Clinical case involving abdominal left lower quadrant or LLQ pain

Before we look at a clinical case involving left lower quadrant (LLQ) pain, let’s review two key components of a medical evaluation.

First, remember the OLD CARTS acronym (onset, location, duration, character, alleviating factors, radiation, temporal patterns, and symptoms), which can help you develop your history of present illness questions. Also, recall how to take SOAP notes (subjective, objective, assessment, and plan). The subjective portion involves allowing the patient to tell you their symptoms. The objective portion includes your physical exam findings. As well, the assessment portion involves your differential diagnoses. Finally, the plan portion is how you plan to treat the patient.

This clinical case involves a 65-year-old male patient who presents with a four-day history of acute LLQ pain.

First, think of your history of present illness questions using the OLD CARTS acronym, and ask the patient what brings them in today. The patient states that the pain is dull and crampy in nature. He reports that the pain is worse with any kind of food, movements such as bending, and urination.

The patient hasn’t had much to eat or drink in the last three days, as he doesn’t have an appetite. Lying still makes the pain better. He also has nausea, vomiting, and constipation, but denies any diarrhea.

So far, the patient has provided a lot of detail about the pain. You can organize his description using the OLD CARTS acronym, which will guide your questions and help create the differential diagnosis.

The onset (O) of the pain was four days ago, and it’s located (L) in the LLQ. He characterizes (C) the pain as dull and crampy, and lying still alleviates (A) his pain. Associated symptoms (S) include nausea, vomiting, constipation, and anorexia.

As you fill in your OLD CARTS list, you notice that he has not told you anything about the duration (D) of pain, radiation (R), or temporal patterns (T), so you ask him directly about those details. He reports that the pain has been crampy for the last four days, but he has noticed episodes like this three times in the last year. The pain radiates into the suprapubic region, and he denies any specific temporal patterns.

When you ask the patient about his past medical history you notice a few things:

• His history is significant for hyperlipidemia (e.g., elevated lipids).
• He takes Lipitor and a daily baby aspirin for heart health.
• He has no allergies to any medications.
• He has had no previous surgeries.

Except for a 102°F (39°C) fever, the patient’s vitals are normal and stable. The patient has a normal BMI of 24 kg / m² but has a distended abdomen. He has no surgical scars or other gross abnormalities.

He has bowel sounds in the upper quadrants but decreased bowel sounds in the LLQ and right lower quadrant (RLQ). No abdominal aortic bruits are heard.

He has appropriate dullness with percussion over his liver and mild tympany over the small bowel near his umbilicus. Upon palpation, he has LLQ and suprapubic tenderness.

Based on the patient’s history and physical exam, a colonic etiology is high on the differential list. In this case, all three of the differential diagnoses are of colonic etiology. But, it is estimated that 50% of patients over 60 years of age have diverticular disease, and 10–25% of those patients develop diverticulitis. Since diverticular disease is more common than ulcerative colitis and ischemic colitis, it is at the top of the differential list for this patient.

Acute diverticulitis is a complication of diverticular disease. Diverticulitis is inflammation of the diverticulum (e.g., herniation of the intestinal wall). Patients usually present with acute LLQ pain and fever. Diverticulitis can be acute or chronic, and uncomplicated or complicated. It can be complicated by an abscess, fistula, bowel obstruction, or perforation.

This patient also has increased pain with urination that radiates to the suprapubic region. This is concerning for a fistula (e.g., an abnormal connection) between the colon and bladder.

Now that you have a differential diagnosis based on the patient’s history and physical exam, you’re well on your way to diagnosing and treating the cause of the pain. The diagnosis may require further assessment with imaging modalities and laboratory findings.

The treatment plan for diverticular disease generally involves antibiotic therapy as well as surgery for recurrent disease. This final component completes the SOAP for your patient with LLQ pain.

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