Abdominal Pain

Question 1

Can’t miss abdominal diagnoses

Answer 1

Ruptured AAA (Hypotension, abd or back pain)
Aortic Dissection (Tearing back pain, unequal pulses)
Mesenteric Ischemia (Pain out of proportion to exam)
Perforated bowel (Peritonitis)
Acute Myocardial Infarction
Ectopic pregnancy

Question 2

Actions to always perform

Answer 2

IV access
O2
Complete VS (w/temp and pulse ox)
EKG
Abdominal exam

Question 3

High yield history

Answer 3

Appetite (No appetite = pancreatitis, appendicitis)
Last Bowel movement or flatus (obstruction, constipation)
Blood in stool/vomit (GI bleed)
Relation to food (Gallbladder disease, ischemic colitis, ulcer)
Pregnancy status (Ectopic pregnancy, other OB/GYN)
Previous surgeries (SBO)
ETOH (Pancreatitis, hepatitis, cirrhosis)
Recent ABX use (C Diff)

Question 4

Ddx for abdominal pain with diarrhea

Answer 4

Non-bloody: C Diff

Bloody: Mesenteric ischemia or infection

Question 5

Ddx for abd pain with no flatus or bowel movements

Answer 5

SBO

Question 6

Ddx for abd pain with anorexia

Answer 6

Pancreatitis, appendicitis

Question 7

Ddx for abd pain with nausea/vomiting

Answer 7

W/ blood: GI bleed

W/ diarrhea: gastroenteritis

W/o flatus/bowel movements: SBO

Question 8

Ddx for abd pain with shortness of breath

Answer 8

PNA
PE
MI

Question 9

Ddx for abd pain with vaginal bleeding

Answer 9

Ectopic pregnancy

Abortion

Question 10

Description of pain for AAA or pancreatitis

Answer 10

Radiates to back

Question 11

Description of pain for SBO

Answer 11

Diffuse
Severe
Colicky

Question 12

Signs and symptoms of mesenteric ischemia on exam

Answer 12

Pain out of proportion to exam

Bloody diarrhea

Question 13

Description of pain of renal colic

Answer 13

Radiates to groin

Question 14

Items to note on abdominal exam

Answer 14

Location of tenderness (quadrants)
Rebound/guarding (surgical abdomen/perforation)
Distention (SBO)
Fluid wave (cirrhosis/ascites)
Bowel sounds (high pitched or absent for SBO)

Question 15

Special abdominal exam signs or tests for cholecystitis

Answer 15

Murphy’s point: Patient ceases inspiration when tested associated with cholecystitis

Question 16

Special abdominal exam signs or tests for appendicitis

Answer 16

McBurney’s point: TTP 2/3 of distance between umbilicus and R anterior superior iliac spine

Obturator: Pain with flexion and internal rotation of R leg

Psoas: Patient on left side, pain with hyperextension of R leg

Rovsing: Pain in RLQ when palpated in LLQ

Question 17

Initial lab work up for ABD pain

Answer 17

UA (Infection, blood)
CBC
BMP
LFT
HCG
Lipase
Lactate

Question 18

In what cases or patients would you get an EKG for ABD pain?

Answer 18

Women
Elderly of either sex
Diabetics
Suspected mesenteric ischemia (arrhythmias)

Question 19

When and why to order X-ray, CT, US?

Answer 19

X-ray: Upright for perforated viscous, KUB to assess SBO - dilated loops of bowel

CT: IV contrast helps visualize vasculature, masses, or abscesses; Oral contrast helps visualize hollow viscous structures

RUQ US: Imaging of choice for biliary system

Pelvic US: If concerned for cysts, torsion, TOA, ectopic, heterotopic

Question 20

Ddx for RUQ pain (8 total)

Answer 20

PE (SOB, pleuritic chest pain)
RLL PNA (SOB, fever, cough)
Biliary colic (associated with food)
Cholecystitis (Asso w/ food, Murphy's point)
GERD (Heartburn, cough, asso w/ food)
hepatitis (ETOH, jaundice)
Ulcer (Assoc w/ food)
Cholangitis

Question 21

Ddx for LUQ pain (7 total)

Answer 21

PE (SOB, pleuritic chest pain)
Pericarditis 
Myocarditis
LLL PNA (SOB, fever, cough)
Pleural effusion (SOB, fever)
Gastritis (ETOH, NSAIDs, asso w/ food)
Splenic pathology (infarction/rupture)

Question 22

Ddx for RLQ pain (13 total)

Answer 22

Appendicitis (Evolving pain, peritonitis, obturator, rovsing)
Hernia
Ectopic preg (HCG, US, hemodynamics?)
TOA (PID, sexually transmitted infections)
Ovarian torsion (Sudden onset, hx of cysts?)
Ovarian cyst (US/CT)
Meckel’s diverticulum (Peds primarily)
Diverticulitis
PID (Inflamed & painful cervix)
Endometriosis (Asso with menstrual cycles)
Psoas abscess (fever, sweats)
Kidney stone (Hx of stones, radiation to groin, severe pain)
UTI (frequency, burning)

Question 23

Ddx for LLQ pain (11 total)

Answer 23

Ectopic Preg (HCG, US, hemodynamics?)
Diverticulitis (CT)
Hernia
Ovarian torsion (sudden onset, hx of cyst?)
Ovarian cyst (US/CT)
TOA (PID, sexually transmitted infections)
PID (Inflamed painful cervix, hx of STI)
Endometriosis (Assoc w/ menstrual cycle)
Psoas Abscess
UTI (frequency, pain/burning, odor)
Kidney stone (Hx of stones, radiation to groin, severe pain)

Question 24

Ddx for epigastric pain

Answer 24

Gastritis (ETOH, NSAIDs, asso w/ food)
Pancreatitis (ETOH, Gall stone dz, hypertriglyceridemia)
ACS (EKG, esp women, elderly, diabetics)
PUD (Assoc w food)
Biliary colic (assoc w food)

Question 25

Ddx for diffuse abd pain (no quadrant)

Answer 25

Early appendicitis
Gastroenteritis (Vomiting and diarrhea)
SBO (Absent bowel sounds, no BM/flatus, vomiting)
LBO (Esp in elderly, no BM/flatus)
Spontaneous Bacterial Peritonitis (Asso w/ ascites)
IBD
DKA (kussmaul, vomiting, hx of DM, acidosis, ^^glucose)
AKA (heavy ETOH, N/V, +/- withdrawal s/sx)

Question 26

Pain control for abdominal pain (2 categories)

Answer 26

Morphine or hydromorphone IV

Famotidine and/or viscous lidocaine for gastritis/GERD (aka: GI cocktail)

Question 27

N/V control for abdominal pain, first (1) and second line (6)

Answer 27

First line agent:
Ondansetron 4mg IV q8hr

Second line:
Metoclopramide 10mg PO/IV q6hr
Prochlorperazine 10mg PO/IV q6hr or 25mg PRx1
Diphenhydramine 25-50mg PO/IV q6hr
Haloperidol 0.5-4mg PO/IV q6hr
Lorazepam 1-2mg IV q6hr
Dexamethasone 4-10mg PO q6hr

Question 28

Which patients have a lower threshold for imaging?

Answer 28

Elderly
Immunosuppressed
Previous surgery (esp gastric bypass = internal hernias)