CC: Abdominal Pain.
HPI:The patient is a 47 year old white female who
presents at 9:30 am complaining of a sudden onset of
moderate to severe periumbilical abdominal pain which
woke her from sleep at 6:30am that morning. The pain
radiates to both flanks and varies in intensity but is
always present. She states that she cannot lay still
because of the pain. She reports a similar pain several
days earlier which lasted 1 to 2 hours which was
attributed to an "abdominal virus". She has some mild
nausea but no vomiting or diarrhea.
Review of Systems: She denies fever or chills, chest
pain, dyspnea, cough, dysuria, urgency or frequency.
There is no vaginal bleeding or discharge. She denies any
known trauma. Her last bowel movement was yesterday and
was normal. The patient has been otherwise well until
this morning.
Past Medical History: She denies any hypertension,
diabetes, heart disease, renal disease, lung disease or
thyroid disease.
Past Surgical History: Varicose vein stripping of legs one
month ago, vaginal hysterectomy and salpingo-oophorectomy
one year ago. Appendectomy one year ago.
Medications: Estrogen.
Allergies: None known.
Social History: One pack per day smoker for 20 years.
Occasional alcohol. Denies any illicit drug use.
Physical Exam:
Temp: 36.7 Celsius, Pulse: 78, Resp: 18, BP: 138/82
General: Well nourished white female who appears stated
age in mild painful discomfort. Alert, and conversant.
Skin: Warm and dry. No rashes or jaundice.
HEENT: Normocephalic, PERRLA, EOMI, mucous membranes
moist, throat clear, normal dentition.
Neck: Supple. No jugulovenous distention. Normal carotid
upstroke.
Lungs: Slight scattered rhonchi bilaterally which clear
with coughing. Otherwise clear.
Heart: Regular rate and rhythm, normal S1 and S2. No
murmurs, rubs or gallop.
Abdomen: No distention. Normal active bowel sounds. No
palpable masses. Very mild tenderness in the right lower
quadrant. There is no guarding or rebound. No hernia
appreciated.
Back: No deformities. Nontender. No costovertebral angle
tenderness.
Pelvic: Nl external genitalia. No lesions. Normal vaginal
vault. No adnexal tenderness or masses.
Rectal: Normal tone. No masses. Guaiac negative.
Extremities: Normal pulses throughout. No edema, cyanosis
or tenderness.
Neurologic: Normal mental status, cranial nerves, motor
and sensory. Normal cerebellar.
Diagnostic Studies:
Labs:
WBC: 12.0 (83% polys, 11% lymphs, no bandemia), HGB:
14.3, platelets: 254.
Na: 141, K: 4.6, Cl: 102, CO2: 26, BUN: 10, Creat: 0.6,
glu: 85, Ca: 9.6, albumin: 3.8, SGOT: 37, SGPT: 28, Alk
phos: 63, Total Bili: 0.6, uric acid: 2.6, Cholesterol:
159.
Urine dip: negative for blood or leukocytes.
EKG: (Normal sinus rhythm at 50. Nonspecific anterolateral
T wave abnormalities.
Chest Xray (upright): No active disease. No free air.
Abdominal Xray: Nonspecific bowel gas pattern. No
distended bowel loops. No abnormal calcifications.
ED course: The patient received dicyclomine IM with no
relief. She continued to have mild to moderate abdominal
pain after returning from the radiology department and
received morphine 2 mg iv. After 15 minutes, there was
almost complete relief of her pain. She remained
comfortable for the following 4 hours when the pain
recurred. It was now a very severe bilateral lower
abdominal pain radiating to both flanks. The patient
stated that she felt like her back was "going to break".
She was now mildly tender in both lower quadrants with
minimal guarding but without peritoneal signs. She was
seen by the surgical team and received another 10mg of iv
morphine with no relief of pain. A repeat chest xray
revealed no free intraabdominal air.