During my amateur residency years , I had this case of an elderly demented lady from a nursing home, who was admitted overnight for right upper quadrant (RUQ) abominal pain progressing since 3-4 days . The night resident had ordered a battery of tests after admitting her to observation unit. She had shown mild tachycardia otherwise stable vitals, labs showed mild hypokalemia, normal lipase, normal liver enzymes. Physical exam on the history & physical note had documented a ‘RUQ tenderness”. An ultrasound of the RUQ had been ordered but not done yet. This RUQ tenderness was persistent in the morning on my rounds when I palpated, I felt the pending RUQ Ultrasound was appropriate.
…..Until I got a page to call the Ultrasound tech. When I called back, my face turned red when tech told me. “Doc did you notice she has a painful rash on the skin on the RUQ area, looks like shingles”.
Dang it !! I should have checked the skin in the area of pain !! Indeed it was shingles – neuropathic pain can predede the actual rash in shingles and be easily mistaken for internal pain. ( On a side-note, some people may never get a rash with Shingles – called “Zoster sine herpete” )
Learning Tip: Abdominal pain can sometimes be just skin deep ! For that matter, always give a skin a good look in the area of pain, I have also seen several cases of abdominal wall cellulitis since where patient complaints of just abominal pain and may not have noticed a rash.
