Here is the link to Emergency Medicine Cases’ Best Case Ever 21 Abdominal Pain – Thinking Outside The Box, By Anton Helman|March 26th, 2014.
Dr. Helman writes:
As a bonus to Episode 42 on Mesenteric Ischemia & Pancreatitis, Dr. Brian Steinhart presents his Best Case Ever of Abodominal Pain – Thinking Outside the Box. While about 10% of abdominal pain presentations to the ED are surgical, there are a variety of abdominal pain presentations that have diagnoses outside the abdomen – so one needs to be thinking outside the box.
This podcast is nine minutes long and in it, Dr. Steinhart discusses five cases of abdominal pain due to processes outside the abdomen.
0:40 – 2:49
Case 1 was an elderly man who was psychotic from home previously normal. He was agitated, vomitting and clutching his abdomen. And he was found to have an injected left eye. Tonometry showed marked increase in intraocular pressure. When Dr. Steinhart gave medical treatment for the acute angle closure glaucoma, all his symptoms resolved.
2:50 – 4:14
Case 2 is an HIV patient Dr. Steinhart took over in handover with belly pain.
Had more left flank pain and had workup, urinalysis, and was awaiting a CT result.
And the CT scan came back nil acute. It was a double contrast CT.
Dr. Steinhart re-examined the abdomen and exam was benign. But when he went to palpate the left CV angle for tenderness, he noted that the patient had obvious herpetic lesions.
And this was the cause of his left flank pain. And this taught me to expose all of the abdomen and the back in order to see everything or we will miss zoster as a cause of flank pain.
4:14 – 5:00
[Case 3] was an individual who was writhing around with abdominal pain. Again was sent for a CT that was normal.
And then his pain gradually subsided to the point he wanted to go home.
So Dr. Steinhart walked into the patient’s room to give a discharge analgesic just as the patient was naked, having removed his hospital. And the doctor noted a right swollen hemiscrotum that turned out to be a torsion.
It taught me that an abdominal exam in a male is not complete until you have examined the external genitalia.
5:01 – 6:20
The 4th case was a shocky individual who had presented with epigastric pain and the team was struggling to get his pressure up.
And Dr. Steinhart was asked to place a subclavian line. And as he worked he heard a very slow heart monitor beeping instead of the rapid audio heart rate you would expect of a shocky patient.
And as I looked up [at the monitor] there is a bradycardia with a third degree block. And I’m going what is going on here?
And when we did the twelve lead, it was a massive infero-posterior MI in a patient who presented with epigastric pain.
And luckily, we caught on to it quickly enough that early [coronary]revascularization got him out of his abdominal pain.
6:21 – 7:56
Lastly is a case of a patient who had progressive abdominal pain that I again inherited and went to see prior to their ordered CT scan.
And interestingly, my abdominal exam showed that she was quite uncomfortable [but] I couldn’t determine the etiology. She was definitely tender everywhere.
And she gave the history of having suffered temporal arteritis and having been on large doses of prednisone. And had finally come off them about a week before.
And I said, that’s interesting. Temporal arteritis is an interesting process.
And as I went back, I thought, I better give this patient a stress dose of methylprednisolone because something horrible is going on in her abdomen in anticipation of a very positive CT scan.
And twenty minutes later after we gave it, the nurse said ‘your patient wants to go home.’
And Dr. Steinhart wondered how he would convince her to stay as she must have something catastrophic going on in the abdomen.
And she said, no, no, what ever you gave me,doctor; My pain is all gone now and I’d like to go home.
And when we looked back at the labs and we reassessed the situation, of course this was an Addisonian crisis presenting as an intra-abdominal catastrophe.
And I cancelled the CT scan and put her back on maintenance prednisone and let her go.
Dr. Steinhart sums up that these five case of thinking outside of the box as examples of thinking of causes of abdominal pain that are outside of the abdomen.
It is not always due to intra-abdominal pathology.