneficus said:


> A couple of red flags, too many unanswered questions for my liking, and intuition something is wrong. Maybe doesn't need "emergency work up" but I would like to see some diagnostics. At least an trans abd ultrasound.



Lets say her GP is in one of those flash places with its own ultrasound machine and X-ray and such and can see her tomorrow; do you think she can stay at home until then or do you want her seen by a Doctor sooner?



Veneficus said:


> You will never include all the info I need, my physical exam skills are very advanced and I can get a lot from it that is often unnoticed by most, but this has been better than 90% of what I have seen here in the past.



Why thank you dear 

I don't think its anything beyond a basic assessment to be honest ... there are people with far better history and exam skills than I and some of them do not even have the Degree.


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## VFlutter (Mar 3, 2013)

Clare said:


> I don't think its anything beyond a basic assessment to be honest ... there are people with far better history and exam skills than I and some of them do not even have the Degree.




No heart tones? Just kidding, Kinda. 

I am amazed how many clicks and murmurs I discover when others either A) do not pick up on them or B) do not even listen. Sadly I think it is the latter because the click of a mechanical valve is blatantly obvious. IMO it should be part of every basic assessment. 

I also like when people hear a murmur but never palpate the pulse during auscultation. 

/End Rant


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## Veneficus (Mar 3, 2013)

Clare said:


> Could it be she is just a bit upset and feeling sick and stressed out enough to have called ambulance?



Certainly, but it has been my experience that asians do not readily call the ambulance. So since she did, I have a higher level of suspicion.



Clare said:


> It sounds very GI but also very potentially gynae



or both.



Clare said:


> True, but as with the above could the BP and tachycardia be transient signs of anxiety?



Anxiety, like every other psych complaint is a Dx of exclusion. I would advise caution about using it as an explanation. You may be right 99% of the time, but sooner or later it will be the only sign and you will get burned.

Anxiety is also a sign of shock.



Clare said:


> I could do a pack/day or pack/week assessment but I have no idea how many fags are even in a pack so um yeah ... all I know is smoking is bad, do you really need to know any more?



yes, smoking predisposes to a host of conditions, the more a person smokes and the longer the more liekly those conditions become. Particularly neoplastic and vascular abnormalities. It can also exacerbate gyn problems.



Clare said:


> Erm ... not sure how to do that?



Press hard. It is just like palpating liver or spleen margins, only you are lower in the abd with a different set of organs. In addition to eliciting pain, there are normal parameters of size.



Clare said:


> What if in the 20 minutes you are at the scene the BP and HR go down because she is a bit calmer now?



Score! You can rule out more sinister things.



Clare said:


> Lets say her GP is in one of those flash places with its own ultrasound machine and X-ray and such and can see her tomorrow; do you think she can stay at home until then or do you want her seen by a Doctor sooner?



Sure, she could even probably wait to go to an urgent care if the GP is not available. She doesn't jump out as " I am going to die" but her combination of symptoms and history needs to be investigated. She may even discover it is all from a UTI.



Clare said:


> I don't think its anything beyond a basic assessment to be honest ... there are people with far better history and exam skills than I and some of them do not even have the Degree.



Physical exam is a skill. Like all skills, the more you do it, the better you get. There are studies showing MDs have poor exam skills. Degree means nothing.


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## wildrivermedic (Mar 3, 2013)

Veneficus said:


> This is another red flag, it is indicative of viceral pain, and not peritoneal distension, pointing to specific organ pathology.



This interests me, as I've been taught to view point-specific abdominal pain as much more of a red flag than generalized pain when it comes to deciding if this is an emergent emergency. 

The idea being that visceral pain indicates an issue that could be or become serious, but peritoneal pain indicates something may have ruptured and is serious right now.

For me reading this scenario, point-specific pain would have decided that the patient was coming with me. I didn't see the generalized pain as a red flag at all. Which is why I read scenarios; to learn. Thanks Clare for posting!


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## Veneficus (Mar 3, 2013)

GranolaEMT said:


> This interests me, as I've been taught to view point-specific abdominal pain as much more of a red flag than generalized pain when it comes to deciding if this is an emergent emergency.
> 
> The idea being that visceral pain indicates an issue that could be or become serious, but peritoneal pain indicates something may have ruptured and is serious right now.



It doesn't mean there is rupture, it means something is irritating the peritoneum, usually an inflammatory process.

There are also retroperitoneal organs and organ specific pathologies that are severe.

As I said, if you have nonspecific pain, you have a problem with an organ, and generally you need those.

peritonitits is an emergent problem, but not the only one in the abd.



GranolaEMT said:


> For me reading this scenario, point-specific pain would have decided that the patient was coming with me. I didn't see the generalized pain as a red flag at all. Which is why I read scenarios; to learn. Thanks Clare for posting!



As somebody who deal with MODS regularly, I prefer when it is only one organ  I also like to know as soon as possible.


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## EpiEMS (Mar 3, 2013)

Thanks for posting this, Clare! This was a great one to read through!


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## CritterNurse (Mar 3, 2013)

What's NAD? I'm drawing a blank at the moment.


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## Veneficus (Mar 3, 2013)

CritterNurse said:


> What's NAD? I'm drawing a blank at the moment.



I had to ask too.

No abnormalities detected.


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## Clare (Mar 3, 2013)

So who wants the answer?


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## FLdoc2011 (Mar 3, 2013)

GranolaEMT said:


> For me reading this scenario, point-specific pain would have decided that the patient was coming with me. I didn't see the generalized pain as a red flag at all. Which is why I read scenarios; to learn. Thanks Clare for posting!



While "point specific" pain and generalized pain maybe something to keep in mind when forming a differential I'd caution against using those to decide on your course of treatment... at least in prehospital setting where you have limited data to go on.  

Recently had an elderly gentlemen admitted with some vague complaints of abd fullness with a completely benign physical exam, but did have a white count up in the 20's and mild LFT elevation.   Otherwise vitals and exam were normal but knew something had to be going on.  Turned out to have a common bile duct stone and perforated gallbladder with forming abscess.  Certainly looked ok initially and could've been something that may have been brushed aside were it not for some basic labwork.


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## FLdoc2011 (Mar 3, 2013)

If anything she at least needs a beta-HCG and likely pelvic and/or ABD US. 

Woman of child bearing age with abd/pelvic pain will always throw ectopic high on my list.

GYN:  ovarian torsion, ruptured cyst, endomitriosis, fibroids, PID, complication from IUD, etc...

 Beyond a detailed history and exam, a few basic labs and probably an ultrasound should be enough.


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## PaddyWagon (Mar 3, 2013)

My strictly amateur call is peritonitis, unsure of the cause but it's in the time frame for a small puncture caused by something in the food(?) and also based on generalized pain and what is possibly rebound tenderness.  No vomiting maybe rules out food poisoning, as does no mention of diarrhea.  It's not a triple-A and no radiating pain to the back rules out a couple organs.

Pulse and BP seem a little high for someone that young, it's reacting to something.

Would counsel taking a trip to the ER because of the recent onset time, generalized pain and vitals.

(hope y'all don't mind my trying to work through these scenarios as a newbie, every one I get wrong I learn a lot more from the feedback than simply reading answers and can correct my thinking, thanks)


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## medicsb (Mar 4, 2013)

I'm a little more concerned by the increase in pain with percussion.  It's a little close to the bed-bump sign (or whatever you want to call it) associated with peritonitis.  

While I may not immediately jump and down over this woman, and I may not think she needs ALS in US terms of prehospital care, but she needs to be worked up by a physician.

Anyhow, it is pretty amazing how 'not-sick' a patient can initially look with a severe GI pathology.  Yesterday I encountered a pt. with a physical exam that was largely benign with just a diffuse abdominal pain and tenderness and relatively normal VS (for someone w/ pulm HTN), mentation, etc.  By the time she went to the OR for an ex-lap, she was septic.  Anyhow, a perf'd duodenal ulcer was found and fixed with a Graham patch.  Her mentation changed (as did the CT scan), but her abdominal exam did not from what I was told.


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## Veneficus (Mar 4, 2013)

I am always cautious about focusing in too quickly on gyn problems in females.

Most of medicine is GI, and women have that system too.


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## medicsb (Mar 4, 2013)

Veneficus said:


> I am always cautious about focusing in too quickly on gyn problems in females.
> 
> Most of medicine is GI, and women have that system too.



I'm not so sure anyone was focusing in "too quickly", but just giving it its due regard.  Considering that the reproductive organs of women are frequent causes of abdominal and pelvic pain, that "most of" is much less than men.


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## Clare (Mar 5, 2013)

The answer was ectopic pregnancy, the patient was left at home (because the crew believed she had gastroenteritis after eating uncooked chicken) and was dead the next morning from subsequent rupture and exsanguination.  

Red flags for were her race (non-White), age (> 35), IUD, smoker and vaginal bleeding, all of which are higher risk factors for ectopic pregnancy so putting all that together with her vague symptoms warranted immediate referral to a Doctor.

I can also see how this one would be very easy to miss; the risk factors are subtle and unless you actually know them then they can easily be overlooked or explained away, as can her vaginal bleeding and abdominal pain either to normal mensturation (as she did not feel different than normal) or abdo pains to her confounding symptoms of an upset tummy; especially given that the pain was not severe nor typical of say, appendicitis (no RIF pain) or an infection (no fever)

But, in saying all this, it is simply not possible nor sensible to simply transport everybody so we will continue to see each year a very small number of patients who are inappropriately not immediately referred to a Doctor (I think at last count over the last 2 years we might have had 5 or so) 

Hope you learnt something anyway


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## Veneficus (Mar 5, 2013)

medicsb said:


> I'm not so sure anyone was focusing in "too quickly", but just giving it its due regard.  Considering that the reproductive organs of women are frequent causes of abdominal and pelvic pain, that "most of" is much less than men.



I wasn't suggesting that people were unduly focused, just stating something that I try to follow.


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## mycrofft (Mar 5, 2013)

ALS: everything above. Plus: characterize abdo sounds per qudrant (tinkles, gurgles, other). Was abdo distended? Did palpation of thoracic spine elicit pain? Bruits? Tympanies? Does quadrant "A" hurt when you press on "C"? (BP elevation: diastolic is not as quick to change as systolic unless something really pivotal is going on, or your BP reading was off.

BLS: go.

IN THE FIELD: how long are you going to wait and how deep/firmly will you push on a belly when the OR is so far away? 

The belly is a dark and dangerous place.h34r:


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