Sample Board Case
An elderly woman in her mid-eighties comes in with acute onset abdominal pain that started after dinner. She has multiple cardiovascular risk factors and is on digoxin and a DOAC for unknown cardiac reasons. She has received multiple doses of morphine and hydromorphone and still says to you that her pain is greater than the pain from having her children vaginally. And this woman had six children vaginally. She doesn’t strike you as a drug seeker and her family members tell you she normally doesn’t use pain medication. When you examine her abdomen, it is firm and almost rubbery. She points to the point where it hurts the most. You start touching from the other site and gradually palpate over it and she says it hurts but she doesn’t wince in pain from your palpation. Yet she still affirms to you that the pain is killing her.
What is the right description of her pain?
Pain out of proportion to physical examination!
“One of the distinctive findings in mesenteric ischemia is that of abdominal pain that is out of proportion to examination. The patient may be screaming in pain, but their abdomen is soft with no guarding or rebound.”
Note: There is a difference between peritoneal signs (signs of peritoneal irritation) and pain out of proportion to examination.
If you touch a patient’s abdomen a little and they jump or seem to experience more pain, those are signs of peritoneal irritation, not pain out of proportion to physical examination!