Mnemonic for Right Lower Quadrant Pain

A 19-year-old female

Tubo-Ovarian Abscess chapter written by Matthew Lisankie, Charlotte Derr, Tomislav Jelic from Canada is just uploaded to the Website!

A 19-year-old female presents to the emergency department complaining of 48 hours of worsening, stabbing left lower quadrant abdominal pain. The patient notes an intermittent, foul-smelling vaginal discharge for the past week. She also endorses fever, nausea, vomiting, dyspareunia, dysuria, and generalized fatigue. The patient is sexually active with one male partner and uses combination OCPs in conjunction with inconsistent utilization of condoms. She denies vaginal bleeding, fevers, jaundice, vomiting, constipation, or diarrhea. Her last menstrual period (LMP) ended 16 days ago and was typical of her usual menses. The patient has a history of menarche at 14 and coitarche at 17. She denies any use of tobacco but admits intermittent alcohol and marijuana use. She has no past medical or relevant family history. There are no known drug allergies.

Physical exam reveals a well-developed female in mild discomfort but no acute distress. Her vitals are unremarkable except for a temperature of 38.5 and a heart rate of 102. Her abdominal exam reveals moderate tenderness to palpation, worse in the left lower quadrant, with no rebound tenderness. There is no costovertebral angle tenderness, Rovsing sign or McBurney point tenderness. External genitalia is unremarkable. A pelvic exam demonstrates foul purulent discharge in the vaginal vault emanating from the cervical os with no visible blood products. Cervical motion tenderness and pain on palpation of bilateral adnexa are present. Left adnexa is more tender and has a palpable mass on it.

by Matthew Lisankie, Charlotte Derr, Tomislav Jelic from Canada.

What is your next move?

In case you didn’t encounter an elderly with abdominal pain today!

A 72-year-old male patient presented with mild abdominal pain. BP: 145/68 mmHg, HR: 83 bpm, RR: 16/min, T: 37, SpO2: 98% in room air. He has a history of hypertension and diabetes mellitus around 25 years. On the exam, you appreciated a pulsatile mass and checked for the aorta with bedside ultrasound. Here is the cine record of the patient.

What is your next action?

Feel free to give your answers at the comment box below.

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A 35-year-old female with abdominal discomfort

A New Chapter Is Just Uploaded To The Website!

A 35-year-old woman presents to the emergency department with right upper quadrant pain of two hours duration. She awoke several hours after eating a large meal. Based on increasing pain and nausea she presents for evaluation. She denies vomiting, fever or dysuria.
Her past history is notable for diet-controlled type II diabetes, dyslipidemia, and essential hypertension. Her BMI is 33. Her only medication is lisinopril 10 mg daily. She has never had surgery. Her social history is unremarkable. She neither drinks alcohol nor uses tobacco. She has begun to diet and reports recent weight loss.

Her temperature is 37ºC, blood pressure: 110 / 70 mm Hg, pulse: 90 beats per minute. Physical exam reveals an overweight female in mild distress secondary to right upper quadrant pain. She cannot find a position of comfort and describes the pain as similar to labor pains. Pertinent exam findings include: chest exam normal, cardiac exam normal, abdominal exam demonstrates normal bowel sounds and no rebound in any quadrant. She has guarding to inspiration with palpation over the gallbladder which called positive Murphy’s sign. Rectal exam normal, stool is hemoccult negative for blood.

Pertinent lab values: glucose 110 mg/dL, alkaline phosphatase 120 U/L, alanine aminotransferase (A.L.T.) 25 U/L, aspartate aminotransferase (A.S.T.) 25 U/L, gamma glutamyl transferase (GGT) 20 U/L, direct bilirubin 0.1 mg/dL, total bilirubin 0.5 mg/dL, lipase 20 U/L.

The emergency physician performs a focused right upper quadrant ultrasound and finds gallstones without associated gallbladder wall thickening or pericholecystic fluid. In addition, the patient has a “sonographic Murphy sign”: there is maximal abdominal tenderness when the ultrasound probe is pressed over the visualized gallbladder.

57 - Gallstones

An I.V. was established, and the patient received an isotonic fluid bolus. In addition, ketorolac 30 mg I.V. and ondansetron 4 mg I.V. were administered.
Over the course of an hour symptoms resolved. Absent evidence of gallbladder inflammation or infection, she was discharged from the emergency department and referred to a general surgeon for elective cholecystectomy. She was advised that her pain might return but if it is prolonged, is associated with fever or jaundice she is to return to the emergency department.

by Dan O'Brien from USA.

Don’t Touch My Belly!

A New Chapter Is Just Uploaded To The Website!

A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of worsening abdominal pain. He felt nauseated and vomited twice. His pain started around the umbilicus, moved to the left side of his abdomen and then become generalized. It peaked the last few hours, and the painkillers did not work. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. The past and family histories were unremarkable. His blood pressure was 100/60 mmHg, pulse rate 120/min, the temperature 37.8°C (100°F), and respiration rate 24/min. Physical examination showed diffuse abdominal tenderness and voluntary guarding. Bowel sounds were not heard. 

52 - Perforated Viscus

Bedside ultrasonography (USG) exhibited increased echogenicity of the peritoneal stripe, with corresponding horizontal reverberation artifacts over the liver. Plain chest radiographs confirmed the presence of free abdominal air. Oral intake was stopped, intravenous (IV) catheter was inserted, fluid therapy was started, and cefoperazone sodium was administered intravenously. Blood type and cross, complete blood count and coagulation were ordered. He transferred to the operation theater with the diagnosis of the perforated viscus.

Turkey
by Ozlem Dikme from Turkey.

Severe Fecal Impaction And…

In case you didn’t encounter abdominal pain today!

19.1 - fecal impaction 1

iEM Education Project Team uploads many clinical picture and videos to the Flickr and YouTube. These images are free to use in education. You can also support this global EM education initiative by providing your resources. Sharing is caring!

A 24-year-old female with pelvic pain

How ectopic pregnancy should be delivered to the students/interns. 

Clear, to the point! 

Ectopic Pregnancy

by Dan O’Brien, USA

A 24-year-old woman presents to the emergency department with the complaint of lower abdominal pain and vaginal spotting. She has never been pregnant. Her last normal menstrual period was two months ago. She had light spotting last month and states that her period this month is late. Her history is notable for one episode of lower abdominal pain two years ago thought to be the pelvic inflammatory disease that responded to a two-week course of oral antibiotics. She has no medical allergies and is not on any medications. 

Can you show uterus and ectopic pregnancy in the ultrasound?

Review of systems and family history are unremarkable. Her social history is significant in that she is in a monogamous relationship and is not using birth control. Her general appearance is that of a well-developed female with a temperature of 37ºC, a blood pressure of 110/70 mm Hg and a pulse of 90 bpm. An examination of her abdomen reveals normal bowel sounds, no masses, distension, organomegaly or rebound tenderness. She is mildly tender to palpation in the left lower quadrant. Pelvic exam reveals left adnexal tenderness without palpable masses. The rectal exam is normal with hemoccult negative stool. Pertinent lab values: urine dip pregnancy testing is positive, quantitative serum B-hCG is 2000 mIU/mL, hemoglobin 13 gr/dL, hematocrit 40%. She is Rh-positive. A transvaginal ultrasound performed by the emergency physician during the pelvic exam fails to demonstrate an intrauterine pregnancy. There is a small amount of fluid in the rectouterine cul-de-sac. 2 cm ectopic pregnancy was identified. Two large-bore IV’s were started, the patient was crossmatched for blood and OB-GYN was consulted. Treatment options were discussed.

Elderly With Abdominal Pain!

Acute Mesenteric Ischemia

Rabind Antony Charles, Singapore

A 75-year-old woman presents to your Emergency Department (ED) with diffuse abdominal pain for the past day, associated with diarrhea and vomiting. She says the pain is increasingly worse and has failed to respond to paracetamol and charcoal tablets. She has a history of hypertension, hyperlipidemia, and atrial fibrillation. She has no history of laparotomy. She is alert and oriented. However, she is in distress because of her abdominal pain. The pain score is 9 out of 10. Blood pressure: 96 over 56 mmHg, pulse rate: 125 (irregularly, irregular), respiratory rate 20, pulse oximetry: 98% on room air, tympanic temperature: 37.5 degrees Celsius. Heart sounds: (irregular) S1S2 positive. Lungs sounds are bilateral equal and clear. Abdominal exam reveals diffuse tenderness; it is worse in periumbilical region, no guarding, bowel sounds are sluggish. No scars or hernias noted. Per rectal exam: brown stool. ECG is given on the side.

Rabind Antony Charles

What is the mortality risk?

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Mortality

rates can be between 60-80% especially in patients with greater than a 24-hour delay in diagnosis or presentation
Answer

Is this AAA going to be ruptured?

AAA rupture

Abdominal Aortic Aneurysm (AAA)

Lit Sin Quek

A 75-year-old obese man comes to the emergency department. He has history COPD, hypertension. He is a smoker and on regular follow-up with primary care. He describes sudden onset severe flank and back pain for past 2 hours. He denies any chest pain or dyspnea. He informs the physician about his chronic abdominal pain. His initial vital signs are HR 98 bpm, RR 24/min, BP 190/105 mmHg, T 36.9C. His examination revealed mild abdominal pain without rigidity or rebound tenderness. Bedside ultrasonography performed and the result is shown on the side.

What is the risk of rupture?

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Risk of Rupture

increases with emphysema, smoking, hypertension. Regarding Powell’s (2003, 2007) study aneurisms above 5.5 cm have 9.4% to 32.4% rupture risk in one year.
Answer