1.5 Abd Complaint Evaluation Flashcards
Name key components of history-taking for a chief complaint of abdominal pain
- Complete OLDCARTS
- Insidious vs acute onset
- Progressive, constant, waxing/waning
- Character
- Visceral: dull, aching, colicky, poorly localized
- Peritoneal: sharp, stabbing, localized
- Referred: chest, shoulder, upper back, lower back, flank, genitalia
- Social hx
- Sexual history
- Substance abuse
What are core components of physical exam for CC of abd pain?
- Vitals
- Gen appearance
- Abd/GU
- Cardiopulmonary
- Peripheral vascular
- Integumentary
Your patient presents with CC of abd pain, and you understand the following to be “red flags”
- Toxic appearance
- Abnormal vitals
- Fever, tachy, hotn, htn, hypoxia
- Severe, intractable pain
- Associated chest, back, flank pain
- Fever
- Intractable vomiting
- Elderly
- Recent trauma
What risk factors may worry you in particular in a patient with CC of abdominal pain?
- Age > 50
- Women of childbearing age
- Heavy EtOH use
- Remote/recent abdominal surgery
- Recent hospitalization/critical illness
- Hx of smoking
- Significant PVD
- Coagulopathy
- Poor historian
- Immunocompromise
- Pregnancy
What in particular will you be on the lookout for if your patient with CC of abdominal pain is an older adult?
- Atypical presentation
- Sx may be mild/non-specific
- Delay in seeking care
- Poor historian
- Multiple comorbidities
- More likely to have poor outcome
- Decreased Immune response
Your patient presents with CC of abdominal pain, and you immediately think about these 10 never-miss diagnoses:
- Ischemic bowel
- Perforated viscus
- Appendicitis/diverticulitis
- Ectopic pregnancy
- Torsion (testicular or ovarian)
- AAA rupture
- Solid-organ injury
- MI
- Ascending cholangitis/acute cholecystitis
- PE
Describe your general approach to diagnostic workup for CC of abdominal pain.
Then, specific tests for these scenarios:
- Epigastric pain and/or vomiting in elders
- Women under 50 years
- Pleuritic upper abd pain
- Bedside imaging?
- Concern for sepsis?
- Prioritize differentials, which will guide tests and mgmt
- Acuity
- Most likely
- Consider clinical value of test, imaging study
- Limit radiation when possible
- Don’t delay early surgical consult if indicated
- Specific:
- Epigastric pain and/or vomiting in elders
- EKG, troponin
- CXR (r/o perf ulcer vs. pna)
- CT w IV contrast
- Large clot in mesenteric circulation
- Hepatic vein thrombosis
- Renal artery thrombosis
- RUQ US
- Gallbladder, kidneys, liver
- Will miss perforated ulcer
- CTA
- Not everyone needs, but r/o mesenteric ischemia, dissection, ruptured AAA
- Women under 50 years
- HCG (even with IUD)
- Pleuritic upper abd pain (pna vs. PE vs. diaphragmatic inflammation)
- CXR
- D-Dimer
- Bedside imaging?
- POCUS - gallbladder, kidneys, solid organ damage
- Concern for sepsis?
- Lactic acid - severity of illness
- Epigastric pain and/or vomiting in elders
Describe your initial management of the patient with CC: abd pain
- Fluid resuscitatation
- Abx
- Enteric coverage
- Analgesics
- Antiemetics
- PPI
- If GI bleed (bolus vs infusion)
- NGT
- Life threatening hematememsis
- SBO
- Specialty consult
- Surgery
- GI
- Vascular
- IR
- Urology
- Gyn
- Obs vs. d/c?
What are your standard ‘belly labs’ youll want to get for your abd pain patient?
- CBC
- BMP
- LFTs
- Lipase
- UA
Describe the diagnostic value of the following tests:
- UA
- D-Dimer
- POCUS
- CBC
- Abd US
- CT abd/pelv
- Abd XR
- UA
- Ketones = dehydration
- Blood = kidney stone, AAA
- Protein = renal injury
- Limitations:
- Pyuria - don’t anchor to UTI
- D-Dimer
- High SE, low SP
- POCUS
- Dx value limited by training of operator
- CBC
- Acute anemia
- Leukocytosis/penia
- Can be non-specific/reactive/inflammatory
- Immunocompromised = wont mount white count
- Abd US
- Appendicitis in young, thin adults
- CT abd/pelv
- Can be falsely reassuring, even w IV contrast
- Acute abdomen + normal CT = dont be satisfied
- Abd XR
- Low SE/Sp