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IM OSCE > Abdominal pain > Flashcards

Abdominal pain Flashcards

1
Q

Three types of abdominal pain

A

1) Visceral
2) Somatoparietal or peritoneal
3) Referred

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2
Q

Visceral

A
  • Poorly localized but site roughly corresponds to dermatome that innervates the affected organ
  • Characteristics may vary (dull, cramping, burning)
  • Frequently accompanied by secondary autonomic effects (nausea, vomiting, pallow, diaphoresis, restlessness)
  • Patient moves around in an attempt to alleviate discomfort
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3
Q

Somatoparietal or peritoneal pain

A
  • More localized and more intense than visceral pain
  • Arises from peritoneal irritation
  • Aggravated by movement (patient attempts to lie still)
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4
Q

Referred pain

A
  • Usually well localized but felt in areas remote to affected organ
  • May be felt in skin or in deeper tissues
  • Results from convergence of visceral afferent neurons with somatic neurons from different anatomic regions
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5
Q

Important history items in abdominal pain

A
  • Associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic)
  • History of similar symptoms
  • Hx of gallstones, renal stones, atherosclerotic vascular disease
  • Previous abdominal or pelvic surgeries
  • Chronic medical conditions
  • Sexual activity
  • Medications, alcohol and drug use
  • Family history
  • Domestic violence
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6
Q

Physical exam of abdomen in abdominal pain

A
  • Inspection for scars, distension, asymmetry, cutaneous abnormalities (dilated veins, ecchymoses)
  • Auscultation for abnormal BS and bruits
  • Percussion for detection of hepatomegaly, splenomegaly, abdominal masses, or ascites
  • Palpation for tenderness, signs of peritoneal inflammation (guarding, rebound), murphy sign, psoas and obturator signs, hepatomegaly, splenomegaly, abnormal masses, pulsations, or hernias
  • CVA palpation
  • Rectal/pelvic exam
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7
Q

Possible DDx in abdominal pain

A
  • Appendicitis
  • Cholecystitis (biliary colic)
  • Pancreatitis
  • Diverticulitis
  • PUD including perforation
  • Gastroenteritis
  • Hepatitis
  • IBS
  • SBO
  • Acute mesenteric ischemia
  • IBD
  • Ruptured AAA
  • Ureteral stones
  • PID
  • Ruptured ectopic
  • Abdominal wall pain
  • Referred pain
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8
Q

Labs to consider in abdominal pain

A
  • CBC with diff
  • UA
  • Pregnancy test
  • Stool for occult blood
  • Hepatic function panel
  • Amylase and lipase
  • Abdominal obstructive series
  • Abdominal US
  • Abdominal CT
  • Paracentesis fluid studies
  • Upper GI endoscopy
  • Sigmiodoscopy/colonoscopy
  • Barium contrast studies
  • HIDA radionucleotide scan of hepatobiliary system
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9
Q

45 M with sudden onset colicky R-side flank pain that radiates to testes, associated N/V, hematuria, and CVA tenderness

A

DDx:

  • Nephrolithiasis
  • RCC
  • Pyleonephritis
  • GI eti (e.g., appendicitis)

Workup

  • Rectal
  • UA
  • UCx and sensitivity
  • BUN/Cr
  • CT-abdomen
  • US-renal
  • IVP
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10
Q

60 M with dull epigastric pain that radiates to back, associated weight loss, dark urine, clay-colored stool. He is heavy drinker and smoker

A

DDx:

  • Pancreatic CA
  • Acute viral hepatitis
  • Chronic pancreatitis
  • Cholecystitis/choledocholithiasis
  • Abdominal aortic aneurysm
  • PUD

Workup

  • Rectal exam
  • CBC/electrolytes
  • Amylase and lipase
  • AST/ALT/bili/Alkaline phosphatase
  • US-abdomen
  • CT-abdomen
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11
Q

56 M with severe midepigastric abdominal pain that radiates to back and improves when leans forward. Also anorexia, n/v. He is alcoholic and spent last 3 days binge drinking

A

DDx

  • Acute pancreatitis
  • PUD
  • Cholecystitis/choledocholithiasis
  • Gastritis
  • AAA
  • Mesenteric ischemia
  • Alcoholic hepatitis
  • Mallory-Weiss tear

Workup

  • Rectal
  • CBC, electrolytes, BUN/Cr, amylase, lipase, AST/ALT/bili/alk phos
  • US-abdomen
  • CT-abdomen
  • Upper endoscopy
  • ECG
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12
Q

41 F obese, RUQ pain that radiates to R scapula, associated n/v, fever 101.5, pain started after fatty food, has had similar but less intense episodes that lasted a few hours, exam reveals positive Murphy sign

A

DDx

  • Acute cholecystitis
  • Hepatitis
  • Choledocholithiasis
  • Ascending cholangitis
  • PUD
  • Fitz-Hugh-Curtis syndrome

Workup

  • Rectal
  • CBC
  • LFTs
  • US-abdomen
  • CT-abdomen
  • HIDA
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13
Q

43 F, obese, RUQ pain, fever, jaundice. Diagnosed with asymptomatic gallstones 1 yr ago.

A

DDx

  • Ascending cholangitis
  • Acute cholecystitis
  • Hepatitis
  • Choledocholithiasis
  • Sclerosing cholangitis
  • Fitz-Hugh-Curtis syndrome

Workup

  • Rectal
  • CBC
  • LFTs
  • Viral hepatitis serologies
  • US abdomen
  • MRCP
  • ERCP
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14
Q

25 M, RUQ pain, fever, anorexia, n/v, dark urine, clay-colored stool

A

DDx

  • Acute hepatitis
  • Acute cholecystitis
  • Ascending cholangitis
  • Choledocholithiasis
  • Pancreatitis
  • Acute glomerulonephritis

Workup

  • Rectal
  • CBC, amylase, lipase, LFTs
  • UA
  • Viral hepatitis serologies
  • US-abdomen
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15
Q

35 M burning epigastric pain starts 2-3 hrs after meals, relieved by food and antacids

A

DDx

  • PUD
  • Gastritis
  • GERD
  • Cholecystitis
  • Chronic pancreatitis
  • Mesenteric ischemia

Workup

  • Rectal
  • Amylase, lipase, lactate, LFTs
  • Endoscopy (including H. pylori testing)
  • Upper GI series
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16
Q

37 M severe epigastric pain, n/v, mild fever, appears toxic, Hx of intermittent epigastric pain relieved by food and antacids, smokes heavily and takes aspirin on regular basis

A

DDx

  • Perforated peptic ulcer
  • Acute pancreatitis
  • Hepatitis
  • Cholecystitis
  • Choledocholithiasis
  • Mesenteric ischemia

Workup

  • Rectal
  • CBC, electrolytes, amylase, lipase, lactate, LFTs
  • KUB
  • CT-abdomen
  • Upright CXR
  • Endoscopy (including H. pylori testing)
17
Q

18 M boxer, severe LUQ pain radiates to L scapula, had mono 3 wks ago

A

DDx

  • Splenic rupture
  • Kidney stone
  • Rib fracture
  • Pneumonia
  • Perforated peptic ulcer
  • Splenic infarct

Workup

  • Rectal
  • CBC, electrolytes
  • CXR
  • CT-abdomen
  • US-abdomen
18
Q

40 M crampy abdominal pain, v, abdominal distention, inability to pass flatus/stool, Hx of multiple abdominal surgeries

A

DDx

  • SBO
  • Small bowel or colon CA
  • Volvulus
  • Gastroenteritis
  • Food poisoning
  • Ileus
  • Hernia

Workup

  • Rectal
  • CBC, electrolytes
  • AXR
  • CT-abd/pelvis
  • CXR
19
Q

70 F acute onset severe crampy abd pain, recently vomited and had massive dark bowel movement, Hx CHF and A-Fib, on digitalis, pain is out of proportion to exam

A

DDx

  • Mesenteric ischemia/infarction
  • Diverticulitis
  • PUD
  • Gastroenteritis
  • Acute pancreatitis
  • Cholecystitis/choledocholithiasis
  • MI

Workup

  • Rectal
  • CBC, amylase, lipase, lactate
  • ECG, CPK-MB, troponin
  • AXR
  • CT-abdomen
  • Mesenteric angiography
  • Barium enema
20
Q

21 F, acute onset severe RLQ pain, n/v; no fever, urinary symptoms, or vaginal bleeding and never taken OCPs; LMP was regular and no Hx of STIs

A

DDx

  • Ovarian torsion
  • Appendicitis
  • Nephrolithiasis
  • Ectopic pregnancy
  • Ruptured ovarian cyst
  • PID
  • Bowel infarction or perforation

Workup

  • Pelvic exam
  • Rectal
  • Urine hCG
  • UA
  • CBC
  • Doppler US pelvis
  • CT abdomen
  • Laparoscopy
21
Q

68 M LLQ abd pain, f/c for 3 days, alternating diarrhea/constipation, consumes low-fiber, high-fat diet

A

DDx

  • Diverticulitis
  • Crohn disease
  • Ulcerative colitis
  • Gastroenteritis
  • Abscess

Workup

  • Rectal
  • CBC, electrolytes
  • CXR
  • AXR
  • CT-abd
22
Q

20 M RLQ pain, n/v, started yesterday with vague periumbilical, became worse, sharp and migrated to RLQ, McBurney and psoas signs positive

A

DDx

  • Acute appendicitis
  • Gastroenteritis
  • Diverticulitis
  • Crohn disease
  • Nephrolithiasis
  • Volvulus or other intestinal obstruction/perforation

Workup

  • Rectal
  • CBC, electrolytes
  • AXR
  • CT-abdomen
  • US-abdomen
23
Q

30 F with periumbilical pain for 6 months, never awakens her from sleep, relieved by defecation and worsens when she is upset, alternating constipation and diarrhea, but no n/v, weight loss, or anorexia

A

DDx

  • IBS
  • Crohn’s
  • Celiac
  • Chronic pancreatitis
  • GI parasitic infection (amebiasis, giardiasis)
  • Endometriosis

Workup

  • Rectal, stool for blood
  • Pelvic
  • Urine hCG
  • CBC/electrolytes
  • Colonoscopy
  • CT-abd/pelvis
  • Stool for ova, parasites, entamoeba histolytica antigen
24
Q

24 F bilateral lower abdomnial pain started first day of menstrual period, associated with fever and thick, green-yellow vaginal discharge, has unprotected sex with multiple sexual partners

A

DDX

  • PID
  • Endometriosis
  • Dysmenorrhea
  • Vaginitis
  • Cystitis
  • Spontaneous abortion
  • Pyelonephritis

Workup

  • Pelvic
  • Rectal
  • Urine hCG
  • Cervical Cx
  • CBC/ESR
  • UA, UCx
  • US pelvis

IM OSCE (17 decks)

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