A case of a girl with stomach pain…

Stomach pain -or as they are medically known – abdominal pain is a very common complaint and one that almost all of us must have had at some point in our lives. There are many kinds of stomach pains. We can categorise them based on how they feel: eg. dull, sharp, burning, crampy. We can do one better and categorise them on location: upper abdominal, lower abdominal, right upper, left lower. We can even categorise them based on how long the pain has been there for: seconds? Minutes? Days? Years!? By doing this we can already start to form what sorts of things are probably going wrong in the abdominal area. This is called a focussed history taking of a patient. Not that I’m an expert but I’m going to attempt to discuss a particular case of a woman with abdominal pain and through that case, hopefully highlight to you how important a good history is.

History taking is possibly the single most important thing to be able to do. Not just for doctors. But for paramedics – they’re often the first on scene in trauma. For police officers – they often want as much detail as possible especially if the pain is a result of a crime related event. For nurses – they see the patient every day. In fact for anyone who ever speaks to a patient, taking a history is vital. How can you solve a problem when you only have half the clues. Clinical histories should follow a set format. This is so everyone who listens understands immediately the urgency of the situation and what further steps should be taken. A good history is short, concise and doesn’t leave the listener with lots of questions. So, lets begin our case.

Patient: 23 YOF (year old female), student, no medical history of note

Presenting Complaint: Lower abdominal pain, onset at 8pm in the evening.

History of presenting complaint: Pain started near the umbilicus (belly button) as a dull pain which steadily got worse. It became a cramp like pain which got worse and then improved but never quite left – was coming on in waves. Pain was reported to be 9/ 10 at its worst and 5/10 at its best. Patient took 2 buscopan tablets one hour apart at 10 pm and 11pm. Patient took two paracetamol tablets at 12am. Patient called NHS 111 at 2am and an ambulance was sent out. Paramedic gave Nitrous oxide (gas and air) and took patient to local hospital A&E. Pain started to recede at 3am but not completely gone. ECG, vitals and blood test done. Intravenous Omeprazole was given at 3:30am. By 4am, patient was fully pain free and self-discharged.

Past medical history none of note

Medicines: Regularly takes Vitamin D. This evening took buscopan (antispasmodic), paracetamol (pain killer), nitrous oxide as prescribed by paramedic (smooth muscle relaxant) and IV Omeprazole (proton pump inhibitor so stops acid secretion in the stomach)

Social History lives with parents, university student, no recreational drug use, non-smoker, occasional use of alcohol. no recent travels, no recent meals outside of home

Examination findings Normal heart rate, normal blood pressure, Oxygen saturation: 98% on room air, ECG tracing normal with some sinus arrhythmia, mild fever, blood tests showed slight elevation of white blood cells (white blood cells often go up in infection)

Systems enquiries: None of note.

This completes the history taking. The next step is to formulate a differential diagnosis list. This is your top 3 ideas of what the cause of the abdominal pain. These are my top 3 and I will explain why:

  1. Ectopic pregnancy – this is a young woman of reproductive age with severe abdominal pain. This is a clinical emergency and must not be overlooked
  2. Appendicitis –  the location, severity and type of pain is typical of appendicitis. Combined with the mild fever makes this very likely.
  3. Gastritis – there were no other organ involvement (eg. liver, kidney or spleen) so this could very well be the cause of the pain

Now you want to decide what you are going to do to confirm the cause of the pain:

  • X-ray?
  • Ultrasound of the abdomen?
  • more blood tests?

Of course it wouldn’t ever be just one person doing all this. Its a team effort. With the patient’s problem being the centre of it all.

That’s all for now!



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