Chapter 3, Module 7; Abdominal Pain

Question 1

Age 10-20 yr, although it can occur at any age; patient reports sudden onset of colicky pain that progresses to constant pain; pain can begin in epigastrium or periumbilicus and then later localizes in RLQ; pain worsens with movement or coughing; vomiting after onset of pain is sometimes present

Answer 1

Appendicitis

Question 2

Patient lying still; involuntary guarding; tenderness in RLQ; other tests for peritoneal irritation positive; rebound tenderness; variation in presentation common, particularly with infants, children, and elderly

Answer 2

Appendicitis

Question 3

DIAGNOSTIC STUDIES FOR Appendicitis?

Answer 3

CBC with differential, ultrasonography, CT, laparoscopy

Question 4

Women of childbearing age; sudden onset of spotting and persistent cramping in lower quadrant that begins shortly after missed period

Answer 4

Ectopic pregnancy

Question 5

Signs of hemorrhage, shock, and lower abdominal peritoneal irritation that can be lateralized; enlarged uterus; CMT; tender adnexal mass

Answer 5

Ectopic pregnancy

Question 6

DIAGNOSTIC STUDIES FOR Ectopic pregnancy?

Answer 6

Positive hCG, ultrasound; ruptured ectopic pregnancy is surgical emergency

Question 7

Sudden onset of severe in¬ tense, steady epigastric pain that radiates to sides, back, or right shoulder; history of burning, gnawing pain that worsens with empty stomach

Answer 7

Peptic ulcer perforation

Question 8

Patient lying still; epigastric tenderness; rebound tenderness; abdominal muscles rigid; bowel sounds can be absent

Answer 8

Peptic ulcer perforation

Question 9

DIAGNOSTIC STUDIES FOR peptic ulcer perforation?

Answer 9

Diagnosis confirmed by upright or lateral decubitus radiograph showing air under diaphragm or in peritoneal cavity; perforation is surgical emergency

Question 10

Most frequent in elderly, especially if hypertensive; sudden onset of excruciating pain that can be felt in chest or abdomen and can radiate to legs and back

Answer 10

Dissection of aortic aneurysm

Question 11

Patient lying still; epigastric tenderness; rebound tenderness; abdominal muscles rigid; bowel sounds can be absent Patient appears shocky, vital signs reflect impending shock; deficit or difference in femoral pulses

Answer 11

Dissection of aortic aneurysm

Question 12

DIAGNOSTIC STUDIES FOR Dissection of aortic aneurysm?

Answer 12

CT or MRI; additional tests include ECG and cardiac enzymes; surgical emergency

Question 13

Upper or diffuse abdominal pain; can be accompanied by nausea, vomiting, dyspepsia

Answer 13

Myocardial infarction

Question 14

Hypertension or hypotension, cardiac arrhythmia, paradoxical S2

Answer 14

Myocardial infarction

Question 15

DIAGNOSTIC STUDIES FOR Myocardial infarction?

Answer 15

Serial ECGs, serial cardiac enzymes

Question 16

Occurs more often in elderly; sudden onset of severe pain that is diffuse and worsens with movement or coughing

Answer 16

Peritonitis

Question 17

Guarding; rebound tenderness; bowel sounds decreased or absent

Answer 17

Peritonitis

Question 18

DIAGNOSTIC STUDIES FOR Peritonitis?

Answer 18

CBC with differential, abdominal radiographs

Question 19

History of cholelithiasis or excessive alcohol use; pain is steady and boring in quality and is unrelieved by change of position; located in LUQ and radiates to back; nausea, vomiting, and diaphoresis

Answer 19

Acute pancreatitis

Question 20

Patient appears acutely ill; abdominal distention, decreased bowel sounds, diffuse rebound tenderness; upper abdomen can show muscle rigidity; can have limited diaphragmatic excursion of lungs

Answer 20

Acute pancreatitis

Question 21

DIAGNOSTIC STUDIES FOR Acute pancreatitis?

Answer 21

CBC with differential, serum amylase and lipase levels, triglyceride level, calcium level, and liver chemistries; ultrasonography; CT

Question 22

Fever, pain in RLQ, other symptoms suggestive of appendicitis

Answer 22

Mesenteric adenitis

Question 23

Pain on palpation in RLQ; there can be pharyngitis, cervical adenopathy

Answer 23

Mesenteric adenitis

Question 24

DIAGNOSTIC STUDIES FOR Mesenteric adenitis?

Answer 24

CBC with differential; adenovirus found in tissue of surgical specimen

Question 25

Appears  in  adults  more  than in  children,  females  more than  males;  colicky  pain with  progression  to  constant pain;  pain  in  RUQ  that  can radiate  to  right  scapular area;  pain  of  cholelithiasis is  constant,  progressively rising  to  plateau  and  falling gradually;  nausea,  vomiting, history  of  dark  urine  and/or light  stools;  may  be  aggravated  by  certain  foods

Answer 25

Cholecystitis/  lithiasis

Question 26

Tender  to  palpation  or percussion  in  RUQ; gallbladder  palpable  in about  half  cases  of cholecystitis;  positive Murphy  sign

Answer 26

Cholecystitis/  lithiasis

Question 27

DIAGNOSTIC STUDIES FOR Cholecystitis/  lithiasis?

Answer 27

CBC  with  differential, ultrasonography, radiographs,  serum amylase  and  lipase levels

Question 28

Sudden  onset,  excruciating intermittent  colicky  pain  that can  progress  to  constant pain;  pain  in  lower  abdomen and  flank  and  radiates  to groin;  nausea,  vomiting, abdominal  distention, chills,  and  fever;  increased frequency  of  urination

Answer 28

Ureterolithiasis

Question 29

CVA  tenderness;  increased sensitivity  in  lumbar  and groin  areas;  hematuria

Answer 29

Ureterolithiasis

Question 30

DIAGNOSTIC STUDIES FOR Ureterolithiasis?

Answer 30

U/A,  noncontrast-enhanced helical  CT

Question 31

Urinary  symptoms  with  UTI, back  pain  with  pyelonephritis;  infants  present  with fever,  failure  to  thrive, irritability;  toddlers  report pain  in  abdomen;  may  not report  dysuria  or  frequency

Answer 31

Urinary  tract  infection (UTI)/pyelonephritis

Question 32

Altered  voiding  pattern, malodorous  urine,  fever

Answer 32

Urinary  tract  infection (UTI)/pyelonephritis

Question 33

DIAGNOSTIC STUDIES FOR Urinary  tract  infection (UTI)/pyelonephritis?

Answer 33

U/A and culture

Question 34

Lower  abdominal  pain  that becomes  progressively  more severe;  can  have  irregular bleeding,  vaginal  discharge, and  vomiting;  most common  in  sexually active  women

Answer 34

Pelvic inflammatory disease  (PID)

Question 35

Abdominal  tenderness,  CMT and  adnexal  tenderness (usually  bilateral);  with peritonitis  can  also  have guarding  and  rebound tenderness;  fever  and vaginal  discharge  common

Answer 35

Pelvic inflammatory disease  (PID)

Question 36

DIAGNOSTIC STUDIES FOR Pelvic  inflammatory disease  (PID)?

Answer 36

WBC  and  ESR  usually elevated;  DNA  testing, cultures  and  Gram staining  for  STIs

Question 37

Sudden  onset  of  crampy  pain usually  in  umbilical  area  of epigastrium;  vomiting  occurs early  with  small  intestinal obstruction  and  late  with large  bowel  obstruction; obstipation  or  diarrhea

Answer 37

Obstruction

Question 38

Hyperactive,  high-pitched bowel  sounds;  fecal  mass can  be  palpated;  abdominal distention;  empty  rectum on  digital  examination

Answer 38

Obstruction

Question 39

DIAGNOSTIC STUDIES FOR Obstruction?

Answer 39

Diagnosis  confirmed  with CT,  abdominal  radiographs

Question 40

Abdominal  distention,  vomiting,  obstipation,  and cramps

Answer 40

Ileus

Question 41

Minimal  or  absent  peristalsis on  auscultation

Answer 41

Ileus

Question 42

DIAGNOSTIC STUDIES FOR Ileus?

Answer 42

Gaseous  distention  of isolated  segments  of  both small  and  large  intestines shown  on  radiographs

Question 43

Sudden-onset  pain  in  infant; occurs  with  sudden  relief, then  pain  again

Answer 43

Intussusception

Question 44

Fever,  vomiting,  currant  jelly stools

Answer 44

Intussusception

Question 45

DIAGNOSTIC STUDIES FOR Intussusception?

Answer 45

Abdominal  films,  ultrasound

Question 46

Seen  in  infants  up  to  1  mo old;  irritability,  pain

Answer 46

Malrotation/volvulus

Question 47

Bilious  emesis,  abdominal distention

Answer 47

Malrotation/volvulus

Question 48

DIAGNOSTIC STUDIES FOR Malrotation/volvulus?

Answer 48

Abdominal  films

Question 49

Seen  in  children  age  2-8  yr

Answer 49

Henoch-Schonlein purpura

Question 50

Rash  on  lower  extremities/ buttocks;  arthralgias; hematuria

Answer 50

Henoch-Schonlein purpura

Question 51

DIAGNOSTIC STUDIES FOR Henoch-Schonlein purpura ?

Answer 51

CBC,  ESR,  serum  IgA

Question 52

More  common  in  elderly; constant  severe  pain  in  RLQ or  LLQ  that  worsens  with coughing  or  straining

Answer 52

Incarcerated  hernia

Question 53

Hernia  or  mass  that  is nonreducible

Answer 53

Incarcerated  hernia

Question 54

DIAGNOSTIC STUDIES FOR Incarcerated  hernia?

Answer 54

MRI,  CT,  ultrasound

Question 55

Children  age  2-5  yr  can present  with  only  abdominal pain  and  fever

Answer 55

Pneumonia

Question 56

Tachypnea,  retractions,  pallor, nasal  flaring,  crackles

Answer 56

Pneumonia

Question 57

DIAGNOSTIC STUDIES FOR Pneumonia?

Answer 57

CBC,  chest  radiograph demonstrating infiltrations

Question 58

Begins  in  adolescence  or  as young  adult;  hypogastric pain;  crampy,  variable infrequent  duration; associated  with  bowel function;  associated  with gas,  bloating,  distention; relief  with  passage  of  flatus, feces

Answer 58

Irritable  bowel syndrome  (IBS)

Question 59

Normal  examination; heme-negative  stool

Answer 59

Irritable  bowel syndrome  (IBS)

Question 60

DIAGNOSTIC STUDIES FOR Irritable  bowel syndrome  (IBS) ?

Answer 60

Proctosigmoidoscopy, colonoscopy  if  onset  at middle  age/older,  stool positive  for  blood,  family history  of  colorectal cancer  or  polyps,  failure to  improve  after  6-8  wk of  therapy

Question 61

Abdominal  pain  with  chronic bloody  diarrhea

Answer 61

Crohn  disease

Question 62

Abdominal  tenderness;  weight loss

Answer 62

Crohn  disease

Question 63

Crampy  pain  after  eating  milk or  milk  products

Answer 63

Lactose  intolerance

Question 64

Negative  physical  examination

Answer 64

Lactose  intolerance

Question 65

DIAGNOSTIC STUDIES FOR Lactose  intolerance?

Answer 65

Trial  elimination  of offending  foods

Question 66

Localized  pain,  usually  LLQ; older  patient

Answer 66

Diverticular  disease

Question 67

Abdominal  tenderness;  fever

Answer 67

Diverticular  disease

Question 68

DIAGNOSTIC STUDIES FOR Diverticular  disease?

Answer 68

CT,  contrast  enema, cystography,  ultrasound, colonoscopy  sometimes useful  but  not  used during  acute  attack

Question 69

Colicky  or  dull  and  steady  pain that  does  not  progress  and worsen

Answer 69

Simple  constipation

Question 70

Fecal  mass  palpable,  stool  in rectum

Answer 70

Simple  constipation

Question 71

DIAGNOSTIC STUDIES FOR Simple  constipation?

Answer 71

  None

Question 72

Lifelong  history;  younger patient

Answer 72

Habitual  constipation

Question 73

Normal  examination; heme-negative  stool

Answer 73

Habitual  constipation

Question 74

DIAGNOSTIC STUDIES FOR Habitual  constipation?

Answer 74

Sigmoidoscopy,  anorectal manometry,  colonoscopy if  symptoms  are  alarming

Question 75

Typical  premenstrual  pain onset  soon  after  menarche, gradually  diminishing with  age

Answer 75

Dysmenorrhea

Question 76

Normal  pelvic  examination

Answer 76

Dysmenorrhea

Question 77

DIAGNOSTIC STUDIES FOR Dysmenorrhea?

Answer 77

Gynecology  consult;  pelvic ultrasound  if  secondary dysmenorrhea,  increasing disability,  or  abnormal pelvic  examination

Question 78

Pain  related  to  menses, intercourse

Answer 78

Uterine  fibroids

Question 79

 Palpable  myomas;  no suspicion  of  other  pelvic disorder

Answer 79

Uterine  fibroids

Question 80

DIAGNOSTIC STUDIES FOR Uterine  fibroids?

Answer 80

Pelvic  ultrasound  if  ovarian or  uterine  neoplasm cannot  be  excluded; gynecology  consult  if abnormal  bleeding  or severe  symptoms

Question 81

Localized  pain  that  increases with  exertion  or  lifting

Answer 81

Hernia

Question 82

Physical  examination documents  hernia

Answer 82

Hernia

Question 83

DIAGNOSTIC STUDIES FOR Hernia?

Answer 83

MRI,  CT,  ultrasound,  BE  if suspect  strangulation  or bowel  obstruction

Question 84

Young  woman

Answer 84

Ovarian  cyst(s)

Question 85

Adnexal  pain  and  palpable ovarian  cysts,  especially  in late  cycle  (corpus  luteum)

Answer 85

Ovarian  cyst(s)

Question 86

DIAGNOSTIC STUDIES FOR Ovarian  cyst(s)?

Answer 86

Pelvic  ultrasound

Question 87

History  of  trauma

Answer 87

Abdominal  wall disorder

Question 88

Visible  ecchymosis  or swelling;  palpable  hernia pain  with  rectus  muscle stress;  no  Gl/genitourinary symptoms

Answer 88

Abdominal  wall disorder

Question 89

DIAGNOSTIC STUDIES FOR Abdominal  wall disorder?

Answer 89

CT  if  internal  disease cannot  be  excluded

Question 90

Burning,  gnawing  pain  in midepigastrium  that worsens  with  recumbency; water  brash;  pain  occurs after  eating  and  can  be relieved  with  antacids;  in infant:  failure  to  thrive, irritability,  postprandial spitting  and  vomiting

Answer 90

Esophagitis/GERD

Question 91

Physical  examination  negative; in  infants:  weight  loss,  in some  cases  aspiration pneumonia

Answer 91

Esophagitis/GERD

Question 92

DIAGNOSTIC STUDIES FOR Esophagitis/GERD?

Answer 92

Endoscopy  if  symptoms  are severe  or  do  not  respond to  therapy;  manometry, pH  monitoring

Question 93

Burning  or  gnawing  pain; soreness,  empty  feeling,  or hunger;  occurs  most  often with  empty  stomach,  stress, and  alcohol,  and  relieved  by food  intake;  pain  steady, mild,  or  severe  and  located in  epigastrium;  can  be  atypical  in  children  and  minimal in  elderly

Answer 93

Peptic ulcer

Question 94

Can  be  epigastric  tenderness on  palpation

Answer 94

Peptic ulcer

Question 95

DIAGNOSTIC STUDIES FOR Peptic ulcer?

Answer 95

H.  pylori  testing;  endoscopy if  no  response  to  therapy

Question 96

Constant  burning  pain  in epigastric  area  that  can  be accompanied  by  nausea, vomiting,  diarrhea,  or  fever; alcohol,  NSAIDs,  and salicylates  make  pain  worse

Answer 96

Gastritis

Question 97

Physical  examination  negative

Answer 97

Gastritis

Question 98

DIAGNOSTIC STUDIES FOR Gastritis?

Answer 98

No  diagnostic  testing necessary  if  patient responds  to  therapy

Question 99

Occurs  at  any  age  and  produces diffuse  crampy  pain  accompanied  by  nausea,  vomiting, diarrhea,  and  fever;  can have  history  of  recent  travel, family  members  ill

Answer 99

Gastroenteritis

Question 100

Hyperactive  bowel  sounds  will be  heard  on  auscultation; dehydration  if  severe

Answer 100

Gastroenteritis

Question 101

DIAGNOSTIC STUDIES FOR Gastroenteritis?

Answer 101

No  diagnostic  testing needed

Question 102

Vague  reports  of  indigestion, heartburn,  gassiness,  or fullness;  belching, abdominal  distention, and  occasionally  nausea

Answer 102

Functional  dyspepsia

Question 103

Physical  examination  negative

Answer 103

Functional  dyspepsia

Question 104

DIAGNOSTIC STUDIES FOR Functional  dyspepsia?

Answer 104

H.  pylori  testing;  consider endoscopy  if  no  response to  empiric  treatment; CBC,  FOBT,  or  FIT

Question 105

Females  age  7-10  yr;  episodic periumbilical  pain  lasting more  than  1  hr  accompanied  by  nausea,  photophobia,  headache,  and vomiting;  family  history of  migraines

Answer 105

Abdominal  migraine

Question 106

Physical  examination  negative

Answer 106

Abdominal  migraine

Question 107

DIAGNOSTIC STUDIES FOR Abdominal  migraine?

Answer 107

Rule  out  other  causes  of episodic  pain

Question 108

Children  age  5-10  yr;  history of  environmental  or  psychological  stress

Answer 108

Recurrent  abdominal pain  (RAP)

Question 109

Physical  examination  negative

Answer 109

Recurrent  abdominal pain  (RAP)

Question 110

DIAGNOSTIC STUDIES FOR Recurrent  abdominal pain  (RAP)?

Answer 110

CBC,  U/A,  ESR,  FOBT,  or FIT,  stool  for  O&P