Abdominal Pain
Acute abdominal pain is a common presenting complaint. It can be due to a range of conditions some of which are benign and self-limiting and others life-threatening medical/surgical emergencies (Cartwright and Knudson, 2008). This paper will address the issue of abdominal pain from a paramedicine perspective in reference to a 29 year old male patient who presents with this complaint. It will interrogate the provided information and identify other essential information that is needed, three differential diagnoses for the patient, and the pathophysiology of the most probable diagnosis. Lastly, the implications of the case on paramedicine practice will be explored.
The information known about the patient includes his age, gender, presenting complaint, attributes of the presenting complaint, associated symptoms, relieving factors, findings of the ABCDE primary survey, and his past medical history. The patient is a 29 year old male. An ABCDE survey should be conducted on all patients even if they appear well (Ambulance Service of New South Wales, 2011). The initial assessment of the patient using the ABCDE algorithm reveals that the patient is alert and oriented and hence his airway is likely to be patent. On breathing, he has a raised respiratory rate (25 breaths/ minute) and a normal SaO2 (99%). On circulation, he has a raised heart rate (105 bpm) and elevated blood pressure (145/90 mmHg). His peripheral circulation is impaired as he is pale, cool, and clammy. On Disability, the patient is alert and oriented (Ambulance Service of New South Wales). The patient’s chief complaint is abdominal pain of acute onset which he rates as severe (8/10). He reports that he has been having intermittent abdominal pain over the past few weeks but it became severe 2 hours after his dinner. The pain is localized in his upper abdomen and is associated with nausea and vomiting and occasionally constipation. The abdominal pain was in the initial period relieved by vomiting but on this episode it is unrelieved. On examination, his abdomen is tense and looks distended. His past medical history is insignificant; he has no known allergies and is on no medications but takes paracetamol occasionally.
The additional information on the vital signs of the patient that should be obtained includes the strength and rhythm of his peripheral pulse, capillary refill time, temperature, and breathing effort. On account of the presenting complaint, abdominal pain, it is also important to do a 12-lead ECG on the patient to rule out cardiac ischemia. This is because pain due to cardiac ischemia can mimic gastro-esophageal reflux (Queensland Department of Health, 2016). It is also essential to do a random blood sugar on the patient as diabetic ketoacidosis can present with abdominal pain and vomiting (Westerberg, 2013). Other important information in categorizing the severity of the condition can be identified from history and examination. On history, it is important to find out if the patient has a history of hematemesis and blood in stool, fever, increased or reduced bowel sounds, frequent urination, and excessive thirst and hunger. The patient should also be asked whether the pain is crampy in nature or focal/constant. Abdominal examination should be done to reveal whether the patient has focal or generalized tenderness, guarding or rigidity, rebound tenderness, or abdominal masses. General examination should reveal signs of dehydration like dry mucus membranes.
Based on the presenting symptoms and location of the pain in the upper abdomen, the likely differential diagnoses for this patient includes intestinal obstruction, myocardial infarction, and peptic ulcer. The most likely diagnosis in this patient is bowel obstruction. This is because the patient has cardinal features of the condition that are abdominal distension and tenderness, history of constipation, on and off abdominal pain, and signs of dehydration which are cool clammy skin.
On the pathophysiology of bowel obstruction, acute intestinal obstruction happens when there is a disruption in the forward movement of intestinal contents. Such an interruption can affect any point of the gastrointestinal tract. The clinical symptoms vary depending on the level of obstruction that is whether the obstruction is partial or complete. Bowel obstruction can be mechanical or functional. Mechanical obstruction of the bowel is most often caused by malignancy, intra-abdominal adhesions, or intestinal herniation. Functional obstruction of the bowel is caused by abnormalities in intestinal physiology. The accumulation of intestinal secretions together with swallowed air results in progressive distension of the intestine proximal to the point of blockage. This bowel distention is worsened by accumulation of gas from bacterial fermentation. Meanwhile, the intestine distal to the obstruction decompresses as luminal contents pass (Jackson & Raiji, 2011). As the blockage continues, edema of the bowel wall develops, normal absorptive function becomes lost, and there is sequestration of fluid into the lumen of the bowel. There can also be transudative fluid losses from the lumen of the intestine into the peritoneal cavity. Ongoing emesis in the bowel proximal to the blockage leads to additional fluid losses and in effect the loss of sodium, potassium, hydrogen, and chloride, and metabolic alkalosis. All these fluid losses can lead to hypovolemia and dehydration. Overgrowth of bacteria, on the other hand, can take place in the proximal small bowel that is normally almost sterile making the emesis feculent. The bacteria can also translocate across the bowel wall. Excessive bowel dilation interferes with blood flow in the intramural vessels of the small intestine causing reductions in the perfusion of the walls of the intestine. Inadequate perfusion to a portion of the intestine leads to ischemia, necrosis, and perforation of the bowel unless this process is interrupted. Ischemic necrosis of the intestine can also be result from its mesentery around lax intestinal attachments or an adhesive band or twisting of the bowels. Overall concerns about intestinal blockage are effects of increased pressure on bowel perfusion and the impact it has on the fluid/electrolyte balance of the whole body (Jackson & Raiji, 2011).
On the implications to paramedicine practice, abdominal pain can have several differential diagnoses some of which require immediate transfer to a hospital for emergency care. Therefore, it is necessary to employ a thorough and logical approach in the diagnosis of Diagnoses of abdominal pain should thus be diagnosed in a thorough and logical approach (Cartwright & Knudson, 2008). The patient in question should be kept nil per oral and started on intravenous fluids preferably ringer’s lactate because he has a high BP. He should also be given analgesics such as morphine and an antiemetic. Finally, he should be transferred to a hospital immediately for further evaluation and management (Queensland Department of Health, 2016).
In summary, this paper has reviewed the case of a 29 year old male patient whose chief complaint is abdominal pain of acute onset. It has established that more information about the nature of the pain, movement, and associated symptoms is needed for a differential diagnoses and as well as determination of the severity of the underlying condition. The most likely differential diagnoses of the patient based on the available information are myocardial infarction, peptic ulcers, and bowel obstruction. Bowel obstruction is, however, the most probable diagnoses. It can result from mechanical or functional causes. Obstruction precipitates a cascade of events that lead to fluid/electrolyte imbalances and intestinal ischemia. The case has important implications for paramedicine practice especially on the management of patients presenting with abdominal pain.
References
Ambulance Service of New South Wales, 2011. Protocols and pharmacology. [Online] Available at: <http://www.ambo.com.au/download/protocol_2011.pdf> [Accessed 5 August 2016].
Cartwright, S. L. & Knudson, M. P. (2008). Evaluation of acute abdominal pain in adults. American family Physician, 77(7), pp. 971-978.
Jackson, P.G., & Raiji, M. (2011). Evaluation and management of intestinal obstruction. American Family Physician, 83(2), pp. 159-165.
Queensland Department of Health (2016). Clinical practice guidelines: Medical/abdominal emergencies. [Online] Available at: <https://ambulance.qld.gov.au/docs/clinical/cpg/CPG_Abdominal%20emergencies.pdf> [Accessed 5 August 2016].
Westerberg, D. P. (2013). Diabetic ketoacidosis: Evaluation and treatment. American Family Physician, 87(5), pp. 337-346.
