Abdominal pain radiating to the back

Abstract

Dr. Teena Kohli: Today’s case is that of a 79-year-old woman who presented to the Emergency Department (ED) via ambulance with a chief complaint of abdominal, back and bilateral leg pain. The patient was in her usual state of health until the evening prior to presentation when she fell in her apartment. After the fall she remained on her couch unable to move her legs. She started to develop abdominal pain, back pain and leg pain. The pain progressively worsened overnight and when she arrived in the ED at 10:00 a.m. the next morning, the pain was severe. She also complained of lack of sensation to both of the lower extremities. The patient had a history of heart disease, diabetes, hypertension, hypercholesterolemia and depression. Dr. Ryan Friedberg: Before Dr. Kohli describes her physical findings, are there any questions regarding the initial history? Dr. Richard Wolfe: Can you describe her cardiac history in more detail? Dr. Kohli: The patient had hypertension and coronary artery disease with a history of myocardial infarction and an ejection fraction of 20%. She underwent a two-vessel coronary artery bypass graft in 1999. She was not known to have any dysrhythmias, did not use tobacco, and was living alone independently. Her medications included lisinopril, gatifloxacin, paroxetine, furosemide, metoprolol, glyburide, atorvastatin, aspirin and doxepin. On physical examination, the vital signs were: temperature 36.4°C (97.5°F), pulse 74 beats/min, blood pressure 130/90 mm Hg, respirations 20 breaths/min, and oxygen saturation 98% on room air. The patient was in moderate distress, sitting up in bed, moaning loudly. She was awake, alert and oriented. The head and neck examination revealed no head trauma, the pupils were equal, round, reactive to light, and the extra-ocular muscles were intact. There was no jugular venous distention. The chest was clear to auscultation bilaterally with no wheezes, rhonchi or rales. The heart had a regular rate and rhythm without any murmurs, gallops or rubs. The abdomen was distended and diffusely tender with guarding, but no rebound tenderness. The back was diffusely tender in the lumbosacral region. The lower extremities were mottled in appearance and cool to the touch. Both legs were plegic and insensate from the groin to the toes. There were no palpable or dopplerable femoral, popliteal or pedal pulses. Are there any questions about the physical examination? Dr. Carlo Rosen: On abdominal examination, did you feel any pulsatile masses? Was a bedside ultrasound examination performed? Dr. Kohli: No pulsatile masses were appreciated on abdominal examination. The tenderness was diffuse throughout the entire abdomen with no specific area that was worse. She described the pain as severe, cramping, aching pain. Before I give the results of the bedside ultrasound, would anyone like to comment on the differ-