ABDOMINAL PAIN Flashcards
If a 63 patient has a distended bowel with tympany – what do you think?
Bowel obstruction
If you get a WBC on a patient you think has a bowel obstruction and her white count is high, and a really high anion gap, so you decide to get a CT scan – what might you see?
Ischemic bowel
What is afib associated with in the bowel?
Ischemic bowel
If a bicarb is 8 (extremely high) with vomiting and a blood glucose of 12,000 – what diagnosis?
DKA
If a patient have RLQ pain with rebound tenderness, what other diagnosis should you think of besides appendicitis?
Kidney stone
What is a positive murphy’s sign?
That take a breath in while you push in and they suddenly stop their breath – almost always gallbladder
What is a positive psoas sign?
Side lying, while extending the leg, with pain in the LQ (something would cause peritoneal pain- ovarian, appendix, or perforation)
What is a positive obturator sign?
flex the hip and rotate in and out
What is a positive rovsings sign?
Pushing on the LLQ & suddenly lifts off causing rebound pain the RLQ
What is a positive heel strike?
Strike the feel and causes jiggling in the belly (can also ask about the car ride in)
If any of those 5 signs (heel strike, rovings sign, obturator sign, posts sign, and murphy’s sign) are positive – what does that mean?
They need to be worked up now (don’t send them to their PCP or the surgeon)
When would you order an xray?
Bowel obstruction, perf, kidney stone, toxic megacolon, FB, constipation
Is an xray good enough to diagnose a bowel obstruction?
Nope… especially if they had any abdominal surgery
What is a KUB?
Kidney, uterine, bladder – xray
Why would we utilize an ultrasound for abdominal pain?
Ovaries, gallbladder, appendix (30% success rate), pregnancy, torsion, testicles, enlarged kidney
What is a FAST exam?
Looking for free fluid around an organ after trauma as performed by an U/S
When would we use an MRI in the setting of abdominal pain?
Preggo women! (especially 1st tri)
When would we order a CT without contrast for the abdomen?
Kidney stones, post-surgery abscess, you can see fluid → but you can’t see where it’s coming from (you need contrast)
When would you need a CT with contrast?
Ischemic bowel, traumatic injuries, when you need to see flow, pancreatitis
Oral contrast = when we need to see plumbing (apple core)
If a patient has a contrast allergy – can you still perform oral or IV contrast?
IV = no
Oral = Yes! (it just takes 2 hours to be absorbed)
What should you document every time for an abdominal exam?
Presence or absence of peritoneal signs
If a patient is over the age of 70 and they present with abdominal pain – what should be on our DDx?
Acute cholecystitis, malignancy, ileus, ulcer, diverticulitis, hernia, acute pancreatitis, appendicitis
If we have a neonate with nonbilious vomiting – what should we keep on our ddx?
GERD, hypertrophic pyloric stenosis
If we have a neonate with bilious vomiting – what should we keep on our ddx?
Malrotation, volvulus, Hirschsprung’s, hernias, meningitis, and sepsis
If you see a neonate with an abdominal mass – what should we keep on our ddx?
Renal (Wilm’s) or neuroblastoma
What should you think of with 2 year old that’s happy and then brings their knees to their chest while crying – what diagnosis?
Intussusception (along with currant-jelly stools & U/S showing target sign or bulls eye)
If a patient is 6-7 years old with persistent lateralization of pain – what should we think of?
Appendicitis
What’s often the most common cause of abdominal pain in children?
Constipation
What’s the best approach to working with a patient with acute abdomen?
Vitals, careful HPI, location of pain, diagnostics
If a patient has severe explosive pain – what do you think of?
perforation of hollow viscus
If a patient has progressive severe pain or cramping pain in a crescendo-decrescendo pattern – what do you think of?
ischemic necrosis
What might we need to consider in the upper quadrants on our DDx that are often forgotten?
PE, lower lobe pneumonia, and kidney stones
What might have referred pain to the low back?
Salpingitis or cystitis
What might have referred pain to the mid-back?
Pancreatitis, ulcer, and cholecystitis
What might have referred pain to the shoulder?
Diaphragmatic irritation
What do you look for on PE of the abdomen during gross inspection & on palpation?
Distended abd, ecchymosis, obvious hernia
Rebound, guarding, rigidity, absence of bowel sounds
What special tests can you do on abdominal exams?
Heel strike, obturator, iliopsoas, murphy’s, Rovsings
What is Borhaave’s syndrome?
When they tear the esophagus from the stomach – after continuous vomiting with acute onset of pain
May have pneumomediastinum (air underneath)
What type of history questions should we consider with a gastric ulcer?
NSAID use, ASA, ETOH, and smoking
Might awaken them at night
Worse or better with food
If a patient has been continuously vomiting and cough with chest pain. And then they start having hematemesis after vomiting – what do you think of?
Mallory-Weiss Tear
What should we rule out with a Mallory Weiss tear?
CXR to r/o free air/pneumomediastinum
Where does cholelithiasis radiate to? When is it often exacerbated?
Radiates to the chest and right shoulder
Pain worse after a fatty meal
What can you control the symptoms of cholelithiasis with?
Toradol, morphine, and Zofran
Do the stones of cholelithiasis always cause pain?
Nope… (so if you find the stones it can be an incidental finding)
If you see a gallbladder with thickening or fluid around the gallbladder on U/S – what does that indicate?
It’s not cholelithiasis it’s cholecystitis
If a patient presents with RUQ pain along with fever, chills, and vomiting – what do you think of?
Acute cholecystitis & choledocolithiasis
What does a patient with acute cholecystitis need?
Surgery
If a patient is jaundiced with RUQ pain – what do you think of?
Choledocolithiasis
What does a patient need with acute choledocolithiasis?
ERCP & consult surgery STAT
Where is a stone in choledocolithiasis?
Common bile duct
What diagnosis presents with severe, unrelenting pain that radiates to the back and epigastric area. Pain is worse with laying down and better if slumped over?
Pancreatitis
Turner’s and Cullen’s signs are associated with what?
Pancreatitis & sometimes AAA
What labs do you definitely want to do to help you rule in/out pancreatitis, what would you see?
Lipase! It would be 3x normal
ALT 3x normal
How do you treat pancreatitis?
IV hydration (LOTS of fluids) & IV pain meds
If a patient is old and has back pain – what do we need to keep on our differential until proven otherwise?
AAA!!!
What do you need to check for on PE for a AAA?
Palpable, pulsatile, non-tender mass. May hear a bruit
If a patient has periumbilical pain that is out of proportion with exam, and they have a history of afib and is on warfarin – what diagnosis should you think of?
Ischemic bowel
What labs would you see with ischemic bowel?
Increased WBC, lactic acid, and LDH
What imaging should you order for definitive diagnosis of ischemic bowel?
CT with oral & IV contrast
How do we treat ischemic bowel?
Surgical consult
Broad spectrum Abx (Zosyn), NPO, and NG tube
What else can present with periumbilical pain that is generally seen in children & young adults?
Mesenteric Adenitis
What is often causing appendicitis?
Bacterial overgrowth by E. coli
Where does appendicitis pain typically start?
periumbilical and then migrates to the RLQ
In a female, what else should you consider besides appendicitis?
UTI, kidney stone, ovarian abcess/torsion, PID, ectopic
What types of labs and imaging do you order for appendicitis?
CBC, UA, HCG, coag
Imaging = Ultrasound and/or CT scan with PO/IV contrast
What diagnosis do you typically think of with LLQ pain that presents with constant pain, fever, and constipation?
Diverticulitis
What causes diverticulitis?
fecolith in diverticulum causing invasion of bacteria
How do we diagnose diverticulitis?
Elevated WBC’s & CT scan with PO or IV contrast
How do we treat diverticulitis?
Cipro + flagyl
What does a CBC tell you?
Infection (but you can have an appendicitis and have a normal WBC), anemia
If a patient is going into surgery for their abdomen – do you give them pain meds?
Yes! (just not a ton, and do it IV)
What does a lactate level tell you?
Sepsis!
If a female has lower abdominal pain – what must we do?
Pelvic Exam – it’s standard of care!!!
Consider STD studies
If a patient has cramping abdominal pain, with N/V, and pencil stools. The abdomen is distended, tympani, and they’re diffusely tender – what diagnosis?
Small Bowel Obstruction
What diagnostic test would we do for a small bowel obstruction?
KUB with upright abdomen (air fluid level), CT if needed, surgery consult
If a patient has painless rectal bleeding with blood/mucous diarrhea are present in what?
UC
What’s the most common suit involving medical emergencies?
Appendicitis
