Abdominal Pain Clinical Reasoning Flashcards
what are some causes of RUQ pain?
Biliary disease (cholelithiasis, cholecystitis)
Pancreatitis (also epigastric)
Diverticulitis
Renal colic (usually flank pain) – from kidney stone, infection
Hepatitis
what are some causes of LUQ pain?
Renal colic (usually flank pain)
Splenic infarct or rupture
Diverticulitis
what are some causes of epigastric pain?
Myocardial Infarction Peptic ulcer Pancreatitis Biliary disease (cholelithiasis, cholecystitis) GERD
what are some causes of diffuse periumbilical pain?
Appendicitis (later RLQ) Bowel obstruction Mesenteric ischemia (acute or chronic) Abdominal aortic aneurysm Gastroenteritis IBD IBS Splenic rupture
what are some causes of RLQ pain?
Appendicitis Diverticulitis Cecal volvulus Ovarian disease (cyst, mass, torsion) Ectopic pregnancy PID
what are some causes of LLQ pain?
Diverticulitis Ovarian disease (cyst, mass, torsion) Ectopic pregnancy Sigmoid volvulus PID
when should you check CVA tenderness?
how do you assess this?
- 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
what does rebound tenderness tell you? how do you assess for rebound tenderness?
-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
what tests can you perform for a patient who you suspect has ascites? describe how to perform them
- 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.
- 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
when should you test for Murphy’s sign? how do you do this?
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.
when should you test for Psoas sign? how do you do this?
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.
when should you test for Obturator sign? how do you do this?
when you suspect appendicitis
- Rotate the leg internally at the hip.
- Increased abdominal pain indicates a positive obturator sign.
when should you perform inguinal palpation?
when you suspect hernias or inguinal lymphadenopathy
when a patient presents with appendicitis, what are next steps for management?
send them to ER!
get a CT scan to rule out appendicitis if diagnosis is uncertain
give IV fluids and antibiotics
surgery likely
classic picture of appendicitis
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
classic picture of biliary disease
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
when a patient presents with cholelithiasis/cholecystitis, what are next steps for management?
send them to the ER
send them to get an ultrasound
may need surgery
how can you tell cholelithiasis and cholecystitis apart?
cholecystitis will present with the same symptoms as cholelithiasis, but also FEVER and persistent rather than episodic symptoms
what is the typical presentation of acute pancreatitis?
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
what is the most common cause of acute pancreatitis?
alcohol abuse and choledocholithiasis (drinking + obstruction of pancreatic outflow)
when a patient presents with acute pancreatitis, what are next steps for management?
- send them to the ER
- they will need to be monitored closely (admitted to hospital)
what is the typical presentation of large bowel obstruction?
waves of severe crampy abdominal pain, diffuse/poorly localized pain, vomiting, abdominal distention, constipation/inability to pass flatus later in course
when a patient presents with large bowel obstruction, what are next steps for management?
get imaging (CT or xray) to confirm, then likely surgery
what is the typical presentation of small bowel obstruction?
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)
when a patient presents with small bowel obstruction, what are next steps for management?
get imaging (CT) to confirm SBO, then patient may need surgery
what is the typical presentation of acute mesenteric ischemia?
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
when a patient presents with acute mesenteric ischemia, what are next steps for management?
get a CT angiogram, then revascularization + surgery to resect necrotic bowel
what is the typical presentation of ischemic colitis?
left sided abdominal pain (mild) with bloody or maroon stools or diarrhea
abdominal tenderness but NOT rebound tenderness
risk factors for ischemic colitis
age >60 hemodialysis CV disease htn DM hypoalbulinemia medications that induce constipation
when a patient presents with ischemic colitis, what are next steps for management?
colonoscopy to diagnose, then supportive therapy
what is the typical presentation of abdominal aortic aneurysm?
male patient with a history of smoking
triad of severe abdominal pain, pulsatile abdominal mass and hypotension
when a patient presents with abdominal aortic aneurysm, what are next steps for management?
screening + elective surgery if necessary, since ruptured AAA have very high mortality
what is the typical presentation of nephrolithiasis?
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
when a patient presents with nephrolithiasis, what are next steps for management?
get a CT scan to confirm diagnosis, pain control, stone passage
what is the typical presentation of irritable bowel syndrome?
years of intermittent (mostly lower) abdominal pain accompanied by diarrhea, constipation or both
crampy pain that is relieved with defecation
what needs to be done before diagnosing someone with IBS?
rule out more serious causes like IBD, colon cancer
what alarm symptoms should you look out for before diagnosis when you suspect IBS?
positive fecal occult blood or rectal bleeding
anemia
unintentional/unexplained weight loss
fever
family history of colorectal cancer, IBD, celiac
recent antibiotic use
what is the typical presentation of chronic mesenteric ischemia?
recurrent postprandial abdominal pain in first hour after eating, food fear, weight loss
epigastric or periumbilical abdominal pain
risk factors for chronic mesenteric ischemia
tobacco use history
peripheral vascular disease
coronary artery disease
htn
treatment for chronic mesenteric ischemia
revascularization surgery
what is the typical presentation of diverticulitis?
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
when a patient presents with diverticulitis, what are next steps for management?
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
what is the typical presentation of ovarian torsion?
sudden-onset, unilateral pelvic pain, nausea, and vomiting. may be accompanied by urinary urgency
what is the typical presentation of ectopic pregnancy?
amenorrhea, abdominal pain, and vaginal bleeding. Can rupture and result in life-threatening intraperitoneal hemorrhage
