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September 2015: Abdomen

A 39-year-old safety officer reported to the medic with a complaint of abdominal pain.  She stated that she first noticed the pain when she woke in the morning but thought it was menstrual cramps, however the pain increased throughout the day and was colicky in nature. By mid-afternoon the pain was severe. She has had no decrease in appetite.

On review of systems she denies fever, chills, diarrhea, constipation, or vomiting. She is on day 5/21 of her hitch.

  • Past History: Diabetes (NIDDM), Ectopic Pregnancy
  • Past Surgical History: C-Section, Breast Augmentation, Tonsillectomy
  • Current Medications: Metformin (Glucophage) 500 mg bid and Birth Control
  • Immunization Status: Tetanus and Influenza are up to date
  • Social History: Social drinker, non-smoker
  • Family History: Mother with diabetes, father with high blood pressure
  • Last menstrual period: ~6 weeks

Vitals

  • Temp: 98.9
  • Pulse: 98
  • Respirations: 12
  • Blood pressure: 105/68
  • Pulse Ox: 99% RA

Physical Exam

  • General: Alert and Oriented x 4, no acute distress, but at times appears uncomfortable and having difficulty finding a position of comfort
  • 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
  • Abdomen: Soft, middle and right lower quadrant tenderness on palpation, non-distended, normal bowel sounds, no organomegaly
  • Back: Positive right CVA tenderness
  • GU: Normal external genital exam
  • Extremities: No clubbing, cyanosis or edema

Lab Work

  • Pregnancy Test: Negative
  • Urinalysis
    • Specific Gravity: 1.020
    • pH: 6.0
    • Glucose: 100 mg/dl
    • Protein: Negative
    • Bilirubin: Negative
    • Ketones: 5 ml/dl
    • Urobilinogen: 0.2 EU
    • Blood: Negative
    • WBC: 2+
    • Nitrites: Negative

How would you approach this patient?

Differential Diagnosis

  • Renal Colic (Kidney Stone)
  • Ovarian Cyst
  • Ovarian Torsion
  • Pregnancy
  • Ectopic Pregnancy
  • Appendicitis
  • Mesenteric Adenitis
  • Crohn’s Disease
  • Diverticulitis
  • Pelvic Inflammatory Disease

Diagnosis: Abdominal Pain With Suspected Renal Colic

Treatment:

  • IV normal saline at rapid rate
  • Ketorolac (Toradol) 30mg IV push
  • Morphine administered intermittently until patient no longer required pain medication (~2:00 AM during observation)
  • Clear liquids as tolerated
  • Serial vital signs and exams
  • Non-emergent evacuation

Patient was observed overnight and felt somewhat better in the morning. She had a good appetite, colicky pain and CVA tenderness resolved, and she remained afebrile. However, she the mild middle and right lower quadrant tenderness continued upon leaving the site.

Final Diagnosis: Appendicitis

Discussion:

The patient was examined when she arrived on shore.  Her laboratory evaluation was normal including CBC, BMP and urinalysis.  However, CT scan was suspicious for an early appendicitis. Classic presentation for appendicitis is migrating abdominal pain that localizes to the right lower quadrant. It is often associated with decreased appetite, fever, nausea and vomiting. On laboratory evaluation you often have an elevated WBC count. While this patient’s initial UA had a positive leukocyte esterase, this does not necessarily represent a urinary tract infection but may be due to the proximity of the appendix to the ureter.

While this case presentation in general was very atypical, it demonstrates the need to thoroughly develop your differential diagnosis and proceed with caution until a positive diagnosis can be made for appropriate treatment.

Remember to always remain vigilant with each patient!

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