Monday, July 8, 2013

Where's the Pain? I

A 40 year old woman with depression, PTSD, and PCOS presents with continued abdominal pain. She localizes the pain to a highly discrete region of her lower right abdomen 2cm in diameter near the lateral aspect of the rectus abdominus sheath. The character of the pain is difficult to describe, and it's worse with standing, walking, stretching, laughing, coughing, and sneezing. While supine, you ask her to raise both legs off the table, and touching the area produces greater pain. Her past surgical history includes a cholecystectomy, appendectomy, and lysis of adhesions. She takes several hydrocodone-acetaminophen pills a day, an oral contraceptive, and sertraline. The rest of her review of systems is negative.

Challenge: What's your diagnosis?

2 comments:

Anonymous said...

DVT in iliac vein?

Craig Chen said...

i like that thought, its definitely on the differential.
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Where’s the Pain? I

This is chronic abdominal wall pain from anterior cutaneous nerve entrapment syndrome. Cutaneous branches of sensory nerves arising from T7-T12 can be entrapped by a fibrous sheath or scarring. The scenario describes the “hover” sign and Carnett’s sign (tensing of the abdominal musculature increases local tenderness).

Source: UpToDate.