Call Review: Possible Causes for Epigastric Pain

[AnthonyM83]

Any thoughts on the cause of this. I know abdominal pain can be any number of things, some we never find out. I'm just weak on this area of epigastric area pain and haven't had any others of this severity for that length of time.

CALL: Abdominal pain. Dispatched at 1AM.

PT: Female, 19, found sitting writhing and moaning in pain at home. Approx. 5'9, 162lbs. Moderate distress.

C/O:

Pain concentrated just above umbilicus to lower sternum, but radiates to entire chest.

Neg back/flank pain.

Sudden onset 8 hours prior while sitting. Described as "sharp" and as "a combination of childbirth and when your sugar is real low, but doesn't feel like either one specifically".

Rates 10/10 feel slightly better laying left lateral.

She says something "feels weird, different" on her stomach when she presses on it, but can't be more specific.

On EMT palpation: Stomach soft/supple, neg pulsating masses, neg rebound tenderness. Could not find what patient was referring to.

Constant, but gets worse in waves.

Nausea/Vomiting all day, whenever she tries eating/drinking.

No longer vomiting, as she fighting it b/c it increases pain (and likely because low stomach contents at this point)

Neg diarrhea (though has avoided bowel movement due to pain)

Neg hematuria

Feels extremely dehydrated.

States difficulty regulating her temperature "I get hot then cold then hot then cold all day".

HX: Neg hx of same. Closest event is pain leading up to appendectomy 2 - 3 months ago. Only complication was that incision wound reopened and was told by hospital to just put a bandaid over it. She was concerned because the reopened wound was very deep "it went all the way in".

Also, Anxiety, Past pregnancies (UNK Gravida/Para), LMP - started earlier that day (UNK if on schedule or not), states very low possibility of pregnancy, but technically possible. Neg allergies. Neg meds. No new/unordinary foods eaten that day. Does not feel sick otherwise. Neg Drugs/ETOH. Neg SOB. Neg Weak/Dizzy.

VS:

BP: 134/68, HR: 96, RR: 24, O2Sat: 100%, Temp: 97.2 Skin: Pink, Warm, Slightly Moist, Eyes: PEARL, EKG: NSR

Impression While the extensive moaning and groaning was probably slightly due to young age and hx of anxiety, her pain seemed very severe. She did not seem to be trying to simply get attention (did not wake up her boyfriend sleeping at home). She was articulate in describing her conditions and answering questions.

[captainstandup]

Although she is afebrile I would be curious regarding some type of nosocomial infection or peritonitis as related to her surgery. Based on your assessment it could be as simple as an unusually painful menstruation cycle, Mittelschmerz, ectopic pregnancy. Another consideration would be gastritis which is fairly common following surgery, trauma, burns etc.

[Dustdevil]

Yeah, my first impression was a peritoneal problem and wondering how she might have ended up with a perforation. The appy answers that question, and leads to the most probable differential. Pain going through to the back is the sign that stands out.

The temp is useless unless I know how it was taken.

[ERDoc]

The differential is large. Which started first the abd pain or the vomiting? Could be gall stones, ulcer, perfed ulcer, gastroenteritis, colitis, pancreatitis, hepatitis, peritonitis, Mallory Weiss tear, Borhave syndrome, some other -itis and an assortment of other things.

[AnthonyM83]

Temp was off an electronic oral thermometer at the ER (who knows how accurate).

To be clear, no radiation to flanks or back.

Pain started first, at first she mistook it for hunger, but it quickly worsened.

[Dustdevil]

To be clear, no radiation to flanks or back.

Ooops, I misread that. :oops:

Thanks for the clarification.

[captainstandup]

Although not related to field care, I'm curious as to what her labs were? Specifically ALT, AST, BUN, Creatnine, Amylase and Lipase, GGT. LDH. Bilirubin.