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Section II General Surgery P203Surgical Recall Sixth > Acute Abdomen and Referred Pain, C35 P203-209 > Flashcards

Acute Abdomen and Referred Pain, C35 P203-209 Flashcards

1
Q

What is an “acute
abdomen”?
P203

A 
Acute abdominal pain so severe that the
patient seeks medical attention
(Note: Not the same as a “surgical
abdomen,” because most cases of acute
abdominal pain do not require surgical
treatment)
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2
Q

What are peritoneal signs?

P203

A 
Signs of peritoneal irritation: extreme
tenderness, percussion tenderness,
rebound tenderness, voluntary guarding,
motion pain, involuntary guarding/
rigidity (late)
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3
Q

Define the following terms:
Rebound tenderness
P203

A

Pain upon releasing the palpating hand

pushing on the abdomen

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4
Q

Define the following terms:
Motion pain
P203

A

Abdominal pain upon moving, pelvic
rocking, moving of stretcher, or heel
strike

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5
Q

Define the following terms:
Voluntary guarding
P203

A

Abdominal muscle contraction with

palpation of the abdomen

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6
Q

Define the following terms:
Involuntary guarding
P203

A

Rigid abdomen as the muscles “guard”

involuntarily

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7
Q

Define the following terms:
Colic
P203

A

Intermittent severe pain (usually because
of intermittent contraction of a hollow
viscus against an obstruction)

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8
Q

What conditions can mask
abdominal pain?
P203

A

Steroids, diabetes, paraplegia

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9
Q

What is the most common
cause of acute abdominal
surgery in the United
States?

A

Acute appendicitis (7% of the population
will develop it sometime during their
lives)

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10
Q 
What important questions
should be asked when
obtaining the history of a
patient with an acute
abdomen?
P204
A 
“Have you had this pain before?”
“On a scale from 1 to 10, how would you
    rank this pain?”
“Fevers/chills?”
“Duration?” (comes and goes vs. constant)
“Quality?” (sharp vs. dull)
“Does anything make the pain better or
    worse?”
“Migration?”
“Point of maximal pain?”
“Urinary symptoms?”
“Nausea, vomiting, or diarrhea?”
“Anorexia?”
“Constipation?”
“Last bowel movement?”
“Any change in bowel habits?”
“Any relation to eating?”
“Last menses?”
“Last meal?”
“Vaginal discharge?”
“Melena?”
“Hematochezia?”
“Hematemesis?”
“Medications?”
“Allergies?”
“Past medical history?”
“Past surgical history?”
“Family history?”
“Tobacco/EtOH/drugs?”
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11
Q

What should the acute
abdomen physical exam
include?
P204

A

Inspection (e.g., surgical scars,
distention)
Auscultation (e.g., bowel sounds, bruits)
Palpation (e.g., tenderness, R/O hernia,
CVAT, rectal, pelvic exam, rebound,
voluntary guard, motion tenderness)
Percussion (e.g., liver size, spleen size)

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12
Q

What is the best way to have
a patient localize abdominal
pain?
P204

A

“Point with one finger to where the pain

is worse”

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13
Q

What is the classic position
of a patient with peritonitis?
P204

A

Motionless (often with knees flexed)

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14
Q

What is the classic position
of a patient with a kidney
stone?
P205

A

Cannot stay still, restless, writhing in pain

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15
Q

What is the best way to
examine a scared child or
histrionic adult’s abdomen?
P205

A

Use stethoscope to palpate abdomen

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16
Q

What lab tests are used to
evaluate the patient with an
acute abdomen?
P205

A

CBC with differential, chem-10,
amylase, type and screen, urinalysis,
LFTs

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17
Q

What is a “left shift” on CBC
differential?
P205

A

Sign of inflammatory response:
Immature neutrophils (bands)
Note: Many call >80% of WBCs as
neutrophils a “left shift”

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18
Q 
What lab test should every
woman of childbearing age
with an acute abdomen
receive?
P205
A

Human chorionic gonadotropin (-hCG)

to rule out pregnancy/ectopic pregnancy

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19
Q

Which x-rays are used to
evaluate the patient with an
acute abdomen?
P205

A

Upright chest x-ray, upright abdominal
film, supine abdominal x-ray (if patient
cannot stand, left lateral decubitus
abdominal film)

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20
Q

How is free air ruled out if
the patient cannot stand?
P205

A

Left lateral decubitus—free air collects
over the liver and does not get confused
with the gastric bubble

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21
Q

What diagnosis must be
considered in every patient
with an acute abdomen?
P205

A

Appendicitis!

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22
Q

What are the differential
diagnoses by quadrant?
RUQ
P205

A

Cholecystitis, hepatitis, PUD, perforated
ulcer, pancreatitis, liver tumors, gastritis,
hepatic abscess, choledocholithiasis,
cholangitis, pyelonephritis, nephrolithiasis,
appendicitis (especially during
pregnancy); thoracic causes (e.g.,
pleurisy/pneumonia), PE, pericarditis,
MI (especially inferior MI)

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23
Q

What are the differential
diagnoses by quadrant?
LUQ
P206

A

PUD, perforated ulcer, gastritis, splenic
injury, abscess, reflux, dissecting aortic
aneurysm, thoracic causes, pyelonephritis,
nephrolithiasis, hiatal hernia (strangulated
paraesophageal hernia), Boerhaave’s
syndrome, Mallory-Weiss tear, splenic
artery aneurysm, colon disease

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24
Q

What are the differential
diagnoses by quadrant?
LLQ
P206

A 
Diverticulitis, sigmoid volvulus,
perforated colon, colon cancer,
urinary tract infection, small bowel
obstruction, inflammatory bowel
disease, nephrolithiasis, pyelonephritis,
fluid accumulation from aneurysm or
perforation, referred hip pain, gynecologic
causes, appendicitis (rare)
25
Q

What are the differential
diagnoses by quadrant?
RLQ
P206

A

Appendicitis! And same as LLQ;
also mesenteric lymphadenitis, cecal
diverticulitis, Meckel’s diverticulum,
intussusception

26
Q

What is the differential
diagnosis of epigastric pain?
P206

A

PUD, gastritis, MI, pancreatitis, biliary

colic, gastric volvulus, Mallory-Weiss

27
Q

What is the differential
diagnosis of gynecologic pain?
P206

A 
Ovarian cyst, ovarian torsion, PID,
mittelschmerz, tubo-ovarian abscess
(TOA), uterine fibroid, necrotic fibroid,
pregnancy, ectopic pregnancy,
endometriosis, cancer of the cervix/
uterus/ovary, endometrioma, gynecologic
tumor, torsion of cyst or fallopian tube
28
Q

What is the differential
diagnosis of thoracic causes
of abdominal pain?
P206

A

MI (especially inferior), pneumonia,
dissecting aorta, aortic aneurysm,
empyema, esophageal rupture/tear, PTX,
esophageal foreign body

29
Q

What is the differential
diagnosis of scrotal causes
of lower abdominal pain?
P206

A

Testicular torsion, epididymitis, orchitis,
inguinal hernia, referred pain from
nephrolithiasis or appendicitis

30
Q

What are nonsurgical causes
of abdominal pain?
P207

A 
Gastroenteritis, DKA, sickle cell crisis,
rectus sheath hematoma, acute
porphyria, PID, kidney stone,
pyelonephritis, hepatitis, pancreatitis,
pneumonia, MI, C. difficile colitis
31
Q

What is the unique differential
diagnosis for the patient with
AIDS and abdominal pain?
P207

A 
In addition to all common abdominal
conditions:
    CMV (most Common)
    Kaposi’s sarcoma
    Lymphoma
    TB
    MAI (Mycobacterium Avium
       Intracellulare)
32
Q

What are the possible causes
of suprapubic pain?
P207

A

Cystitis, colonic pain, gynecologic causes

and, of course, appendicitis

33
Q

What causes pain limited to
specific dermatomes?
P207

A

Early zoster before vesicles erupt

34
Q

What is referred pain?

P207

A

Pain felt at a site distant from a disease
process; caused by the convergence of
multiple pain afferents in the posterior
horn of the spinal cord

35
Q

What is gastroenteritis?

P207

A

Viral or bacterial infection of the GI tract,
usually with vomiting and diarrhea, pain
(usually after vomiting), nonsurgical

36
Q

What is classically stated to
be the “great imitator”?
P207

A

Constipation

37
Q

Name the classic locations of referred pain:
Cholecystitis
P207

A

Right subscapular pain (also epigastric)

38
Q

Name the classic locations of referred pain:
Appendicitis
P207

A

Early: periumbilical
Rarely: testicular pain

39
Q 
Name the classic locations of referred pain:
Diaphragmatic irritation
(from spleen, perforated
ulcer, or abscess)
P207
A

Shoulder pain ( + Kehr’s sign on the left)

40
Q

Name the classic locations of referred pain:
Pancreatitis/cancer
P207

A

Back pain

41
Q

Name the classic locations of referred pain:
Rectal disease
P208

A

Pain in the small of the back

42
Q

Name the classic locations of referred pain:
Nephrolithiasis
P208

A

Testicular pain/flank pain

43
Q

Name the classic locations of referred pain:
Rectal pain
P208

A

Midline small of back pain

44
Q

Name the classic locations of referred pain:
Small bowel
P208

A

Periumbilical pain

45
Q

Name the classic locations of referred pain:
Uterine pain
P208

A

Midline small of back pain

46
Q

Give the classic diagnosis for the following cases:
“Abdominal pain out of
proportion to exam”
P208

A

Rule out mesenteric ischemia

47
Q

Give the classic diagnosis for the following cases:
Hypotension and
pulsatile abdominal mass
P208

A

Ruptured AAA; go to the O.R.

48
Q

Give the classic diagnosis for the following cases:
Fever, LLQ pain, and
change in bowel habits
P208

A

Diverticulitis

49
Q

Give the test of choice for the following conditions:
Cholelithiasis
P208

A

Ultrasound (U/S)

50
Q

Give the test of choice for the following conditions:
Bile duct obstruction
P208

A

U/S

51
Q

Give the test of choice for the following conditions:
Mesenteric ischemia
P208

A

Mesenteric A-gram

52
Q

Give the test of choice for the following conditions:
Ruptured abdominal
aortic aneurysm
P208

A

NONE—emergent laparotomy

53
Q

Give the test of choice for the following conditions:
AAA
P208

A

Abdominal CT scan or U/S

54
Q

Give the test of choice for the following conditions:
Abdominal abscess
P208

A

Abdominal CT scan

55
Q

Give the test of choice for the following conditions:
Severe diverticulitis
P208

A

Abdominal CT scan

56
Q

What is the most common
cause of RUQ pain?
P208

A

Cholelithiasis

57
Q

What is the most common
cause of surgical RLQ pain?
P208

A

Acute appendicitis

58
Q

What is the most common
cause of GI tract LLQ pain?
P209

A

Diverticulitis

59
Q

Classically, what endocrine
problems can cause abdominal pain?
P209

A
  1. Addisonian crisis

2. DKA (Diabetic KetoAcidosis)

Section II General Surgery P203Surgical Recall Sixth (33 decks)

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