Abdominal Pain Flashcards
What key history would you obtain from a patient who complains of abdominal pain?
Location Quality Intensity Duration Radiation Timing (relation to meals) Associated symptoms (GI, cardiac, renal, etc) Exacerbating and alleviating factors Prior history of similar symptoms History of abdominal surgeries Gallstones Renal stones Atherosclerotic vascular disease Medications Alcohol and drug use Domestic violence
What key physical exams would you perform on a patient who complains of abdominal pain?
Vital signs Heart and lung exam Abdominal exam including guarding, rebound, Murphy's sign and CVA palpation Rectal exam Pelvic exam (female)
45 yo M presents with sudden onset of colicky right-sided flank pain that radiates to the testicles, accompanies by nausea, vomiting, hematuria and CVA tenderness. Differentials?
Nephrolithiasis
Renal cell carcinoma
Pyelonephritis
GI etiology (e.g., appendicitis)
45 yo M presents with sudden onset of colicky right-sided flank pain that radiates to the testicles, accompanies by nausea, vomiting, hematuria and CVA tenderness. Differentials: nephrolithiases, renal cell carcinoma, pyelonephritis, GI etiology (e.g., appendicitis). Work up?
Rectal exam UA Urine culture and sensitivity BUN/Cr CT- abdomen U/S - renal IVP
60 yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine and clay-colored stool. He is a heavy drinker and smoker. Differentials?
Pancreatic cancer Acute viral hepatitis Chronic pancreatitis Cholecystitis/cholededocholithiasis Abdominal aortic aneurysm Peptic ulcer disease
60 yo M presents with dull epigastric pain that radiates to the back, together with weight loss, dark urine and clay-colored stool. He is a heavy drinker and smoker. Differentials: pancreatic cancer, acute viral hepatitis, chronic pancreatitis, cholecystitis/choledocholithiasis, abdominal aortic aneurysm, peptic ulcer disease. Workup?
Rectal exam CBC, electrolytes Amylase and lipase AST/ALT/bilirubin/alkaline phosphatase U/S - abdomen CT - abdomen
56 yo M presents with severe midepigastric abdominal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea and vomiting. He is an alcoholic and has spent the past three days binge drinking. Differentials?
Acute pancreatitis Peptic ulcer disease Cholecystitis/Choledocholithiasis Gastritis Abdominal aortic aneurysm Mesenteric ischemia Alcoholic hepatitis Mallory-Weiss tear
56 yo M presents with severe midepigastric abdominal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea and vomiting. He is an alcoholic and has spent the past three days binge drinking. Differentials: Acute pancreatitis, peptic ulcer disease, cholecystitis/choledocholithiasis, gastritis, abdominal aortic aneurysm, mesenteric ischemia, alcoholic hepatitis, Mallory-Weiss tear. Workup?
Rectal exam CBC, electrolytes, BUN/Cr, amylase and lipase, AST/ALT/bilirubin/alkaline phosphatase U/S - abdomen CT - abdomen Upper endoscopy ECG
41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting and fever of 101.5F. The pain started after she had eaten fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy’s sign. Differentials?
Acute cholecystitis Hepatitis Choledocholithiasis Ascending cholangitis Peptic ulcer disease Fitz-Hugh Curtis Syndrome
41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting and fever of 101.5F. The pain started after she had eaten fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals positive Murphy’s sign. Differentials: acute cholecystitis, hepatitis, choledocholithiasis, ascending cholangitis, peptic ulcer disease, Fitz-Hugh Curtis syndrome. Workup?
Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase U/S - abdomen HIDA scan
43 yo obese F presents with RUQ abdominal pain, fever and jaundice. She was diagnosed with asymptomatic gallstones one year ago. Differentials?
Ascending cholangitis Acute cholecystitis Hepatitis Choledocholithiaisis Sclerosising cholangitis Fitz-Hugh Curtis syndrome
43 yo obese F presents with RUQ abdominal pain, fever and jaundice. She was diagnosed with asymptomatic gallstones one year ago. Differentials: ascending cholangitis, acute cholecystitis, hepatitis, choledocholithiasis, sclerosing cholangitis, Fitx-Hugh Curtis syndrome. Workup?
Rectal exam CBC AST/ALT/bilirubin/alkaline phosphatase Viral hepatitis serologies U/S - abdomen MRCP ERCP
25 yo M presents with RUQ pain, fever, anorexia, nausea and vomiting. He has dark urine and clay-colored stool. Differentials?
Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Acute glomerulonephritis
25 yo M presents with RUQ pain, fever, anorexia, nausea and vomiting. He has dark urine and clay-colored stool. Differentials: acute hepatitis, acute cholecystitis, ascending cholangitis, choledocholithiasis, pancreatitis, acute glomerulonephritis. Workup?
Rectal exam CBC Amylase and lipase AST/ALT/bilirubin/alkaline phosphatase UA Viral hepatitis serologies U/S abdomen
35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids. Differentials?
Peptic ulcer disease Gastritis GERD Cholecystitis Chronic pancreatitis
35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids. Differentials: peptic ulcer disease, gastritis, GERD, cholecystitis, chronic pancreatitis. Workup?
Rectal exam Amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase Endoscopy (including H. pylori testing) Upper GI series
37 yo M presents with severe epigastric pain, nausea, vomiting and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a regular basis. Differentials?
Peptic ulcer perforation Acute pancreatitis Hepatitis Cholecystitis Choledocholithiasis Mesenteric ischemia
37 yo M presents with severe epigastric pain, nausea, vomiting and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a regular basis. Differentials: peptic ulcer perforation, acute pancreatitis, hepatitis, cholecystitis, choledocholithiasis, mesenteric ischemia. Workup?
Rectal exam CBC, electrolytes Amylase, lipase, lactate AST/ALT/bilirubin/alkaline phosphatase AXR Upright CXR Endoscopy (including H. pylori testing)
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis three weeks ago. Differentials?
Splenic rupture Kidney stone Rib fracture Pneumonia Perforated peptic ulcer Splenic infarct
18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis three weeks ago. Differentials: splenic rupture, kidney stone, rib fracture, pneumonia, perforated peptic ulcer, splenic infarct. Workup?
Rectal exam CBC, electrolytes CXR CT- abdomen U/S - abdomen
40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries. Differentials?
Intestinal obstruction Small bowel or colon cancer Volvulus of the bowel Gastroenteritis Food poisoning Ileus Hernia
40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries. Differentials: intestinal obstruction, small bowel or colon cancer, volvulus of the bowel, gastroenteritis, food poisoning, ileus, hernia. Workup?
Rectal exam CBC, electrolytes AXR CT - abdomen/pelvis CXR
70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of HF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam. Differentials?
Mesenteric ischemia/infarction Diverticulitis Peptic ulcer disease Gastroenteritis Acute pancreatitis Cholecystitis/choledocholithiasis MI
70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of HF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam. Differentials: mesenteric ischemia/infarction, diverticulitis, peptic ulcer disease, gastroenteritis, acute pancreatitis, cholecystitis/choledocholithiasis, MI. Workup?
Rectal exam CBC, amylase, lipase, lactate ECG, CPK-MP, troponin AXR CT - abdomen Mesenteric angiography Barium enema
21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular and she has no history of STDs. Differentials?
Ovarian torsion Appendicitis Nephrolithiases Ectopic pregnancy Ruptured ovarian cyst PID Bowel infarction or perforation
21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular and she has no history of STDs. Differentials: ovarian torsion, appendicitis, nephrolithiasis, ectopic pregnancy, ruptured ovarian cyst, PID, bowel infarction or perforation. Workup?
Pelvic exam Rectal exam Urine hCG UA CBC Doppler U/S - pelvis CT - abdomen Laproscopy
68 yo M presents with LLQ abdominal pain, fever, and chills for the past three days. He also reports recent onset of alternating diarrhea and constipation. He consumed a low-fiber, high-fat diet. Differentials?
Diverticulitis Crohn's disease Ulcerative colitis Gastroenteritis Abscess
68 yo M presents with LLQ abdominal pain, fever, and chills for the past three days. He also reports recent onset of alternating diarrhea and constipation. He consumed a low-fiber, high-fat diet. Differentials: diverticulitis, Crohn’s disease, ulcerative colitis, gastroenteritis, abscess. Workup?
Rectal exam CBC, electrolytes CXR AXR CT- abdomen
20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney’s and psoas signs are positive. Differentials?
Appendicitis Gastroenteritis Diverticulitis Crohn's disease Nephrolithiasis Volvulus or other intestinal obstruction/perforation
20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney’s and psoas signs are positive. Differentials: appendicitis, gastroenteritis, diverticulitis, Crohn’s disease, nephrolithiasis, volvulus or other intestinal obstruction/perforation. Workup?
Rectal exam CBC, electrolytes AXR CT- abdomen U/S - abdomen
30 yo F presents with periumbilical pain for six months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss or anorexia. Differentials?
Irritable bowel syndrome Crohn's disease Celiac disease Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis
30 yo F presents with periumbilical pain for six months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss or anorexia. Differentials: irritable bowel syndrome, Crohn’s disease, Celiac disease, chronic pancreatitis, GI parasitic infection (amebiasis, giardiasis), endometriosis. Workup?
Rectal exam, stool for occult blood Pelvic exam Urine hCG CBC Electrolytes CT - abdomen/pelvis Stool for ova and parasitology, Entamoeba histolytica antigen
24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual period. The pain is associated with fever and a thick, greenish yellow vaginal discharge. She has had unprotected sex with multiple sexual partners. Differentials?
PID Endometriosis Dysmenorrhea Vaginitis Cystitis Spontaneous abortion Pyelonephritis
24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual period. The pain is associated with fever and a thick, greenish yellow vaginal discharge. She has had unprotected sex with multiple sexual partners. Differentials: PID, endometriosis, dysmenorrhea, vaginitis, cystitis, spontaneous abortion, pyelonephritis. Workup?
Pelvis exam Rectal exam Urine hCG Cervical cultures CBC/ESR UA, urine culture U/S - pelvis
