Virginia Research Day 2021

Medical Resident Research Case Reports

27 Expand Your Differential For Abdominal Pain

Introduction: The evaluation of abdominal pain is a complex task. Many variables must be considered. All of the basic requirements of a good history and physical exam must be included in the initial interview with the patient. Imaging is also a consideration in the initial evaluation of the patient. The topic of evaluation of abdominal pain is extensively discussed and written about in all areas of medicine and is nicely summarized in a recent review on UpToDate. In this review of the extensive differential diagnosis list of non-traumatic abdominal pain and associated etiologies, the musculoskeletal (MSK) system was sparsely, if at all, considered as an etiology. As one of the largest systems in the body and fully intertwined with the other systems, this is unfortunately an often-overlooked source of pain. This case is an example of a common musculoskeletal problem, psoas syndrome, presenting as abdominal pain, and demonstrating the need to consider the MSK system in the differential diagnosis of abdominal pain. Case Description: a 22-year-old woman presents to the VSOM office in November 2020 as a referral from OB/Gyn for evaluation of eight weeks of sub- Via College of Osteopathic Medicine-Virginia Campus VCOM Sports and Osteopathic Medicine John C Biery, Jr, DO, CAQSM; Albert J Kozar DO, FAOASM, R-MSK Corresponding author: jbiery@vcom.edu

acute, sharp, intermittent right lower quadrant (RLQ) pain with radiation to the posterior ipsilateral iliac crest. She initially had pain of insidious onset that she felt was reflux and presented to urgent care in August. From there she was sent to the emergency department (ED), back to the ED, then general surgery, then hospitalized for four days with upper and lower endoscopy performed, and most recently gynecologic evaluation with no diagnosis and continued RLQ pain. On evaluation at the VSOM office, her history was significant for a sedentary, student lifestyle, a fall onto her back in December 2019, and a recent increase in lifting and bending at a new job starting in August. Significant physical exam findings include: presence of bowel sounds; RLQ pain with strength testing of her right hip flexor group and right knee extensors, and with direct palpation of the right psoas muscle; a non-neutral (FRS right) L1; and absence of peritoneal signs. The diagnosis was psoas syndrome. Osteopathic Manipulative treatment (OMT) consisting of muscle energy treatment of the L1 somatic dysfunction (SD) and Counterstrain as taught to all preclinical Osteopathic medical students was used to treat the hypertonic, tender psoas

muscle with 95% resolution of her index pain. At a two week follow up visit she remained essentially pain free unless she was very active, but the RLQ pain was resolved while at rest. The initial SD noted had returned, but less severe and was easily treated with more improvement in her pain. Discussion: Abdominal pain is a challenging patient complaint and appropriate evaluation to diagnose and treat or rule out life threatening conditions is necessary. This case exemplifies the need for expanding the differential diagnosis to include etiologies of MSK origin and employ history & physical exam that targets the same. This differential should not only include psoas syndrome, but also the several well know primary and satellite referred pain zones as described by Travell and Simons.

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