Clinical Case Report: Intermittent Abdominal Pain,
Nausea and Vomiting
1.
Patient Information
The patient was a 24-year-old
female who presented for evaluation of gastrointestinal symptoms. The
clinical assessment was performed in a general medicine setting.
No patient-identifying information
is included in this case presentation in order to maintain confidentiality.
2.
Chief Complaints
The patient presented with the
following complaints:
- Intermittent abdominal pain
- Nausea
- Vomiting
The abdominal pain was reported to
occur intermittently rather than being continuously present. The available
clinical record did not provide further characterization regarding the exact
site, severity, radiation, or aggravating and relieving factors.
3.
Clinical Assessment
At presentation, the recorded vital
parameters were:
- Blood Pressure:
100/50 mmHg
- Pulse Rate:
64 beats/minute
- SpO₂:
98% on room air
- Weight:
46 kg
The available documentation
primarily focused on the presenting gastrointestinal symptoms and subsequent
abdominal imaging. No additional significant systemic examination findings were
documented in the available clinical information.
4.
Diagnostic Evaluation
Ultrasound
Examination of the Abdomen and Pelvis
An ultrasound examination of the
abdomen and pelvis was performed as part of the evaluation of the patient's
abdominal symptoms.
Liver
The liver was normal in size,
measuring approximately 14 cm, with normal echotexture. No focal hepatic
lesion was identified. The portal vein and common bile duct appeared normal.
Gallbladder
The gallbladder was described as partially
distended. No significant abnormality was reported on the available
ultrasound examination.
Spleen
The spleen was normal in size and
demonstrated normal echotexture.
Pancreas
The pancreas was poorly
visualized because of a limited acoustic window. Therefore, complete
sonographic assessment of the pancreas was limited.
Kidneys
Both kidneys were normal in size and
echotexture, with preserved corticomedullary differentiation.
The right kidney measured
approximately 10.5 × 4.8 cm, while the left kidney measured
approximately 10.7 × 4.1 cm.
There was no evidence of
hydronephrosis or renal calculi in either kidney.
Pelvic
Organs
The uterus appeared normal, with an
endometrial thickness of approximately 8 mm. Both ovaries were reported
to be normal.
The urinary bladder was well
distended and did not demonstrate a significant abnormality.
Lower
Abdomen
No mass lesion was identified in the
iliac fossae on the available examination.
Radiological
Impression
Overall, the ultrasound examination
of the abdomen and pelvis showed no significant abnormality.
Clinical correlation was
recommended. Further laboratory evaluation, including serum amylase and
lipase levels, was suggested as clinically appropriate during the
evaluation of the patient's abdominal symptoms.
5.
Treatment and Management
The patient was prescribed
symptomatic medical treatment for the gastrointestinal complaints.
Rifaximin
Rifaximin 400 mg was prescribed at a dose of one tablet twice daily
for 10 days.
Rifaximin is a minimally absorbed
intestinal antibiotic that is used in selected gastrointestinal conditions. Its
use in this case formed part of the prescribed gastrointestinal management.
Mebeverine
Mebeverine 135 mg (Colospa) was prescribed at a dose of one tablet twice daily
for 5 days.
Mebeverine is an antispasmodic
medication commonly used for relief of intestinal smooth-muscle spasm and
associated abdominal discomfort.
Ondansetron
Ondansetron 4 mg (Ondem) was prescribed at a dose of one tablet three times daily
for 5 days.
Ondansetron is an antiemetic
medication used to control symptoms of nausea and vomiting.
Pantoprazole
Pantoprazole 40 mg (Panpraz) was prescribed at a dose of one tablet once daily
for 15 days.
Pantoprazole is a proton pump
inhibitor that reduces gastric acid secretion and is commonly used when
acid-related gastrointestinal symptoms are suspected or require symptomatic
treatment.
6.
Clinical Impression
The patient presented with intermittent
abdominal pain accompanied by nausea and vomiting. The available ultrasound
examination did not demonstrate a significant structural abnormality in the
abdomen or pelvis.
The liver, spleen, kidneys, uterus,
ovaries, urinary bladder, and visualized abdominal structures were essentially
unremarkable. The pancreas was not adequately visualized because of a limited
acoustic window.
The clinical presentation therefore
required correlation with the patient's symptoms and, where appropriate,
additional laboratory evaluation. Serum amylase and lipase testing were
suggested as part of further assessment.
The prescribed treatment was primarily
symptomatic and included an intestinal antibiotic, antispasmodic, antiemetic,
and proton pump inhibitor. The combination was directed toward the patient's
gastrointestinal symptoms rather than treatment of a confirmed structural
abnormality on imaging.
7.
Discussion
Abdominal pain associated with
nausea and vomiting is a common clinical presentation with a broad differential
diagnosis. Causes may range from functional gastrointestinal disorders and
transient gastrointestinal disturbances to inflammatory, infectious,
hepatobiliary, pancreatic, urinary, or gynecological conditions.
In this case, abdominal
ultrasonography did not identify a significant abnormality. The absence of an
abnormal finding on ultrasound does not, by itself, establish a specific functional
gastrointestinal diagnosis, and the final clinical interpretation should be
based on the complete history, physical examination, laboratory investigations,
and subsequent clinical course.
The normal appearance of the kidneys
and absence of hydronephrosis or calculi make a significant sonographically
detectable renal obstructive process less evident. Similarly, the normal
reported appearance of the liver, spleen, uterus, and ovaries provides no
obvious structural explanation for the presenting symptoms on this examination.
Because the pancreas was poorly
visualized, biochemical testing may provide additional information when
pancreatic disease is clinically suspected. Serum amylase and lipase can
therefore be considered according to the clinical presentation and treating
physician's assessment.
8.
Conclusion
This case describes a 24-year-old
female presenting with intermittent abdominal pain, nausea, and vomiting,
with no significant abnormality identified on abdominal and pelvic
ultrasonography. The patient received symptomatic treatment with rifaximin,
mebeverine, ondansetron, and pantoprazole. Further clinical correlation and
laboratory evaluation were advised according to the persistence or progression
of symptoms.
This case highlights the importance
of correlating gastrointestinal symptoms with clinical examination and
appropriate investigations, particularly when initial imaging does not
demonstrate a definite structural cause.
References
National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Diagnosis of Indigestion (Dyspepsia).
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