Podcast: Play in new window | Download
Sue Bodner is a 31 year old woman complaining of abdominal pain following a repeat cesarean section this morning.
Her pain is located in the area of her Pfannenstiehl incision and she describes it as nearly 10/10.
- The location of her pain helps focus our attention to specific issues and away from others.
- Upper abdominal pain would suggest upper abdominal problems, such as stretching of the liver capsule, internal bleeding, ruptured hollow organ, or gastric ulcerative disease.
- Lower abdominal pain suggests a problem with the pelvic organs, bowel, and the incision.
- The severity of the pain tells me that this is not just simple postoperative pain, but more likely has a significant underlying cause.
The pain developed gradually over the last two hours.
- A sudden onset of pain is associated with embolic problems and loss of incisional integrity. This more gradual onset is less specific.
Since surgery this morning, she’s received intravenous ketorolac and hydrocodone bitartrate/acetaminophen orally.
- Intramuscular or intravenous narcotics, such as Dilaudid, Demerol or Morphine provide excellent postoperative pain relief, if administered in adequate dosage and adequate frequency.
- While IV ketrolac can be very helpful in reducing pain, it is not really in the same category as systemic narcotics.
- The oral hydromorphone/acetaminophen is good for mild to moderate pain, but probably not very effective for the intense pain immediately following surgery.
- I would conclude that this patient is undermedicated for pain.
The surgery was reported as uneventful, with EBL of 500 cc.
- This is an important historical fact. It is difficult to estimate blood loss accurately, but this loss is certainly not above average, confirming the uncomplicated nature of the surgery.
- While it’s true that even uncomplicated cesarean sections can have later issues, such as ongoing bleeding, dehiscence and infection, these problems are more likely to occur in the presence of a difficult, complicated surgery.
Her Foley catheter was removed 8 hours ago and since then, she has voided twice, for 200 cc each time.
- Once the Foley catheter is removed, the patient needs to be able to empty her own bladder. This process may be inhibited by incisional pain and localized swelling following cesarean section.
- Postpartum urinary retention is a common problem, presenting with abdominal pain and the patient complaint of inability to urinate.
- In this patient, she is experiencing pain in the general area of the bladder, but has a story of successful urination twice earlier in the day, each resulting in apparently normal amounts of urine.
Her temperature is 97.4, her pulse is 104, her BP is 110/72, and her RR=18
- The absence of a fever suggests a non-infectious cause of her pain.
- The pulse of 104, in a woman who is in severe pain following cesarean section earlier in the day is likely normal.
- The normal blood pressure makes internal bleeding as a cause of her pain less likely.
- The respiratory rate of 18 is also probably normal for someone in her situation.
Her abdomen is soft and non-tender in both upper quadrants.
- The soft upper abdomen rules out such serious complications as ruptured hollow organ or massive internal hemorrhage.
Her uterus is somewhat tender and both lower quadrants are tender with mild rebound tenderness.
- Following a cesarean section, the uterus can normally be slightly tender, although uterine tenderness can also be a sign of uterine infection.
- Rebound tenderness is a nonspecific finding indicating inflammation of the peritoneal surface at the target of the rebound pain.
Her incision is clean and dry.
- With wound dehiscence, there is usually a serosanguinous drainage from the wound.
- With a subcutaneous hematoma, the incision would probably be leaking some blood
Her lungs are clear.
