Upper Abdominal Pain in COPD

Vital signs

• Repeat oxygen saturation measurement immediately; check measurement quality.
• Start controlled oxygen administration, for example via a 24% Venturi mask with 2–3 l/min.
• Initially target SpO₂ 88–92%; monitor saturation continuously.

Physical examination

General condition: The patient is awake, oriented and responsive. She appears mildly exhausted but can speak in full sentences. Skin is warm and dry; no marked cold sweating.

Lungs: Breath sounds are reduced bilaterally. Expiration is prolonged; occasional expiratory wheeze is audible. No focal crackles are auscultated.

Heart and circulation: Heart sounds are rhythmic. No pathological heart murmur is heard. No peripheral edema.

Abdomen: Abdomen is soft. There is mild tenderness in the epigastrium without guarding. The right upper quadrant is not tender to palpation; Murphy’s sign is negative. No rebound tenderness.

Orders

Monitoring and access

• Transfer the patient immediately to the monitoring area.
• Connect continuous ECG and SpO₂ monitoring.
• Measure blood pressure and respiratory rate every 15 minutes initially. Assess consciousness, work of breathing and upper abdominal pain simultaneously; document pain intensity from 0 to 10.
• Place a peripheral IV access 18 G (green).

Oxygen and blood gas analysis

• Repeat SpO₂ measurement immediately and ensure a reliable pulse signal. Document whether the measurement was on room air or oxygen.
• Apply a 24% Venturi mask with 2–3 l/min. Initially titrate oxygen to an SpO₂ of 88–92%.
• Draw an arterial blood gas now including pH, pCO₂, pO₂, bicarbonate and lactate. Recheck blood gases after oxygen adjustment or with clinical deterioration.
• If SpO₂ remains below 88% despite oxygen, inform physician immediately.

ECG and blood draws

• Obtain a 12‑lead ECG now, time‑stamp it and present to the physician immediately. Request a prior ECG for comparison. Repeat ECG if symptoms increase or new findings occur.
• Take blood now: CBC, CRP, sodium, potassium, creatinine with eGFR, urea, liver enzymes, bilirubin, lipase and high‑sensitivity troponin.
• Repeat high‑sensitivity troponin according to the institution’s 0/1‑ or 0/2‑hour protocol; document the time of first blood draw precisely.
• Measure capillary blood glucose now and then every 4 hours initially.

Imaging and further measures

• Order chest X‑ray; continue oxygen therapy and monitoring during transport.
• If upper abdominal pain persists, request abdominal ultrasound.
• Keep the patient nil by mouth until the first physician reassessment. Reevaluate after ECG, blood gas and initial lab results.

Medications and reporting

• Document already administered pantoprazole with dose, route and time. Check what exactly was given before further doses.
• If pain persists or nausea continues, report to the physician before giving medication so agent and dose can be chosen based on ECG, blood gases and clinical status.
• Inform the physician immediately in case of changes in consciousness, increasing dyspnea, new chest pain, circulatory instability or falling SpO₂.

EKG

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ECG summary

There is a regular sinus rhythm at approximately 88/min. The PQ interval is 120 ms, the QT interval 388 ms. Tall, peaked P waves suggest a P pulmonale.

In V1 the R wave measures five large boxes (25 mm), in V6 the S wave one large box (5 mm). Together with ST depressions and T‑wave inversions in the precordial leads this speaks for right ventricular hypertrophy with a strain pattern.

For an accurate QT assessment the rate‑corrected QT (QTc) should also be provided; at 88/min Bazett correction yields approximately 470 ms from 388 ms.

Regarding the cardiac axis: Lead II is approximately isoelectric. The electrical axis is therefore roughly perpendicular to lead II, whose axis is at +60°. Two directions are possible:

• +60° − 90° = −30°
• +60° + 90° = +150°

Since the QRS complex is negative in lead I and positive in lead III, the cardiac axis is approximately +150°. This corresponds to a marked rightward deviation of the electrical axis (extreme right axis).

Initial laboratory values

Arterial blood gas analysis on 24% oxygen

The arterial blood gas on 24% oxygen shows hypoxemia and hypercapnia. The elevated bicarbonate with near‑normal pH is compatible with chronic compensated CO₂ retention in the context of known COPD.

Course and further management

The chest X‑ray shows no acute finding. Nausea and upper abdominal pain have decreased markedly. The patient is awake and hemodynamically stable. Under controlled oxygen administration the SpO₂ is 88%. A repeat blood gas is being performed to assess oxygenation, CO₂ and pH over time.

Additionally she received two puffs of salbutamol spray (100 µg each) via a spacer due to wheeze.

High‑sensitivity troponin T is 9 ng/l after two hours compared with 8 ng/l initially. There is no relevant rise. Together with the clinical course and ECG there is currently no indication of an acute myocardial infarction.

Cardiology and pulmonology are being consulted. Before discharge oxygen was tapered under monitoring. Oxygen saturation and blood gases were rechecked under the documented oxygen flow. Since the patient is respiratory stable and no cause requiring inpatient treatment was found, further pulmonological and cardiological evaluation will be performed on an outpatient basis. This includes review of COPD therapy and an echocardiography to assess the suspected right heart strain.