Ok, this case is pretty complex – let’s get to it.
68 yo female presents to your ED by EMS c/o severe LLQ and epigastric abdominal pain for 3 days. She was discharged from your facility 21 days ago s/p cholecystectomy with concomitant mild gallstone pancreatitis. While here, her enzymes normalized and at D/C all prior ABD pain had resolved. She hasn’t been on antibiotics since surgery, and she has been able to eat without difficulty. Of note, she has lost 40lbs over last 8 months and has had an extensive history of prior bouts of abdominal pain – all of which were non-diagnostic until this recent bout of cholecystitis. States pain is 10/10, cramps, achy pain. Last BM 4 hours ago. Solid stool, no obvious discoloration, blood or mucus. Denies CP or SOB. Appears very uncomfortable.
Undifferentiated ABD pain
AAA at thoracoabdominal junction – 4.8cm last exam 30 days ago.
-has had this for 5 years
Smoker 2 packs/day 50+ years
Drinks 1-2 glasses of wine daily
Hydrocodone with APAP
Allergies: Morphine (hives per patient)
BP: 210/112 R arm, 146/90 L arm
Pulse: 130-140 bpm at rest
RR 20 Temp 98.7F
O2 sat 96% on 2lpm via NC
Gen: AOx3, appears very uncomfortable, dusky can’t find position of comfort. Appears frail amd unkempt. In obvious pain.
HEENT: patent airway, PERRLA, EOMI, bounding carotid pulses
Chest: Tachycardic, regular, no M/R/G. Mild wheezing all fields, no rhonchi or rales. Able to move air without significant distress
ABD: Soft, moderately TTP all quads with increased pain on palpating of epigastrium and LLQ. No rebound tenderness. Negative leg lift, Rovsing’s or CVA TTP. Bilateral femoral pulses equal but moderately weaker than carotids.
Ext: full ROM, no calf tenderness, no CCE. Very pale and dusky
Neuro: AOx3, no gross deficits noted
Ok, there is a lot going on here but at the same time, from an EM perspective, think about the case and put the following in perspective:
1) Sick or not sick?
2) What are the immediate life-threatening concerns?
3) What is your differential diagnosis – most likely to least
4) What one test do you want to do?
5) What is the definitive treatment?
6) What else do you want to know?
Remember, you have 2 nurses, a respiratory therapist, and a general surgeon on call. If you can’t handle it, it needs to go elsewhere.