January 2025 Case Study – Abdominal Pain

 

ABDOMINAL PAIN

HPI:  This is a 67-year-old female who presents to the ER at 06:15 complaining of nausea, vomiting, sweating, a feeling of general malaise, and dizziness. She was brought in by family. The patient states she was awakened from sleep at approximately 03:45 with a feeling of bilateral upper quadrant abdominal pain, nausea and vomiting. She has sweating with the vomiting. She has had multiple episodes of vomiting and began to feel dizzy starting approximately 30 to 45 minutes prior to arrival. She states she feels weak all over and just doesn’t feel “right.” She denies any new or restaurant foods in the past 48 hours. She denies eating any “left-overs” in the past 48 hours. She was unable to take her morning medications due to her inability to keep anything down. She denies any bloody or dark vomit or stools. She denies anyone else in the household being ill. COVID immunizations are up to date.

ROS:  She denies any, fever, chills, change in her vision, diplopia, change in hearing, ear pain, rhinorrhea, sore throat, difficulty swallowing, chest pain, shortness of breath (except with vomiting), abnormal heart beat, physical difficulty breathing, abdominal distention, dysuria, hematuria, incontinence of urine or stool, retention of urine or stool, back pain, muscle pain, focal weakness, focal numbness, environmental or food allergies.

DRUG ALLERGIES: COMPAZINE, PENICILLIN, BACTRIM.

MEDS:

Glyburide/Metformin 5mg/500mg, 2 tablets, P.O., BID

Reglan 10mg, P.O., QID PRN

Amlodipine 5mg, P.O, Q Day

Omeprazole 20mg, P.O., Q Day

PMHX:

Hypertension

Diabetes Mellitus, Type II, diet and medication controlled.

Gastroparesis

GERD

GALLSTONES

DYSFUNCTIONAL UTERINE BLEEDING

LEFT WRIST FRACTURE – Age 8

PSHX:

CHOLECYSTECTOMY – three months ago

VAGINAL HYSTERECTOMY – Age 57 Ovaries still In-Situ

ORIF – Left Wrist Age 8

SOCIAL HX:

Tobacco – Never

Alcohol – One glass of wine per night

Drugs – Smokes Marijuana at night for sleep. Denies any other drug use other than prescribed medications.

PHYSICAL EXAM: (non-pertinent sections removed)

Vitals: Temp 97.9, Pulse 92, Respiration 24, BP 153/89

General: Well-developed, mildly obese female, ill appearing but in no acute distress.

Skin warm and dry without lesion.

Eyes: PERRLA, EOMI, No Nystagmus

Ears: Bilateral TM clear

Heart RRIR, S1, S2, without S3, S4, or murmur.

Resp: CTA in all fields. No respiratory difficulty.

Abdomen: Diffuse mild discomfort in all quadrants, Bowel tones decreased in all quadrants, No palpable masses, Nondistended. No Cullen’s sign, Grey-Turner sign, McBurney’s sign, Murphy’s sign, Allen’s sign, or Obturator sign, present on exam.

Musculoskelital/Neurological/Phycological: Unremarkable

TESTS:

Laboratory:

CBC:  WBC 10.2 (10.0 normal high), HGB 15.1, Hemoglobin 45.4, PLT 352K, No shift.

CMP: Glucose:196, Bun Mildly high, Creatinine WNL, Potassium mildly low at 3.2, rest of panel WNL

Lipase: WNL

Magnesium: WNL

Lactic Acid: 1.4

UA: SG 1.032 otherwise unremarkable

Radiology:

CXR: Read as “No Cardiopulmonary abnormality.”

CT ABD/PELVIS (with IV contrast): Read as “few scattered air/fluid levels in the mid small intestine suggestive of ileus. Otherwise, unremarkable exam.”

Cardiac Monitor: NSR with occasional PVC. Rate ranging between 74 and 97 during stay.

Pulse Oximetry: Constantly greater than 92% on room air.

ER Course: An IV was established and the patient was given one liter of normal saline along with Reglan 10mg IV. Another liter of normal saline was given after the patient returned from CT-Scan. The Reglan was ineffective in controlling the patient’s emesis. Zofran 4mg was given IV (no signs of serotonin syndrome developed). The Zofran was also ineffective in controlling the patient’s emesis. The patient continues to complain of bilateral upper quadrant pain mostly in the epigastric area. She continues to complain of nausea with occasional emesis (clear), feeling weak, and “not right.” Her dizziness has mildly improved but not resolved. The patient has now been in the ER for 4 hours.

What is your diagnosis?

1. Gastroparesis
2. Marijuana induced cyclic vomiting syndrome
3. Gastroenteritis
4. Central versus peripheral vertigo induced emesis
5. A combination of the above.

What is your disposition?

1. Discharge to home with either an RX for an antiemetic or continue her own Reglan. Return PRN. Follow-up with PMD in 2 to 3 days…
2. Admit the patient to observation.
3. Ordering more tests and continuing treatment.

DISCUSSION:

The correct answer is “c.”

Why? The case presents a through work-up for the patients presenting symptoms. However, there is one system that was not checked. A system that may prove life threatening.

The EKG computer gives a reading of NSR with non-specific ST changes. Looking at the EKG there is almost (but not quite) 1mm ST elevation in II, III, and aVF, along with 1mm ST depression in aVL. Not really diagnostic, but not normal either. High Sensitivity Troponin returns and is 467 (high is 60). The patient is in the process of developing an inferior-posterior MI.

Up to 50% (in some studies) of females having a myocardial infarction will present with symptoms other than chest pain. Nausea/vomiting have been reported in as high 60% in cases of MI. Further, this patient is a type II diabetic, up to 16% of patients with type II diabetes will not have chest pain (or other pain) as a presenting symptom of a myocardial infarction. Inferior and posterior MI’s are notorious for presenting with epigastric area discomfort, nausea, and vomiting. This case is a compilation of three different (2 female, 1 male) patients that have presented to the ER strictly complaining of GI symptoms and were actually having an MI. This case could have easily had any of the diagnoses presented above. However, an EKG and Troponin are indicated for anyone with possible risk factors in the setting of upper abdominal pain and/or intractable nausea/emesis. A “rule out” may well be indicated for those cases of unexplained abdominal pain and/or intractable nausea and vomiting.