Acute abdomen case questions

Question 1

26 year old male presents with abdominal pain and N/V of 24 hours duration

• Pain initially located near umbilicus but now is at RLQ
• Pain proceeded onset of N/V
• 90/60, 142, 30, 102.7°F, 97%RA
• Patient lying still on bed not wanting to move or be touched

Answer 1

Appendicitis

Question 2

44 year old female complaining of epigastric abdominal pain

• Pain began approximately 30 minutes after eating fried chicken
• Pain radiates to the right scapular tip
• 110/60, 130, 36, 103.6°F, 96%RA
• Murphy’s sign – inspiratory arrest elicited by palpating RUQ

Answer 2

Cholecystitis

Question 3

73 year old female complains of generalized abdominal pain

• 100/70, 135 irregular, 24, 98°F, 94%RA
• Pain is poorly localized and is associated with nausea and vomiting
• Abdomen is relatively soft but she complains of severe pain

Answer 3

Mesenteric ischemia

Question 4

16 year old female with generalized abdominal pain but worse on palpation to right lower quadrant

• 70/40, 128, 22, 100°F, 94%RA
• FDLMP ~ 6-7 weeks ago
• Also has vaginal bleeding

Answer 4

ectopic pregnacy

Question 5

32 year old female complaining of generalized abdominal pain

• 90/70, 140, 30 shallow, 101°F, 97%RA
• Has been taking “pain medications” for pain in her knees post-arthroscopy
• Lying still on gurney

Answer 5

perforated gastric ulcer

Question 6

56 year old male with generalized cramping abdominal pain

• Also with diarrhea and nausea
• 130/80, 100, 20, 98.6°F, 99%RA
• History of appendectomy and cholestectomy 14 years previously

Answer 6

SBO

Question 7

87 year old male with right testicle pain

• 80/40, 130, 22, 99°F, 94%RA
• Dip urinalysis is positive for blood (trace)

Answer 7

AAA

Question 8

12 year old male with abdominal pain

• 120/70, 130, 24, 99°F, 100%RA
• Admits to “being swollen down there” once mother leaves the room

Answer 8

Testicular torsion

Question 9

32 year old female with sudden onset left flank pain which radiates to the left lower quadrant

• 180/90, 130, 20, 98.6°F, 100%RA
• Unable to find comfortable position
• Feels need to urinate but can’t

Answer 9

Urolithiasis

Question 10

44 year old female complaining of epigastric abdominal pain

• Radiates to back
• N/V
• Onset after weekend of binge drinking
• 100/60, 132, 22, 99.9°F, 97%RA

Answer 10

pancreatitis

Question 11

72 year old male with LLQ pain

• 90/60, 128, 22, 103.6°F, 95%RA
• Also with N/V, rectal bleeding
• Patient gives additional history of recently eating “many nuts” while watching TV at home

Answer 11

diverticulitis

Question 12

65 year old male with generalized abdominal pain

• 80/50, 137, 28, 97.6°F, 94%RA
• Also with weakness, weight loss, N/V, urinary frequency
• Accucheck - Hi

Answer 12

DKA

Question 13

What is the difference between visceral and somatic pain? Give an example of each type.

Answer 13

Visceral – colicky, ill defined 
Intestinal obstruction, renal colic
Early appendicitis
Somatic – sharp, well defined
Late appendicitis

Question 14

Give some examples of common pain referral patterns.

Answer 14

Right shoulder/scapula – biliary problem
Left arm/neck/jaw – MI
Back – pancreatitis
Groin – renal colic

Question 15

What is the clinical significance of Cullen’s and Grey Turner signs?

Answer 15

Retroperitoneal hemorrhage

Question 16

What is the pathophysiologic process that leads to appendicitis?

Answer 16

Luminal obstruction of the appendix

Question 17

T/F – Appendicitis cannot be present if the white blood cell count is normal.

Answer 17

False

Question 18

T/F – Pain medications should be withheld from patients with abdominal pain, as this will make the physical examination less reliable.

Answer 18

False

Question 19

What are the risk factors for gallbladder disease?

Answer 19

5 F’s – fat, forty, female, flatulent, fertile

8 F’s – 5 above +, fair skinned, family, foreign

Question 20

What ultrasound findings suggest cholecystitis?

Answer 20

Thickened gallbladder wall (>3mm)
+ Pericholecystic fluid
Stones/sludge
+ Sonographic Murphy’s sign

Question 21

What are the components of Charcot’s triad of cholangitis?

Answer 21

Fever
Jaundice
RUQ abdominal pain

Question 22

Reynold’s pentad?

Answer 22

Triad plus shock and confusion

triad= Fever
Jaundice
RUQ abdominal pain

Question 23

What diagnosis should be considered in a patient with pain out of proportion to examination?

Answer 23

Mesenteric ischemia
Necrotizing fasciitis
Compartment syndrome

5 Ps - Pain, pallor, paresthesia, paralysis, pulseless

Question 24

What are the risk factors for mesenteric ischemia?

Answer 24

Age over 60
Atrial fibrillation
CHF
MI
Hypercoagulable state
Hypotension

Question 25

What is the triad of signs/symptoms for ectopic pregnancy?

Answer 25

Abdominal/pelvic pain
Vaginal bleeding
Amenorrhea

Question 26

What is the most common cause of small bowel obstruction?

Answer 26

Adhesions from prior surgery

Incarcerated hernia

Question 27

MCC of Large bowel obstruction?

Answer 27

Malignancy

Volvulus

Question 28

What is triad of signs/symptoms for ruptured abdominal aortic aneurysm?

Answer 28

Abdominal/back/flank pain
Pulsatile abdominal mass
Hypotension

Question 29

T/F – Since testicular torsion can be reliably distinguished from epididymitis on clinical examination, an ultrasound is not indicated.

Answer 29

false