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OSCE IV > Abdominal Pain Clinical Reasoning > Flashcards

Abdominal Pain Clinical Reasoning Flashcards

1
Q

what are some causes of RUQ pain?

A

Biliary disease (cholelithiasis, cholecystitis)
Pancreatitis (also epigastric)
Diverticulitis
Renal colic (usually flank pain) – from kidney stone, infection
Hepatitis

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2
Q

what are some causes of LUQ pain?

A

Renal colic (usually flank pain)
Splenic infarct or rupture
Diverticulitis

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3
Q

what are some causes of epigastric pain?

A 
Myocardial Infarction
Peptic ulcer
Pancreatitis
Biliary disease (cholelithiasis, cholecystitis)
GERD
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4
Q

what are some causes of diffuse periumbilical pain?

A 
Appendicitis (later RLQ)
Bowel obstruction
Mesenteric ischemia (acute or chronic)
Abdominal aortic aneurysm
Gastroenteritis
IBD
IBS
Splenic rupture
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5
Q

what are some causes of RLQ pain?

A 
Appendicitis
Diverticulitis
Cecal volvulus
Ovarian disease (cyst, mass, torsion)
Ectopic pregnancy
PID
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6
Q

what are some causes of LLQ pain?

A 
Diverticulitis
Ovarian disease (cyst, mass, torsion)
Ectopic pregnancy
Sigmoid volvulus
PID
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7
Q

when should you check CVA tenderness?

how do you assess this?

A
  • when you suspect pyelonephritis (renal tenderness)

- make a fist and gently hit the area over the costovertebral angle on both the right and left side

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8
Q

what does rebound tenderness tell you? how do you assess for rebound tenderness?

A

-Rebound tenderness is a sign of peritoneal irritation

  • It is elicited by palpating deeply and slowly.
  • The palpating hand is then quickly removed.
  • If the pain is greatest when you release the pressure suddenly, the patient has rebound tenderness
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9
Q

what tests can you perform for a patient who you suspect has ascites? describe how to perform them

A
  1. shifting dullness: Have the patient lie supine, then determine the borders of dullness and tympany. The area of tympany is present above the area of dullness. The patient is then asked to turn on the side, and the examiner again determines the borders of tympany and dullness. If ascites is present, the “dullness” will shift to the dependent position. The area around the umbilicus that was initially tympanic will become dull.
  2. fluid wave: Another examiner or the patient’s own hand is placed in the middle of the patient’s abdomen. The examiner then taps one flank while palpating the other side. Detection of the fluid wave suggests ascites
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10
Q

when should you test for Murphy’s sign? how do you do this?

A

when right upper quadrant pain and tenderness suggest cholecystitis

  • Place your fingers under the right costal margin and ask the patient to take a deep breath
  • A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy’s sign of acute cholecystitis.
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11
Q

when should you test for Psoas sign? how do you do this?

A

when you suspect appendicitis

  • The examiner places hand above the patient’s right knee.
  • Ask the patient to flex the right hip against resistance.
  • Increased abdominal pain indicates a positive psoas sign.
  • An alternative is to ask the patient to lie on the left side and passively extend the right hip backwards. Again, increased pain is a positive psoas sign.
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12
Q

when should you test for Obturator sign? how do you do this?

A

when you suspect appendicitis

  • Rotate the leg internally at the hip.
  • Increased abdominal pain indicates a positive obturator sign.
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13
Q

when should you perform inguinal palpation?

A

when you suspect hernias or inguinal lymphadenopathy

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14
Q

when a patient presents with appendicitis, what are next steps for management?

A

send them to ER!

get a CT scan to rule out appendicitis if diagnosis is uncertain
give IV fluids and antibiotics
surgery likely

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15
Q

classic picture of appendicitis

A

migration of pain from periumbilical reaction to RLQ to McBurney point (2/3 of way between belly button & iliac crest)

positive psoas/obturator signs on exam

patients often complain of bloating + anorexia

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16
Q

classic picture of biliary disease

A 
episodic, crampy pain that begins an hour or so after eating
pain commonly wakes patients from sleep
pain may radiate to back/shoulder
pain assoc w/ nausea and vomiting
Murphy sign is positive
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17
Q

when a patient presents with cholelithiasis/cholecystitis, what are next steps for management?

A

send them to the ER
send them to get an ultrasound
may need surgery

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18
Q

how can you tell cholelithiasis and cholecystitis apart?

A

cholecystitis will present with the same symptoms as cholelithiasis, but also FEVER and persistent rather than episodic symptoms

19
Q

what is the typical presentation of acute pancreatitis?

A

constant moderate-to-severe intensity abdominal pain that starts in the epigastrium and may radiate to the back

assoc w/ nausea, vomiting, low-grade fever and abdominal distention

20
Q

what is the most common cause of acute pancreatitis?

A

alcohol abuse and choledocholithiasis (drinking + obstruction of pancreatic outflow)

21
Q

when a patient presents with acute pancreatitis, what are next steps for management?

A
  • send them to the ER

- they will need to be monitored closely (admitted to hospital)

22
Q

what is the typical presentation of large bowel obstruction?

A

waves of severe crampy abdominal pain, diffuse/poorly localized pain, vomiting, abdominal distention, constipation/inability to pass flatus later in course

23
Q

when a patient presents with large bowel obstruction, what are next steps for management?

A

get imaging (CT or xray) to confirm, then likely surgery

24
Q

what is the typical presentation of small bowel obstruction?

A

waves of severe crampy abdominal pain, diffuse/poorly localized pain, vomiting, abdominal distention, constipation/inability to pass flatus later in course
pts often have prior abdominal surgery (surgery means SBO is more likely than LBO)

25
Q

when a patient presents with small bowel obstruction, what are next steps for management?

A

get imaging (CT) to confirm SBO, then patient may need surgery

26
Q

what is the typical presentation of acute mesenteric ischemia?

A

abrupt onset of acute, severe abdominal pain that seems out of proportion to a benign physical exam. seen more in patients with risk factors for embolization (afib)
vomiting, diarrhea
patient looks very ill

27
Q

when a patient presents with acute mesenteric ischemia, what are next steps for management?

A

get a CT angiogram, then revascularization + surgery to resect necrotic bowel

28
Q

what is the typical presentation of ischemic colitis?

A

left sided abdominal pain (mild) with bloody or maroon stools or diarrhea
abdominal tenderness but NOT rebound tenderness

29
Q

risk factors for ischemic colitis

A 
age >60
hemodialysis
CV disease
htn
DM
hypoalbulinemia
medications that induce constipation
30
Q

when a patient presents with ischemic colitis, what are next steps for management?

A

colonoscopy to diagnose, then supportive therapy

31
Q

what is the typical presentation of abdominal aortic aneurysm?

A

male patient with a history of smoking

triad of severe abdominal pain, pulsatile abdominal mass and hypotension

32
Q

when a patient presents with abdominal aortic aneurysm, what are next steps for management?

A

screening + elective surgery if necessary, since ruptured AAA have very high mortality

33
Q

what is the typical presentation of nephrolithiasis?

A

rapid onset of excruciating back and flank pain, which may radiate to abdomen or groin
pts moving constantly in an attempt to find a comfortable position

34
Q

when a patient presents with nephrolithiasis, what are next steps for management?

A

get a CT scan to confirm diagnosis, pain control, stone passage

35
Q

what is the typical presentation of irritable bowel syndrome?

A

years of intermittent (mostly lower) abdominal pain accompanied by diarrhea, constipation or both
crampy pain that is relieved with defecation

36
Q

what needs to be done before diagnosing someone with IBS?

A

rule out more serious causes like IBD, colon cancer

37
Q

what alarm symptoms should you look out for before diagnosis when you suspect IBS?

A

positive fecal occult blood or rectal bleeding
anemia
unintentional/unexplained weight loss
fever
family history of colorectal cancer, IBD, celiac
recent antibiotic use

38
Q

what is the typical presentation of chronic mesenteric ischemia?

A

recurrent postprandial abdominal pain in first hour after eating, food fear, weight loss
epigastric or periumbilical abdominal pain

39
Q

risk factors for chronic mesenteric ischemia

A

tobacco use history
peripheral vascular disease
coronary artery disease
htn

40
Q

treatment for chronic mesenteric ischemia

A

revascularization surgery

41
Q

what is the typical presentation of diverticulitis?

A

constant gradually increasing LLQ pain, present for several days. may present with diarrhea or constipation and fever
on physical, may see rebound tenderness and guarding

42
Q

when a patient presents with diverticulitis, what are next steps for management?

A

CT to confirm diagnosis
colonoscopy later down the line to rule out colon cancer
outpatient management w/ antibiotics for mild case, may need to be hospitalized if pts can’t tolerate oral intake

43
Q

what is the typical presentation of ovarian torsion?

A

sudden-onset, unilateral pelvic pain, nausea, and vomiting. may be accompanied by urinary urgency

44
Q

what is the typical presentation of ectopic pregnancy?

A

amenorrhea, abdominal pain, and vaginal bleeding. Can rupture and result in life-threatening intraperitoneal hemorrhage

OSCE IV (4 decks)

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