A 76-Year-Old Woman With Abdominal Pain

Craig A. Goolsby, MD

Disclosures

October 02, 2017

Upon physical examination, the patient appears to be in intense pain. She has an oral temperature of 99.4°F (37.4°C). She has an irregular heart rhythm, with a rate of 118 beats/min. Her blood pressure is 101/68 mm Hg, and her respiratory rate is 22 breaths/min. Her pulse oximetry reading is 93% on room air.

In general, she appears older than her stated age. She is appropriately alert and oriented. She has slight expiratory wheezing throughout the bilateral lung fields. No murmurs are appreciated on cardiac auscultation, and her abdomen has only mild tenderness to palpation diffusely. No peritoneal signs on examination, palpable masses, or abnormal pulsations are noted. Rectal examination reveals dark-brown stool that is negative for occult blood. She has no costovertebral angle tenderness. Her extremities are warm, with 1+ bilateral dorsalis pedis pulses.

The patient is placed on a cardiac monitor, 2 large-bore peripheral intravenous lines are placed, and fluid resuscitation with normal saline is started. The patient is given two 8-mg doses of morphine, with some pain improvement. She is given 4 mg of ondansetron for her nausea. A bedside laboratory test shows a hemoglobin level of 12.1 g/dL (121 g/L). Bedside ultrasonography reveals no free fluid in the abdomen. An electrocardiogram (ECG) demonstrates rapid atrial fibrillation, without an acute injury pattern. A stat upright chest radiograph is obtained that demonstrates hyperinflated lung fields, but no free air under the diaphragm or other acute abnormalities are seen.

Laboratory studies, including electrolytes, a hepatic panel, lipase, cardiac enzymes, and a complete blood count, are performed and found to be without significant abnormalities. Her international normalized ratio (INR) is subtherapeutic at 1.4. An abdominal CT angiography scan is obtained; representative images are shown (Figures 1 and 2).

Figure 1.

Figure 2.

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