# 27yo F. Abd. pain



## adamjh3 (Oct 6, 2011)

Alright, this one's going off memory, and it kind of had me baffled. I'll wait to unveil what my impression was until I get a couple replies. 

It's 1700 on an overcast Monday afternoon and you're nearing the end of your shift on a BLS truck staffed with two EMTs. You're sent from your post at the beach to an urgent care about 30 minutes inland from your location for a transfer to the emergency room. The Motorola gods inform you that you will be attending to a 27yo Female complaining of abdominal pain. 

You arrive on scene and are greeted in the crowded lobby by a woman who looks to be in her late thirties to early forties. She stands up, asks if you're there for her, you ask her name and find out that she is indeed the patient you are here for. While you and your partner are lowering the gurney to get her on she says "No, that's embarrassing, I can just walk." After a shrug and a "well, we already have it set up for you" from your partner she hops on the gurney. 

The staff at this location makes a point of being generally unhelpful and dodgy  just last week you came to this location, the chief came out as "back pain" when you arrived on scene you found out it was chest pain with associated SOB from your patient, the doctor said the patient complained of neither to him only to find out that very same doctor marked those two items on the transfer sheet, and that wasn't the first time you've had an incident like that at this particular facility. All you get from them is that the Doctor wanted her to be seen at the closest ER and a recent set of vitals which are
P: 84
R: 18 with an SpO2 of 96% on room air
BP: 132/90

You opt to begin your assessment in the truck so as to give the patient a bit of privacy and begin your questioning while your partner obtains vitals. You determine that despite how worn she looks, she is indeed 27. You notice your patient is belching loudly once or twice each minute, each belch is followed by a gag or cough which sounds almost like a dry heave. When asked about this frequent belching, the patient states she's been doing this since this morning and that her "stomach feels like it has lots of stuff in it." She denies nausea or vomiting.

Your patient states she came into the urgent care to see the doctor about getting her Percocet prescription for back pain filled. her last script ran out two nights ago, she states she takes "painkillers every day" but is unable to give you a dosage. Her last intake of medication was a vicodin yesterday morning which she said she received a three day supply from another doctor to hold her until she could get her percocet filled. 

After some more prodding you're able to find out that your patient has been experiencing abdominal pain which has steadily gotten worse since last night, the pain is dull and throbbing at the midline lower abdomen, non radiating at about a 7/10 on the pain scale. Your patient states she has also been experiencing some minor rectal bleeding. As described by the patient the blood is a dark red, the bleeding occurs when she urinates, but she is positive that she is bleeding from her rectum and not her vagina. She states the bleeding is light, only small amounts of spotting when she wipes after urinating. She states the amount of blood is similar to her periods, which are described as "light". She states she finished her last menstrual cycle a week ago.

The patient reveals that she has not had a bowel movement in several days, and that her appetite has decreased significantly over the last week. She last ate a "small amount of food" around 2000 the previous night. 

The patient has a Hx of Chronic back pain and hepatitis C, along with a few stomach ulcers, the most recent being 3yrs ago. 

Pt. is allergic to shellfish, denies known medication allergies

Pt. denies any medications besides the percocet which she has been taking daily for "at least a year" 

At this point your partner passes her vitals to you
P:80, strong and regular at the radial site
R: 16 full and effective with clear lungs
BP: 134/90
E: PERRL @ 3mm
Pt. is A&Ox3
Skins: Pink warm and dry
Bowels sound "sluggish" 
The abdomen does not feel distended, firm, or otherwise abnormal. Patient denies any changes in the quality or quantity of abd. pain upon palpation. 

En route to the ER the patient's status does not change, no interventions are given other than giving her a basin just in case that belching turns into vomit.

Thoughts?


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## fast65 (Oct 6, 2011)

Hmmmm, this is kind of a tough one. My initial thoughts on this one were either bowel obstruction or Crohns disease, however those both present usually present with an initial bout of diarrhea if memory serves. Did she complain of any diarrhea? The fact that she feels "full" and hasn't had a bowel movement in several days points me towards a bowel obstruction, but that still doesn't explain the rectal bleeding.

With the use of Percocet and Vicodin, it's not uncommon to experience some sort of constipation and abdominal pain, so perhaps there was some sort of bowel obstruction caused by the switch from Percocet to Vicodin?


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## Anjel (Oct 6, 2011)

Finally a BLS scenario.

Ok... So my gut reaction is a twisted bowel or obstructed like doogie said. 

She also could have ulcertive colitis perhaps? She has already admitted to having ulcers and there are a lot of drugs that irritate them. Plus the fact she said she was stressed.

has she thrown up at all? Or just gagging? Did you asked what the burps taste like? She could have bile buildup. 

I wouldnt do anything for her except keep her comfy and monitor.


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## fast65 (Oct 6, 2011)

Anjel1030 said:


> Finally a BLS scenario.
> 
> Ok... So my gut reaction is a twisted bowel or obstructed *like doogie said. *
> 
> ...



I feel as though that needs to be my new title 

Anyways, I had also considered ulcerative colitis, but I kind of went away from that thought due to the absence of body aches and hematochezia. That's not to say that this still isn't a viable option, she is right in the age range where ulcerative colitis is most prevalent.


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## Anjel (Oct 6, 2011)

fast65 said:


> I feel as though that needs to be my new title
> 
> Anyways, I had also considered ulcerative colitis, but I kind of went away from that thought due to the absence of body aches and hematochezia. That's not to say that this still isn't a viable option, she is right in the age range where ulcerative colitis is most prevalent.



Right and no diarhhea( I can never spell that)


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## fast65 (Oct 6, 2011)

Anjel1030 said:


> Right and no diarhhea( I can never spell that)


Just remember that the suffix _rrhea_, means "discharge or flow", it helps me remember how to spell things, but I'm weird


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## MrBrown (Oct 6, 2011)

Bowel obstruction
Ectopic pregnancy
Gastroenteritis
Reflux
GI bleed

or any combination thereof


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## mycrofft (Oct 6, 2011)

*A torted bowel is an acute emergency, so no twisted bowel.*

 What kind of place was this, a transenit hotel, a sanitarium, the Hilton? BLEEDING: get a look at the underpants, that will tell you about the bleeding. If clean, you will invariably be told "I just changed them". Well, maybe.
Belching with cough: either an aerophage (air swallower) or maybe a PRONOUNCED hiatal hernia with reflux and belching. 
Three day narc order: okay. Right. Means GOMER.
This is a BS run but you cannot afford to leave it unaddressed. How about bowel sounds, palpated abdomen, etc.?


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## adamjh3 (Oct 6, 2011)

mycrofft said:


> What kind of place was this, a transenit hotel, a sanitarium, the Hilton? BLEEDING: get a look at the underpants, that will tell you about the bleeding. If clean, you will invariably be told "I just changed them". Well, maybe.
> Belching with cough: either an aerophage (air swallower) or maybe a PRONOUNCED hiatal hernia with reflux and belching.
> Three day narc order: okay. Right. Means GOMER.
> This is a BS run but you cannot afford to leave it unaddressed. How about bowel sounds, palpated abdomen, etc.?



It was an urgent care in a lower class area of the county.
Abd did not feel abnormal in any way, pt denied changes in pain level upon palpation. Bowel sounds were sluggish. As far as the bleeding she said it was only when she used the toilet. Denied spotting on undergarments. 

Sent from my DROIDX using Tapatalk


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## mycrofft (Oct 6, 2011)

*Sounds like she needed a whole body scan/ultrasound/MRI*

Or it's just soothing really weird. Or BS.


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## DrankTheKoolaid (Oct 6, 2011)

*re*

Sounds like a classic bowel obstruction.  Patient takes Percocet (slows GI motility) along with poor intake (assuming both fluid and solid both of which water is extracted )leading to patient being FOS.  As bowel fills reverse peristalsis sets in causing the belching though no vomiting yet.  Many other questions need to be asked.  Was she having diarrhea (wont rule out BO as diarrhea can leak past the blockage), still passing gas, smell of her breath etc etc.   

As to the rectal bleeding makes me wonder since she is aware of her being FOS for multiple days was she straining prior to try to have a bowel movement causing a hemorrhoid to cuts loose.  With the history of Hep C she will have vessel enlargement already and any straining is going to make it worse. 


Good thinker call


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## abckidsmom (Oct 6, 2011)

And with that Hep C and daily Percocet use you've got to suspect that the GI bleed is caused by liver disease, and all the associated happiness that comes with it.  Remember the Tylenol in there...daily percocet users develop a tolerance and up their dose of Tylenol too, easily can exceed 2g acetaminophen for the day.  Blood coagulation factors can go wonky, worsening the trouble on hand in the bleeding gut.


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## AlphaButch (Oct 6, 2011)

How long had she been on percocet?

My initial is abdominal pain / spotty bleeding due to percocet withdrawal and constipation (blockage symptoms) due to the vicodin switch (common side effect). Would transport for scans to r/o obstruction, bleed, and ectopic; and do a liver panel depending on the length of time she had been on percocet.


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## bigbaldguy (Oct 6, 2011)

Symptoms of acetaminophen overdose

    * Abdominal pain
    * Appetite loss
    * Coma
    * Convulsions
    * Diarrhea
    * Irritability
    * Jaundice
    * Nausea
    * Sweating
    * Upset stomach
    * Vomiting


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## Handsome Robb (Oct 6, 2011)

The single dose toxicity of acetaminophen is 140-150mg/kg. She does have hep-c so her liver function could be affected but she isn't really displaying any of those symptoms except for the anorexia, abd pain and blood in the stool although it was never confirmed.

I'm going with bowel blockage of some sort.


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## adamjh3 (Oct 6, 2011)

She stated she'd been taking percocet daily for over a year. 



> you've got to suspect that the GI bleed is caused by liver disease, and all the associated happiness that comes with it



I thought that GI bleeds associated with liver disease were almost always upper GI, and generally lots of blood. Remember the majority of my education has come from reading on my own, so don't lay into me too hard


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## Handsome Robb (Oct 6, 2011)

adamjh3 said:


> She stated she'd been taking percocet daily for over a year.



That's not really a huge issue. She would have to be taking A LOT of it daily. For the average sized pt your looking at ~7000mg in a single dose for toxicity. Thats 20+ pills of standard percocet, 14 if they are 10/500 percocets.


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## abckidsmom (Oct 6, 2011)

NVRob said:


> That's not really a huge issue. She would have to be taking A LOT of it daily. For the average sized pt your looking at ~7000mg in a single dose for toxicity. Thats 20+ pills of standard percocet, 14 if they are 10/500 percocets.



I'm not sure that's completely correct in the presence of Hep C, though.  Digging around to find some documentation of that.


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## Handsome Robb (Oct 7, 2011)

I agree. The Hep-C can decrease liver function and lower the toxic dose but she doesn't seem to be presenting with decreased function. 

I'm all ears though your much smarter and more experienced than I am


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## Aidey (Oct 7, 2011)

NVRob said:


> That's not really a huge issue. She would have to be taking A LOT of it daily. For the average sized pt your looking at ~7000mg in a single dose for toxicity. Thats 20+ pills of standard percocet, 14 if they are 10/500 percocets.



For daily users I think the recommended daily max is 4000g.


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## abckidsmom (Oct 7, 2011)

http://www.hepcassoc.org/news/article110.html

Bunny trail relatively dead ended.  This seems to be the consensus of a handful of articles I read.


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## AlphaButch (Oct 7, 2011)

She's also at the most likely usage timeframe for development of a peptic ulcer (will have to look for the study - results were highest at 1 year of use).

A couple of other articles regarding cirrhosis/hep C and pain management;

Mayo Clinic Proc, 2010

Hepatitus Central (compiled from the Am. J. Gastroenterology

recommended max is 2-3g/24 hr for persons with compromised liver activity.


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## mycrofft (Oct 7, 2011)

*And, and, and...*

Tell her to come in tomorrow for a blood draw for hep C, H.pylori, CBC with crit and RDW. Bet she doesn't show.


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