Case of the Month

Medical Student Elective
Case of the Month
March
Submitted by: Katherine Brown, MS4 Columbia P&S

Chief Complaint
Abdominal Pain and Vomiting x3 hours


HPI
The patient is a 39 yo woman presenting with sudden onset abdominal pain and vomiting over the past 3 hours. The patient reports feeling well at her baseline when she suddenly began to have abdominal pain and feel nauseous after eating dinner. She has since vomited several times, her last bowel movement was 2 days ago, she denies constipation at baseline. She reports 10/10 diffuse crampy abdominal pain, she has never had pain like this before. She denies fevers, chills, sick contacts, CP, SOB, diarrhea, melena, hematochezia, dysuria, hematuria, or history of heavy alcohol use. She has a history of 3 c-sections, s/p lap cholecystectomy, and ex-lap with splenectomy after sustaining MVC several years ago. Also of note she has a ventral abdominal hernia, she is unsure if currently reducible and denies skin changes or localized pain over the location of the hernia.

Review of Systems:
General: no fevers, no chills
HEENT: no HA, no changes in vision, no nasal congestion
Cardiac: no CP, no SOB
Resp: no wheezing
GI: see HPI
GU: no dysuria, no hematuria
Skin: no rashes, no skin changes


Medications:
Omeprazole


Allergies:
IV Contrast


PMH:
None


Past Surgical History:

  1. Cesearean section x3
  2. Laproscopic cholecystectomy
  3. Exploratory laparotomy with splenectomy


Social History:
Occasional alcohol use, no tobacco use, no drug use


Physical Exam:
Vitals: T 97.5 HR 85 BP 159/103 RR 21
General: Obese woman moaning, appears to be in pain
HEENT: head atraumatic normocephalic, mucous membranes moist
Cardiac: RRR, nl S1, S2, no m/r/g
Pulm: CTAB
Abdominal: Obese abdomen, hypoactive bowel sounds, no rashes, no erythema, diffuse tenderness to palpation with rebound and guarding, large palpable rigid mass in lower central abdomen.
Ext: warm and well perfused, no lower extremity edema


Initial Assessment:
39 yo woman with history of multiple surgeries and ventral abdominal hernia presenting with an acute abdomen.


Differential Diagnosis:
SBO secondary to adhesions or incarcerated/strangulated hernia, possibly further complicated by perforated viscus. The differential diagnosis also includes appendicitis, diverticulitis, pancreatitis.


Initial Plan:

  • 1L NS bolus
  • Morphine 6 mg IV for pain control
  • Labs
  • CXR
  • CT abdomen and pelvis with PO contrast
  • Surgery consult


Labs:
Na: 137 / Cl: 103 / BUN: 15 / K: 4.2 / HC03: 20 / Cr: 0.71 / Glucose: 177 / Ca: 9.7
WBC: 21.1 / Hb: 15.4 / Hct: 45.9 / Plt: 340
Differential: Neutrophils 83.3%, no bands
Lactate: 2.0 / Lipase: 111
AST: 39 / ALT: 41 / AlkPhos: 115 / Bili: 0.6 / Prot: 7.6 / Alb: 4.6
Labs notable for a leukocytosis of 21.1, otherwise unremarkable


ED Course:

  • CXR: no free air
  • NG tube placed to suction, 400cc bilious contents suctioned
  • Oral contrast taken via NG tube
  • Patient’s pain improved with 6mg Morphine IV x3


CTAP:




Every month during director’s rounds, our students present interesting and educational cases. This is a synopsis of the case voted to be the best by the students and directors at the end of director’s rounds along with an interesting image.


Program Directors

Jennifer Stratton, MD and Patricia Van Leer, MD
slredmedstuds@yahoo.com
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