Page 128 - Journal of Special Operations Medicine - Spring 2015

An Ongoing Series

Abdominal Pain

Joshua Banting, Tony Meriano, MD

CONCEPT AND OBJECTIVES
The series objective is to review various clinical con­ last 18 hours. He has had two bouts of loose stool and
ditions/presentations, including the latest evidence on feels fatigued. He has been compliant with his malaria
management, and to dispel common myths. In the pro­ medication (mefloquine). He has been eating the same
cess, core knowledge and management principles are en­ food you have been eating. He has no symptoms to sug­
hanced. A clinical case will be presented. Cases will be gest a urinary tract infection, and is not at risk for sexu­
drawn from real life but phrased in a context that is ap­ ally transmitted illness. He has no prior medical illness
plicable to the Special Operations Forces (SOF) or tac­ or surgeries.
tical emergency medical support (TEMS) environment.
Details will be presented in such a way that the reader When you examine him, you find he has a temperature
can follow along and identify how they would manage of 38.0°C (100.4°F). He is alert, his pulse his 80/min,
the case clinically depending on their experience and blood pressure is 125/70mmHg, his oxygen saturation
environment situation. Commentary will be provided is 96%, and his respiratory rate is 14/min. He appears
by currently serving military medical technicians. The hydrated and the results of an examination of his head,
medics and author will draw on their SOF experience neck, chest, and heart sounds are unremarkable. His ab­
to communicate relevant clinical concepts pertinent to domen is soft without any rigidity; bowel sounds are
different operational environments including SOF and present. He has minimal periumbilical tenderness, and
TEMS. Commentary and input from active special op­ no pain with palpation of the right lower quadrant, no
erations medical technicians will be part of the feature. rebound or referred pain, and no tenderness over the
costal vertebral angles.
Keywords: pain; abdominal pain; appendicitis; diagnosis;
treatment
What is going on with this patient? What is your dif-
ferential diagnosis?

This is quite a vague presentation. In summary, you
CLINICAL PRESENTATION: ABDOMINAL PAIN
have a 25­year­old man with nausea, indigestion, cen­
tral abdominal pain, and some diarrhea. Your exami­
SITUATION
nation really does not clarify things any further. Thus,
You are a clinician supporting a Military Training and you are left to make clinical decisions with incomplete
Assistance Program (MTAP) in a permissive country. information—a not wholly uncommon scenario. As a
You are providing medical support for your training team member, you often really “know” the members of
cadre personnel and assisting in medical training of in­ your team. This firsthand knowledge can give insight
digenous personnel. The country is remote, you have into their presentation. For instance, are they usually
limited resources, and evacuation is lengthy and compli­ stoic about pain complaints, have they presented at an
cated. The indigenous medical care in the country is not odd time, or have they awakened from sleep versus not
as advanced as back home. being able to sleep due to pain? Have they missed an ap­
pointment they would have been known to keep? These
One of your male team members comes to see you with types of key behavioral features can help identify pa­
abdominal pain. He is 25 years old. He has been experi­ tients who truly have an immediate concern and direct
encing abdominal pain, nausea, and indigestion for the intervals between serial examinations and reassessment.

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