Abdominal Pain

[Mateo_1387]

How does the back appear? Discoloration noted? Pain to the flanks/retro-peritoneal area?

With the severe tenderness, internal hemorrhage seems to be a real possibility. The bradycardia seems to be the most obvious problem, contributing to the hypotension.

Has there been any other signs or symptoms that have occurred in the past few days?

[paramedicmike]

Does her pain response seem proportionate to your findings?

[J306]

Hmm.. So I'm now leaning towards Post-Partum eclampsia, which can develop anywhere from 24 hrs to 6 weeks after the baby is delivered. In severe cases of eclampsia, especially when untreated, can lead to HELLP syndrome (hemolysis, elevated liver enzymes, and low platelet count). HELLP syndrome presents with RUQ pain/tenderness, fatigue/malaise, nausea/vomitting and can cause DIC (which could explain her cold extremities). It can lead to liver hemorrhage and renal failure if left untreated.

Explains abdominal pain, low BP, and cold peripherals.

[ERDoc]

All good thoughts J306 (although she is not seizing so we would call it pre-eclampsia). Does everyone think she is some form of shock based on the hypotension? How do we account for the hypotension and bradycardia? I'm going to be lazy and ask if we already know what meds she's on instead of going back through 3 pages to find it.

EDIT: Any problems with lactation?

Edited September 10, 2012 by ERDoc

[Bieber]

Last oral intake was a meal of roasted chicken approximately nine hours ago.

Posterior is unremarkable. No bruising, CVA tenderness.

Mike, my findings are yours. Pain response is extreme. Do YOU think it's proportionate based on what you're seeing?

Doc, good to bring up the question of the bradycardia in addition to the hypotension. Only med is Zoloft.

So, no abdominal bruising, rigidity, or distention. Are we thinking this is an internal hemorrhage, or does someone have another idea?

J306, patient has no nausea/vomiting and is not jaundiced, and though she is cold, it is not localized to the skin and there is no presence of petechiae or purpura. Do we think she's cold due to vasopcclusion or from generalized hypotension? Still thinking HELLP syndrome? Why or why not?

Why is her blood pressure low? Why is her heart rate low?

[HarryM]

20mcg Fentanyl and repeat every 3-4min up to 100mcg. Obviously stop if bradycardia or hypotension worsens.

What is the effect of fentanyl administration as above as well as 500ml of NaCl?

At this stage lets also ask about intentional OD or any self-harm that may have occurred.

Edited September 10, 2012 by HarryM

[Bieber]

After about 60 mcg of Fentanyl and 500 ml of NS, patient's heart rate and blood pressure rise. Your new set of vital signs are:

HR: 70

BP: 96/60

RR: 16

Patient adamantly denies any intentional or accidental overdose.

[DFIB]

Because of the elusive etiology I think I would consider this patient to have a probability of decompensation. It could very possibly be hypovolemic because the bolus of NaCl seemed to help.

Epinephrine perhaps?

Maybe a little atropine?

If this patient has post partum pre-eclampsia wouldn't we expect hypertension as opposed to low blood pressure?

Edited September 10, 2012 by DFIB

[J306]

I was considering pre-eclampsia progressing to HELLP/DIC and possible hemorrhage of the liver. Internal hemorrhgage with clotting disorder would explain the low bp and if the patient progressed to decompensated shock would also account for the bradycardia. Yeah, no nausea/vommitting or signs of internal hemorrhage, but I still think that it's a post partum disorder since she has a clean history other than her cholecystectomy 1 year ago..

[ERDoc]

Any chest pain or trouble breathing? Are we in one of those fancy ambulances that have pre-hospital US?