Acute Abdominal Pain: Manage Without Delay

Chris Pasero, MS, RN-BC

Disclosures

August 02, 2013

Clinical Presentation: Abdominal Pain in the Emergency Department

The patient is a 21-year-old woman admitted to the emergency department (ED) with nontraumatic abdominal pain. She is being evaluated for possible appendicitis.

History and Physical Examination

History. The nurse obtains the following information about the patient's pain and other symptoms:

  • She guards her abdominal area and describes severe "cramping" and "sometimes sharp" pain in her lower right abdominal area ("feels much worse than cramps during my period").

  • She rates the intensity of her pain as 10 on a 0-to-10 numerical pain rating scale.

  • The pain has been continuous and has worsened since it began 48 hours ago.

  • Although the 650-mg of oral acetaminophen taken 3 hours ago reduced her fever of 100.8°F to the current 99.6°F, it has been ineffective in reducing the pain. She has taken no other analgesics.

  • She tried both warm and cold application to her abdomen, without relief.

  • She is intermittently nauseated and has vomited clear greenish fluid twice in the past 24 hours. The only oral intake she has been able to retain in the past 24 hours was one half of a cup of clear soup 6 hours ago.

  • She reports constipation; her last bowel movement was 3 days ago. Her usual bowel pattern is daily evacuation.

  • Her most recent menses ended 10 days ago.

  • She denies tobacco or alcohol use and has no known allergies.

Physical examination. Physical examination revealed the following:

  • General appearance: otherwise healthy, alert, and oriented woman demonstrating behavioral signs of pain, including grimacing, moaning, and guarding of abdomen

  • Height, 5'4"; weight, 122 lb

  • Oral temperature: 99.6°F

  • Pulse: 92 beats/min

  • Respiratory status: Bilateral breath sounds are equal and clear; respiratory rate is 20 breaths/min.

  • Skin is warm, with no diaphoresis; nail beds and general skin color are pink

  • Blood pressure: 128/72 mm Hg

  • The patient describes "sharp" pain when the physician palpates her abdomen; she recoils and pushes away the physician's hands during the examination.

  • Psoas sign is positive.

The admitting ED nurse requests pain medication for the patient, but the ED physician replies that analgesia can mask the diagnosis, so it will be withheld until a complete physical exam, CT scan, and all lab work are obtained and evaluated.

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