Clinical solution: 50-year-old female with nausea and vomiting
You are asked to respond to an office for a woman with nausea and abdominal pain; did you get the diagnosis right?
Abdominal pain can be a particularly difficult presentation for EMS providers to assess and diagnose. Causes of abdominal pain in patient’s activating the 911 system can range from simple (constipation) to complex (bowel obstruction) and trivial (flatulence) to life threatening (abdominal aortic aneurysm). Abdominal pain complaints require careful analysis to understand the patient's problem and its severity.
Assessing the abdomen
One of the first steps in assessing a patient’s abdomen is to get an accurate picture of the type of pain the patient is experiencing. Accomplishing this task involves collecting a detailed history of the compliant and taking the time to listen to the answers the patient gives. Make sure that you do not skip ahead to thinking of your next question as soon as you ask the current question.
Ask the patient to rate the severity of their pain and to point with one finger to where the pain is most severe. Be a detective and ask these questions to learn more about the pain:
- Does the pain radiate (move) anywhere else?
- Is the pain constant or does it comes and goes in waves?
- Does anything make the pain better or worse?
- What was the patient doing when the pain started?
- What was the patient doing before that?
Be sure to ask the patient about urination, bowel movements and menstruation, but do so in a setting which provides the patient appropriate privacy. Ask if the patient has a history of similar pain and if so determine how long the episodes generally last.
The list of potential medical conditions which cause abdominal pain is lengthy. Be sure to consider other possible causes, particularly those which are cardiac in nature. Pay attention to associated signs and pertinent negatives of an underlying cardiac condition. For instance, abdominal pain in the presence of shortness of breath, chest or arm pain, dizziness or diaphoresis may lead your assessment toward a differential diagnosis of a cardiac nature. If trained and approved by your system, a 12-lead ECG may be indicated for abdominal pain patients.
After collecting a thorough history, visualize the abdomen and look for any obvious bruising or other injuries or abnormalities. Then begin to palpate the patient's abdomen. Much like listening to lung sounds, palpating the abdomen requires practice to gain and maintain proficiency and is best performed in a slow, methodical manner in the same order every time. One method is to begin palpation in the quadrant furthest from the patient’s pain with light pressure then again with deeper pressure. Potential findings include guarding (protecting a painful area), rebound tenderness (pain increasing when pressure is released) and any sort of mass. Determine if palpation makes the patient’s pain worse.
Abdominal pain refresher
One of the most important steps in treating a patient with abdominal pain is to understand the anatomical structures underlying the area where the patient complains of pain. Many disease processes also have specific groups of symptoms which can result in a certain differential diagnosis.
In Margaret’s case, her pain began shortly after eating. She describes cramping pain which comes in waves and radiates to her back. She has experienced this pain before and it resolves without treatment. This time, however, Margaret is experiencing nausea and vomiting. These symptoms, along with Margaret’s history of Crohn’s disease and being overweight, point to a differential diagnosis of a gallstone .
The gallbladder is a small organ which serves to collect and concentrate bile produced in the liver for later release into the small intestine. A gallstone is a stone formed by the components of bile. Some gallstones can occur without producing any symptoms. Other stones, however can result in inflammation of the gallbladder (cholecystitis) or may block the bile ducts entirely. Determining the extent of a patient’s gallbladder involvement requires a physician assessment and imaging studies.
Pre-hospital treatment of abdominal pain
In most cases, the treatment of patients presenting with abdominal pain in the prehospital setting is largely supportive. Patient’s suffering from hypotension may be treated by ALS providers with fluids and those experiencing pain or nausea should be made as comfortable as possible. Previously paramedics were discouraged from treating abdominal pain patients with narcotics, but this practice has been abandoned in many systems. Refer to your local guidelines before constructing a specific treatment plan for any patient.
Treatment for the woman with abdominal symptoms
After obtaining a history and performing a physical exam you have determined that Margaret may be suffering from gallstones. Based on her vital signs, there is no indication for supplemental oxygen. Your lieutenant advises that the ALS transport unit has a five minute ETA and you confirm that they can continue non-emergent.
Once the transporting unit arrives and you give a report, you assist in lifting Margaret to the stretcher as she still does not feel well enough to stand. The paramedic starts an IV and gives Margaret ondansetron, asking you to help with the medication administration cross-check, to treat her nausea. By this time Margaret says that her pain is beginning to subside. She requests to wait for pain medication until she arrives at the hospital.
The ALS crew transports Margaret without incident.
1. Stern, S. D., Cifu, A. S., & Altkorn, D. (2006). Abdominal pain. In Symptom to diagnosis: An evidence-based guide(pp. 9-31). New York: Lange Medical Books.