Practice Clinical Scenario: Case of Abdominal Pain
Practice clinical case scenario! Try to solve the case! Figure out the diagnosis and how you would manage it. Great for medical, nursing, and healthcare students or professionals, and USMLE, NCLEX, licensure/board prep!
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Practice Clinical Case Scenario
This lecture will walk you through a high-yield clinical case.
You’ll first be given a scenario, and then as we go through the case try to figure out the diagnosis and how you would manage it.
This is good practice for nursing, medical, and healthcare students, and is also great preparation for the USMLE, NCLEX, and any medical licensure or board exam.
Stay tuned until the end to see if you diagnose and manage the patient correctly!
There will be some high-yield learning points at the end too!
Let’s get right into it!
Clinical Case Scenario: 68-year-old male presenting with epigastric abdominal pain
The Case: Patient Arrival
A patient arrives to you for further evaluation.
Initial Triage Information:
A 68-year-old male presenting with epigastric abdominal pain.
Vital Signs on Arrival:
Blood Pressure (BP): 117/78
Heart Rate (HR): 67
Respiratory Rate (RR): 22
Temperature (T): 37.2 C or 98.9 F
Oxygen Saturation (O2 Sat): 96%
Ask Yourself…
What is your initial broad differential diagnosis?
What other questions would you ask the patient to help figure out the diagnosis?
Clinical Case Scenario: Triage chief complaint and vital signs on arrival
History of Present Illness (HPI)
Examples of more questions you might ask the patient:
Location of the pain?
Whether the pain radiates or is localized?
What does the pain feel like? (Burning, stabbing, sharp, dull, etc.)
How severe is the pain? (1-10 rating)
Does anything make the pain better or worse?
Has he tried anything for his symptoms?
Does he have any associated symptoms?
Has he had similar symptoms in the past?
What is his past medical, surgical, social, and family history?
Any allergies?
Does he take any medications?
History of Present Illness
As you evaluate the patient you learn the following:
The patient is a 68-year-old male with a history of hypertension and diabetes presenting with 3 days of localized epigastric abdominal pain. The pain is intermittent and a “burning” sensation. Today’s episode began while raking the leaves. Pain is currently a 7/10. He reports nausea without vomiting. Denies dyspnea (shortness of breath), cough, congestion, fevers, urinary symptoms, or changes to stool.
Past Medical, Surgical, Social, and Family History
Past Medical History (PMHx): Hypertension and Type 2 Diabetes
Past Surgical History (PSHx): None
Social History (SHx): Former smoker (1 pack of cigarettes/day), quit 5 years ago
Family History (FHx): Hypertension - Father
Allergies and Medications
Allergies: None
Medications: Lisinopril and Metformin
Practice Case Scenario: History of present illness (HPI) and past medical (PMHx), surgical (PSHx), social, and family history (FHx) along with allergies and medications
Physical Exam
After obtaining information from the patient, you perform a physical exam.
General
When you walk in the room you see a 68-year-old man who is alert and oriented, is in mild distress due to pain, and appears pale and clammy.
ABCs (Primary Survey)
Airway: Intact, speaking in full sentences
Breathing: No significant respiratory distress, but does have an increased respiratory rate
Circulation: Cool, clammy, and pale skin, normal pulses and normal capillary refill
Physical Exam (Secondary Survey)
Head and Neck: Normal
Chest: No reproducible pain to palpation to chest wall, no signs of chest trauma
Heart: Regular rate and rhythm (RRR) without rubs, gallops, or murmurs
Lungs: Clear to auscultation bilaterally without wheezes, rhonchi, or rales
Abdomen: Soft, non-tender, non-distended, without signs of trauma. Bowel sounds present. No masses. No rigidity, rebound tenderness, or guarding
Extremities: Normal
Back: Normal
GU: Normal
Neurological: Normal
Skin: Cool, clammy, and pale without edema or clubbing
Ask Yourself…
What is your differential diagnosis now?
What are your next steps in management?
Practice Case Scenario: Physical exam including primary and secondary survey
Practice Case Scenario: Physical exam
Initial Management
Next steps include:
Cardiac monitor
Continuous pulse oximetry
2 large-bore peripheral IVs placed
Given the patient has a history of diabetes and is cool, clammy, and nauseous after raking the leaves, a quick point of care glucose should be obtained to assess his blood sugar.
Fingerstick glucose results: 122
Ask Yourself…
What would your work up be?
What labs or tests would you order?
Clinical Case Scenario: Initial management
Diagnostic Work Up
Let’s go through work up considerations and why they should be ordered.
EKG
Hopefully you thought of an EKG to assess cardiac etiologies.
Given the patient is a 68-year-old male with cardiovascular risk factors (hypertension, diabetes, is a former smoker, etc.) and is presenting with epigastric abdominal pain, this patient should have an EKG performed immediately on arrival.
Complete Blood Count (CBC)
Labs should also be ordered including a CBC.
Although non-specific, the white blood cell count may be abnormal with infectious or inflammatory causes of his symptoms.
Based on your differential diagnosis, there were likely conditions that may require intervention, anticoagulation, reversal of bleeding, or are associated with bleeding, so it is helpful to have hemoglobin and platelets as well.
Chemistry
A chemistry should also be ordered, especially given his abdominal pain and history of diabetes.
A chemistry will include electrolytes, renal function, and glucose.
Liver Function Tests (LFTs)
Given his epigastric pain, you should consider liver function tests to assess hepatobiliary causes to his symptoms (liver, gallbladder, or biliary system) such as hepatitis, cholecystitis, gallstones, etc.
Lipase
Similarly, a lipase should be ordered to assess pancreatic causes of his epigastric abdominal pain such as pancreatitis.
Troponin (Cardiac Enzymes)
As mentioned above, cardiac etiologies should be considered given his cardiovascular risk factors and epigastric pain.
Therefore, a troponin or cardiac enzymes should be ordered.
Coagulation Studies (PT/INR/PTT)
Finally, you can consider coagulation studies.
This is good to have especially if the patient requires procedures, anticoagulation, or reversal of bleeding for any reason.
Other Labs
While these are the main labs to consider for this particular case, you may have thought of others including (but not limited to) lactate, urinalysis, blood gas, d-dimer, etc.
Imaging
What about imaging?
You could consider a chest x-ray as part of the cardiac work up given the patient’s presentation, increased respiratory rate, and the cardiac reasons mentioned for the EKG and troponin.
You could also consider a quick bedside abdominal US if concerned for AAA, or a thoracic US to view the heart, lungs, etc.
Even though the patient complains of epigastric pain, an abdominal x-ray to assess an acute abdomen (such as perforated gastric ulcer) or a CT abdomen and pelvis are probably not necessary at this time.
The patient has a very benign abdominal exam and other conditions need worked up first.
Remember you can always adjust the plan as you get more information.
Clinical Case Scenario: Diagnostic work up
Results
As you finish putting in orders and are considering what medications to give the patient for his pain and symptoms, you’re handed this EKG.
EKG
Practice Case Scenario: EKG results
Ask Yourself…
How would you manage this patient?
What are your next steps?
EKG interpretation below.
EKG Interpretation
There are ST elevations in leads II, III, and aVF.
There are also reciprocal ST depressions in lead aVL.
Leads II, III, and aVF represent the inferior leads, so this EKG is concerning for an acute inferior myocardial infarction.
Ask Yourself…
How would you manage this patient?
What medications would you administer?
Practice Case Scenario: EKG interpretation showing an inferior wall myocardial infarction (Inferior STEMI)
Management and Treatment
You should follow your institutional protocols for a STEMI.
STEMI protocols can change over time so make sure you follow current guidelines.
Activate the Cardiac Cath Lab
You should activate the cardiac catheterization lab for intervention and potential coronary stent placement for his myocardial infarction.
The top priority is to restore blood flow to the heart as quickly as possible.
Communicate with Cardiology
You should consult and communicate with the interventional cardiologist or appropriate provider.
Aspirin
The patient should receive aspirin.
Antiplatelet (Clopidogrel, Ticagrelor, Etc.)
Most facilities recommend dual antiplatelet therapy with aspirin and a P2Y12 inhibitor such as clopidogrel or ticagrelor.
Remember many STEMIs are caused by coronary artery plaque rupture.
This then causes platelet adhesion, activation, and aggregation, as well as activation of the coagulation cascade to form a thrombus.
The thrombus can occlude the coronary artery and reduce blood flow to the heart.
By inhibiting platelet function, you are trying to reduce and minimize thrombus formation and worsening of the coronary artery occlusion.
You want to try to improve blood flow through the artery.
Anticoagulant (Heparin, Etc.)
Similar to the reasoning above, many protocols will include an anticoagulant such as heparin.
This again is to help reduce thrombus formation from the coagulation cascade.
You should discuss which medications to give in conjunction with the cardiologist because they might be giving medications too as the patient goes to the cath lab.
Good communication is important for the patient!
Symptom Management
Finally, you might need to treat the patient’s symptoms as long as there are no contraindications.
This might include pain control with analgesics, and nausea control with antiemetics.
Some analgesics may interfere with anti-platelet effects, so be aware of that.
Again you can discuss additional medications with cardiology.
What About Nitroglycerin? Fluids
What about nitroglycerin?
Did you include nitroglycerin when you were brainstorming your treatment?
What about fluids, are they safe?
Clinical Case Scenario: Management and treatment
What about Nitroglycerin? Fluids?
Let’s look at nitroglycerin first.
Nitroglycerin
Should you give nitroglycerin to this patient?
Remember nitroglycerin is often given for angina or acute myocardial infarctions (MIs) because it causes vasodilation.
Coronary artery dilation increases blood flow to the myocardium, which is what we want during a myocardial infarction.
Inferior wall MIs are different, however.
Inferior wall MIs can involve the right ventricle, and the right ventricle relies on preload for adequate cardiac function,
Nitroglycerin reduces preload through its vasodilation, and this could potentially be detrimental to right ventricular function.
This can cause hypotension and hemodynamic instability.
As a result, nitroglycerin should be avoided in inferior wall MIs especially if right ventricular involvement is unknown or suspected.
Right-Sided EKG
You should consider getting a right-sided EKG for all inferior wall MIs.
A right-sided EKG can be obtained by placing some or all of the V1-V6 leads in a mirror-image on the right side of the chest.
Or you can simply place V4 in the right 5th intercostal space in the mid-clavicular line.
If ST elevations/changes are present in the right-sided leads, then that could suggest a right coronary artery occlusion and right ventricular involvement.
Hypotension can ensue without adequate preload or if nitroglycerin is administered.
Fluids
What about fluids? Are they safe?
If the inferior wall MI involves the right ventricle, then the patient may require sufficient preload to maintain adequate cardiac function as discussed above.
So if the blood pressure is low, then giving small fluid boluses may be helpful up to a certain point as long as there are no contraindications.
Clinical Case Scenario: Management considerations for nitroglycerin and fluids
Key Learning Points
Let’s go over the key learning points.
Diagnosis
This was a case of acute coronary syndrome, specifically an inferior wall myocardial infarction with ST elevations in the inferior leads II, III, and aVF.
Atypical ACS Presentations
Be mindful of atypical ACS presentations, especially in populations involving the elderly, diabetics, and females.
They may not present with the classic exertional crushing chest pain.
Instead they can present with epigastric pain, nausea, dyspepsia, fatigue, etc.
Do not forget an EKG! You do not want to miss an MI. An EKG and cardiac labs should be ordered and/or considered.
Right-Sided EKG
Consider getting a right-sided EKG with inferior wall MIs.
If a right-sided EKG had been performed in this case, it would have shown ST elevations in the right sided leads suggesting right coronary artery occlusion and right ventricular involvement.
Nitroglycerin
Avoid nitroglycerin with inferior wall MIs, especially if right ventricular involvement is unknown or suspected.
Nitroglycerin decreases preload which can be detrimental to right ventricular/cardiac function.
This can cause hypotension and hemodynamic instability.
Other Results
The other results would have come back with a positive troponin, and the rest of the labs and chest X-ray were overall unremarkable.
Clinical Case Scenario: Learning points
Differential Diagnosis
Here is an example differential diagnosis for the case.
This is not necessarily a complete list, and you may have thought of others.
Clinical Case Scenario: Differential diagnosis example
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