Abdominal pain

Question 1

Important history to obtain for abdominal pain
HPI (5)
PMH (5)
FH (5)
SH (7)
ROS (4)

Answer 1

• HPI: alleviating / aggravating factors (position, food, bowel movements, stress, antacids)
• PMH: illnesses including previous GI / GU / Gyn diagnoses, abdominal surgeries (risk of bowel obstruction), meds
• FH: GI / GU / Gyn, colon cancer, IBS
• SH: travel, environmental exposures, nutrition, tattoos, piercings, alcohol, IV drugs
• Relevant ROS: constitutional (fever, chills, sweats, infections, weight loss), GI, GU/Gyn

Question 2

Strategies to alleviate voluntary guarding (6)

Answer 2

Alleviate by having arms at side, legs bent, warm stethoscope, warning before exam, distraction, and use px’s hand

Question 3

Where does foregut, midgut, and hind gut pathology cause pain?

Answer 3

• Foregut causes epigastric pain.
• Midgut causes periumbilical pain.
• Hindgut causes suprapubic pain

Question 4

Visceral pain
Location
Description
Onset

Answer 4

Midline, poorly located
Dull, crampy, burning
Gradual onset

Question 5

Parietal pain
Location
Px clue

Answer 5

Unilateral, easily located

Px often wants to lie still

Question 6

Gall bladder referred pain

Answer 6

Gall bladder causes referred pain to right scapula, abdomen, or mid back.

Question 7

Pancreatitis referred pain

Answer 7

Pancreatitis radiates to mid back

Question 8

Aortic dissection referred pain

Answer 8

Aortic dissection radiates to back or inner thigh

Question 9

MI referred pain

Answer 9

MI may cause upper epigastric pain

Question 10

Clues suggesting bowel obstruction

Answer 10

Previous surgery, abd distension, crampy, N/V, anorexia, inability to pass stool / gas

Question 11

Clues suggesting ischemia

Answer 11

severe pain, benign exam

Question 12

Clues suggesting AAA

Answer 12

Vascular disease, smoking, very sick px. Radiates to back / inner thigh. Hypotension, syncope, pulsatile abdominal mass

Question 13

Clues suggesting IBD

Answer 13

recurrent, chronic

Question 14

Clues suggesting sigmoid volvulus

Answer 14

Most common in elderly. Sigmoid twists upon itself b/c it is not attached to peritoneum. Commonly causes nausea / vomiting.

Question 15

Clues suggesting mesenteric ischemia

Answer 15

Most common in elderly. Often have CV risk factors. Association with eating. May be acute or chronic. Acute may present similar to ruptured AAA, severe pain. Chronic is similar to stable angina: get pain every time they eat due to low blood flow.

Question 16

Clues suggesting PID

Answer 16

Often have fever and vaginal discharge. Pain is bilateral. Cervical motion tenderness.

Question 17

6 not to miss diagnoses

Answer 17

Bowel obstruction / perforation, vascular thrombosus, AAA rupture, ruptured ectopic pregnancy, sepsis

Question 18

Clues suggesting biliary disease

Answer 18

Intermittent sxs. Pain raidates to right shoulder / back. N/V. Postprandial / nocturnal pain.

Question 19

Clues suggesting splenic infarct / rupture

Answer 19

Left shoulder pain

Endocarditis, clotting disorder, trauma, orthostasis.

Question 20

Clues suggesting peptic ulcer

Answer 20

Hunger-like pain. Back pain. Early satiety, melena, his of NSAIDs. Food may increase or decrease the pain

Question 21

Clues suggesting pancreatitis

Answer 21

Boring / constant back pain. N/V. Worse when supine. Hx of alcohol abuse or gallstones.

Question 22

Early appendicitis radiating pain

Answer 22

Groin, occasionally back