An 82-Year-Old Woman With Abdominal Pain

James J. McCombie, MB ChB

Disclosures

March 13, 2017

Physical Examination and Workup

The patient is afebrile, with a heart rate of 75 beats/min and a blood pressure of 145/88 mm Hg. Her respiratory rate is 17 breaths/min, and she has an oxygen saturation of 94% on room air. Her tongue is dry, and her skin turgor is reduced.

Figure1.

Auscultation of the lungs reveals globally poor air entry, with some scattered wheezes. The heart sounds are normal. Inspection of the abdomen reveals massive distention. No scars are noted. The abdomen is soft, tympanitic, and without shifting dullness; no tenderness is elicited. No evidence suggests hernia. Bowel sounds are high-pitched, and digital rectal examination reveals no stool in the vault.

Initial interventions in the emergency department include intravenous fluid resuscitation and nebulized bronchodilators. Laboratory testing reveals a normal white blood cell count and differential, a hemoglobin value of 13.6%, a C-reactive protein level of 4 mg/L, sodium level of 134 mEq/L, potassium level of 4.1 mEq/L, urea level of 30.1 mEq/L, and creatinine level of 1.5 mg/dL.

An upright anteroposterior abdominal radiograph is obtained (Figure), which demonstrates a greatly dilated loop of sigmoid bowel extending into the upper abdomen, with an absence of rectal gas. Emergency treatment is rendered before admission, and the patient is admitted for observation. Surgical consultation and evaluation are arranged to determine the most appropriate course of further management.

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