Case of the Month
January 2006

42-year-old female — Upper right quadrant pain

Dispatch

"Aid 32, Medic 6; 42-year-old female, upper abdominal pain"

En route your crew discusses the following considerations:

• Reasons for upper abdominal pain
• Cardiac pain in women
• Postural vital signs

Dispatch relays that the patient has had pain in her upper abdomen about 45 minutes.  She is also experiencing some mild dizziness.

Scene Size-up
You arrive at a residence and the husband of the patient meets you in the front door. He leads you into the living room where the patient is lying on the sofa. The room appears to be safe and there appears to be one patient only.

Initial Assessment
The patient is lying on her back and writhing somewhat. Her skin is pale and mildly diaphoretic. She is guarding her upper right quadrant and wincing. She begins to moan and becomes louder and louder to almost a yell...after a moment she lets up and acts as if she is doing better.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Short report to the medics?

Initial Treatment
You decide that the patient is SICK based on her abdominal discomfort, pale moist skin, and knowing that there are several potential life-threatening conditions that can present as upper abdominal pain.

You quickly advise the medic unit that you have "a SICK patient with upper right quadrant pain." You begin oxygen therapy using a NRM at 10 liters per minute.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The focused history reveals that this abdominal pain has never occurred before. At it’s low it is a 5 of 10 and more of a "severe ache," however it intensifies to a 10 of 10 and becomes "very sharp." The patient writhes on the sofa trying to find a position of comfort, however nothing seems to help. With the second crescendo of pain the patient feels nausea and becomes more sweaty, however those symptoms improve as the pain subsides. The pain does not radiate.

Due to the complexity of the abdomen, and the possibility that the pain could be referred from the chest, your crew does a complete abdominal and chest work up, including:

• Bilateral blood pressures
• Abdominal palpation
• Pulse oximetry
• Breath sounds
• Visualization of the affected area

The medic unit arrives and places the patient on a heart monitor, quickly performing a 12-lead and finding nothing abnormal. The medics shift their exam to focus on the upper right quadrant and perform a test where one of the medics holds pressure on the area of the pain while having the patient slowly inhale deeply. As the patient begins to inhale she immediately stops saying the pain is so intense.

The medics discuss this finding and decide that the patient is most likely suffering from a gall stone or some other billiary (bile system) problem. They explain to the aid unit crew that a BLS transport to the nearest hospital is needed.

Abdominal Pain
The abdomen is a very complicated area of the body. Major organs, major blood vessels and other important structures reside there. The nerves of the abdomen are often vague in reporting pain to the brain. Evaluation of belly pain can be extremely difficult and often a field assessment is very broad.

EMS providers must remember that his or her job is not to find an answer for every diagnostic question but to treat the symptoms seen and, through a thorough exam, try to anticipate if the patient’s condition will worsen.

Gall Stones
In this case the patient seemed to be exhibiting "billiary colic."  This discomfort is most commonly generated by an irregular stone that passes from the gall bladder into the duct that bile uses to travel into the digestive system. These "gall stones" form in the gall bladder over time. The cause is not known. The gall bladder stores bile, which is used by the body to break down fats in the digestive system.

When a person eats a fatty meal the gall bladder excretes additional bile to cope with the fats. This usually occurs about an hour after eating. If a stone is passed into the billiary duct an intense pain occurs. As the stone moves down the duct, the duct spasms which greatly intensifies the pain. As the duct then relaxes the pain subsides. This cycle continues until the stone migrates to the end of the duct.

A similar situation occurs in the ureters when the kidney excretes a stone. Pain from these stones is often described as the equivalent to childbirth without pain control.