9/10 abdomen pain when I called the ambulance an hour ago. It's now probably 6/10. It's always there and spikes up every fifteen minutes to a point where it's unbearable. I've been getting these pains yearly in my lower abdomen for the past six years. It all started 12 years ago when I had part 4 feet of my terminal ileum and part of my caecum removed after a severe flare up of Crohn's disease. It was fine for the few years after the operation but the pain started 6 years later. Being the holidays and all, I had a really big meal two nights ago with my family. It started to really hurt past midnight, but was bearable until 12 hours later when it really got painful.
Further Hx: Last bowel motion 12/24 ago soft/brown/formed. Severe nausea and vomiting, unable to tolerate solids and only taking small sips of clear liquids. Otherwise well, not on any medications/steroids. No current medical issues.
O/E: Stable afebrile. Rebound and guarding in the lower abdomen with maximum severity in the RIF. Bowel sounds present. Nil renal angle tenderness. Nil masses. Abdomen looks distended but patient says it's normal for him.
Ix: FBE U&E n. CRP 8. AXR shows feacal loading. Otherwise nad erect and supine. No free gas below the diaphragam.
Rebound and guarding are very clinically important signs. The surgical registrar was called.
What is the next step in this patient's management?
Surgial Registrar: First do a DRE. Given the circumstances, a FLEET enema would be helpful and you could do it at the same time as the DRE.
As it turns out, this guy was just really constipated. The DRE was in fact normal and I did not feel anything. There was a bit of soft brown stool on the glove. I did not feel any impacted stool.
10 minutes after the FLEET (read: salt water) enema, he had the "biggest shit in my life". When I saw him next his pain had nearly completely resolved. (now 1/10) and the tenderness in his RIF was gone.
TIL: Constipation can be very very painful. Soft brown stool the previous day does not mean a person is not constipated!
0 comments:
Post a Comment