1-877-660-7367 1-504-293-5959

July 2015: Abdomen

A 26 year old painter presents to the medic with a complaint of right lower abdominal pain for 2 days.  The patient first noted the pain while he was carrying a 5-gallon bucket of paint.  The pain is intermittent, worse with certain positions including picking up his paint can, better while lying down.  The pain radiates into the right groin.  The patient describes a similar pain approximately one year ago although pain was localized to the left lower quadrant, which resolved on its own at that time. He is on day 8/21 of his hitch.

On review of systems he denies fever, chills, joint or muscle pains, dysuria, hematuria, diarrhea, constipation, nausea or vomiting

  • Past History: Allergic rhinitis
  • Past Surgical History: Hernia repair as young child, tonsillectomy
  • Current Medications: Cetirizine (Zertec) hcl 10mg po daily
  • Immunization Status: Tetanus and influenza are up to date
  • Social History: Social drinker, smokes ½ a pack a day
  • Family History: Mother with diabetes, father with prostate cancer

Vitals

  • Temp: 98.9
  • Pulse: 76
  • Respirations: 12
  • Blood pressure: 139/87
  • Pulse Ox: 98% RA

Physical Exam

  • General: Alert and oriented x4, no acute distress, skin cool and dry
  • HEENT: AT/NC, eyes anicteric, TMs clear, nose clear, mucus membranes somewhat dry, no lesions appreciated
  • Cardio: Regular rhythm and rate, no murmurs appreciated
  • Lung: Clear to auscultation bilaterally
  • Back: No CVA tenderness, normal ROM of spine
  • Abdomen: Soft, non-distended, normal bowel sounds, tenderness to palpation over lower right abdomen/pelvis, no rebound, mild voluntary guarding
  • GU: Normal external genital exam, normal testicular volume, no masses or tenderness appreciated
  • Extremities: No clubbing, cyanosis or edema
  • Skin: Cool and dry, no rashes, anicteric

Lab Work

  • Urinalysis
    • Specific gravity: >1.020
    • pH: 7
    • Blood: negative
    • WBCs: negative
    • Bilirubin: small
    • Urobilinogen: 0.2 EU
    • Protein: small
    • Ketones: negative
How would you approach this patient?

Differential Diagnosis

  • Appendicitis
  • Renal Colic (Kidney Stone)
  • Mesenteric Adenitis
  • Hernia
  • Crohn’s Disease
  • Hepatitis
  • Cholelithiasis

Diagnosis:  Direct Inguinal Hernia

Treatment:

  • CASE-EVAC for further work-up, definitive diagnosis and treatment
  • Maintain patient in supine position
  • Icepack to area
  • No lifting

Discussion

Abdominal pain is one of the most challenging presentations in the remote environment. Looking at the differential diagnosis above, all of these entities must be considered and ruled in/out. The list should go from highest index of suspicion to lowest.

This patient’s presentation gives the remote practitioner certain clues leading him/her to the most likely entity on the differential diagnosis. Looking at the diagnoses above, each entity has a typical presentation, which may include some or all of the following signs and symptoms:

  • Appendicitis – Fever, chills, anorexia, nausea/vomiting, right lower quadrant pain which eventually becomes constant
  • Renal Colic (Kidney Stone) – pain usually intermittent coming in waves, can start in the back on the affected side and radiate down into the groin, may present with hematuria, nausea/vomiting, pain can move with movement of the stone
  • Mesenteric Adenitis – Presents very similarly to appendicitis usually associated with viral illness
  • Crohn’s Disease – Can also present similarly to appendicitis with intermittent flair ups
  • Hepatitis – discomfort usually constant, often associated with jaundice, tenderness usually in right upper quadrant, nausea/vomiting
  • Cholelithiasis – Pain is typically intermittent, usually right upper quadrant or epigastric, is colicky in nature, can radiate, nausea/vomiting

In this case, on physical examination the diagnosis could easily be missed. Examining the patient’s abdomen in the classic supine position very often will not allow you to feel the defect. In order to diagnose a hernia the patient should be in a standing position allowing gravity to exaggerate the bulging of the intestine within the defect. Further maneuvers which will assist you in making the diagnosis include asking the patient to valsalva (bear down) or cough both causing increased intra-abdominal pressure pushing the bowel into the defect, which you will feel against your finger.

For patients with an incarcerated hernia, you can place the patient in Trendelenburg position and you may use a muscle relaxer such as diazepam (Valium) and gentle kneading of the mass in order to reduce the hernia. WARNING: You should only attempt to do this if you are certain of the length of time the hernia has been incarcerated and you have a low index of suspicion that the hernia is strangulated. If you believe the entrapped bowel is strangulated then it is better to leave it alone and allow the surgeon to address it in the operating room. This allows him to readily identify the affected bowel without having to look in the abdominal cavity decreasing the risk of overlooking a small section of dead bowel, which could possibly rupture post operatively.

Logos