Approach to Pain out of Proportion Diagnoses

Have you ever heard the term “pain out of proportion”? Have you examined an abdomen that seems benign but your patient was suffering in 10/10 pain?  Let’s go over some of the common “Pain out of Proportion to findings” diagnoses to make sure you don’t miss these on your next ED shift!
 

Case 1

14 year old otherwise healthy male presents to the emergency department with sudden onset abdominal pain. The pain began suddenly while lying down after dinner. 10/10 in severity, radiating into his groin on the left side. He feels nauseous but has not vomited. He endorses testicular pain on further questioning. Vitals at triage: HR 112, BP 118/75, RR 20, SpO2 98%, Temperature 36.9^oC.

Top 3 DDx for this young male:
1. Testicular Torsion

2. Epididymitis

3. Torsion of the appendix testis

 

Testicular torsion is a clinical diagnosis, however most surgeon’s will request a testicular ultrasound prior to taking a child to the operating room. The TWIST score is a CDR that can help determine the benefit of obtaining an ultrasound. It is based on the following

1. Testicular swelling (2 points)
2. Hard testicle (2 points)
3. ABSENT cremasteric reflex (1 point)
4. High, horizontal lie (1 point)
5. Nausea and vomiting (1 point).

Scores of 6-7 indicate that the ED physician should contact urology prior to obtaining an U/S. Scores between 1 and 5 warrant obtaining an U/S. Scores of 0 indicate that torsion is unlikely, however, in the presence of unilateral testicular pain it would be reasonable to obtain U/S based on clinician experience.  However, it is important to note that the TWIST score is NOT a CDR Level I or Level II tool, and this limitation should be kept in mind.

If unsure, you can send for ultrasound OR a quick, bedside POCUS with color doppler can help determine if there is testicular blood flow. Treatment for torsion is emergent urology consult. Salvage rates start decreasing at 6 hours!

Case 2

 

A 68 year old female comes into the emergency department with severe crampy abdominal pain that worsens after food. States the pain is 10/10. She has had one episode of emesis earlier today which was non-bilious and non-bloody. PMHx is remarkable for AFib, HTN, Dyslipidemia, Type 2 diabetes. On exam the abdomen is soft, diffusely tender, and non-distended.

What is your DDx?
- Biliary colic, pancreatitis, peptic ulcer disease, mesenteric ischemia, acute myocardial infarction

A CT scan revealed SMA thrombus with bowel ischemia!

Mesenteric ischemia is a catch-all term for four different pathophysiological states:
1. Hypoperfusion (e.g. inadequate perfusion to the bowel, such as in low cardiac output states or shock)

2. Thrombotic (e.g. atherosclerotic plaque)

3. Embolic (e.g. clot thrown in a patient with AFib)

4. Venous occlusion (SMV occlusion)

With the exception of hypoperfusion of the bowel, patients typically present with cardiovascular risk factors including AFib, hypertension, dyslipidemia, Diabetes Mellitus. On history, watch out for “abdominal angina” – severe abdominal pain post-prandially!

While CT Abdo/Pelvis is about 94% sensitive and 95% specific, bloodwork can help prognosticate as well. Consider ordering:

• Lactate
• VBG
• Electrolytes
• CBC
• Investigations to support and rule-out other differential diagnoses (lipase, troponin, EKG, liver enzymes, bilirubin)

Management in the ED:
Remember the RAPID Mnemonic:

Resuscitation

Analgesia

Patient needs

Investigations

Disposition

For our patient:

Resuscitation – IV crystalloid bolus and maintenance fluids, as third spacing is likely due to ischemia

Analgesia – consider judicious pain control using IV analgesia

Patient needs – keep these patients NPO as they will likely end up in the OR. You can consider starting broad-spectrum antibiotics if the patient appears to be in sepsis

Investigations – see above!

Disposition – be sure to contact your friendly neighbourhood general (or vascular) surgeon, depending on your cause of mesenteric ischemia!

 

Case 3

36 year old male comes into the ED 2 days after a circumferential long-arm plaster splint was placed at a rural urgent care site. He fell off a tree during a hike and fractured his proximal radius and ulna. He comes in today with severe increasing pain and feeling “numb” in his distal extremities. Vitally stable.

DDx:

1. Compartment syndrome
2. DVT

Always consider other diagnoses, but remember the 5 P’s of compartment syndrome:

Pain (out of proportion to clinical findings)

Paresthesia

Pallor

Pulselessness

Paralysis

ED management:

Resuscitation – external compression (e.g. cast) should be removed and the patient’s arm placed at the level of his heart to avoid any dependent swelling

Analgesia – provide IV analgesics

Patient needs – The patient is likely to require surgery, so keep NPO until surgical consultation

Investigations – while compartment syndrome is a clinical diagnosis, direct measurement of the compartment pressure may be warranted if the patient is going for surgery

Disposition – call your friendly neighbourhood Orthopaedic Surgeon for urgent consultation

Case 4

34 year old male presents to emerg with a rapidly progressing blistering “rash” on his arm. He states 10/10 pain. He is otherwise healthy, however states that he had surgery to his arm about a month ago. He also endorsed accidently cutting his wrist with a kitchen knife while at work. On exam he has minimal pain to palpation but still endorses 10/10 pain. Vitals at triage were: 37.9^oC, HR 114, BP 115/80, RR 20, SpO2 96% on RA.

 

What is your differential for this gentleman?
- Necrotizing fasciitis

- cellulitis

This case vignette is trying to portray Necrotizing Fascitis! There are two types of Necrotizing Fascitis:

Type 1 – polymicrobial. Generally both aerobes and anerobes
Type 2 – Single organism, likely group A strep.

Risk factors for Nec Fasc include the following:
- Diabetes, IVDU, Immunosuppression, recent surgery, cut or laceration, peripheral vascular disease, obesity

• Those with diabetes or immunosuppression are more likely to develop type 1 Necrotizing Fascitis

ED Management of Necrotizing Fascitis

Resuscitation – if vitals are unstable, provide appropriate supportive care

Analgesia – Patients are often in severe, out of proportion pain, so IV analgesia is appropriate

Patient Needs – Keep NPO for surgery. Consider early antibiotic treatment with broad spectrum choices such as: clindamycin, vancomycin, pip-tazo if worried about pseudomonas

Investigations – CBC, CBC, Lytes, creatinine, blood cultures, CK. Order a CT scan to evaluate the degree of fasciitis and for surgical debridement planning.

Disposition – the patient will need to be admitted to hospital for surgery.