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59 Cards in this Set
- Front
- Back
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What is an "acute abdomen"? |
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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What are peritoneal signs? |
Signs of peritoneal irritation: - Extreme tenderness - Percussion tenderness - Rebound tenderness - Voluntary guarding - Motion pain - Involuntary guarding / rigidity (late) |
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What is "rebound tenderness"? |
Pain upon releasing the palpating hand pushing on the abdomen |
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What is "motion pain"? |
Abdominal pain upon moving, pelvic rocking, moving of stretcher, or heel strike |
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What is "voluntary guarding"? |
Abdominal muscle contraction with palpation of the abdomen |
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What is "involuntary guarding"? |
Rigid abdomen as the muscles "guard" involuntarily |
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What is "colic"? |
Intermittent severe pain (usually because of intermittent contraction of a hollow viscus against an obstruction) |
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What conditions can mask abdominal pain? |
- Steroids - Diabetes - Paraplegia |
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What is the most common cause of acute abdominal surgery in the US? |
Acute appendicitis (7% of the population will develop it sometime during their lives) |
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What important questions should be asked when obtaining the history of a patient with an acute abdomen? |
- “Have you had this pain before?” - “Fevers/chills?” - “Quality?” (sharp vs. dull) worse?” - “Migration?” - “Point of maximal pain?” - “Urinary symptoms?” - “Anorexia?” - “Constipation?” - “Any change in bowel habits?” - “Any relation to eating?” - “Melena?” - “Hematemesis?” - “Medications?” - “Family history?” - “Tobacco/EtOH/drugs?” |
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What should the acute abdomen physical exam include? |
- Inspection: eg, surgical scars, distention - Auscultation: eg, bowel sounds, bruits - Palpation: eg, tenderness, R/O hernia, CVAT, rectal exam, pelvic exam, rebound voluntary guard, motion tenderness - Percussion: eg, liver size, spleen size |
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What is the best way to have a patient localize abdominal pain? |
"Point with one finger to where the pain is the worse" |
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What is the classic position of a patient with peritonitis? |
Motionless, often with knees flexed |
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What is the classic position of a patient with a kidney stone? |
Cannot stay still, restless, writing in pain |
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What is the best way to examine a scared child or histrionic adult's abdomen? |
Use stethoscope to palpate abdomen |
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What lab tests are used to evaluate a patient with an acute abdomen? |
- CBC w/ differential - Basic chem - Amylase - Type and screen - Urinalysis - LFTs |
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What is a "left shift" on CBC differential? |
Sign of inflammatory response: - Immature neutrophils (bands) - Note: many call >80% of WBCs as neutrophils a "left shift" |
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What lab tests should every woman of childbearing age with an acute abdomen receive? |
Human chorionic gonadotropin (beta-hCG) to rule out pregnancy / ectopic pregnancy |
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Which x-rays are used to evaluate the patient with an acute abdomen? |
- Upright CXR - Upright abdominal film - Supine abdominal x-ray (if pt cannot stand, left lateral decubitus abdominal film) |
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How is free air ruled out if the pt cannot stand? |
Left lateral decubitus - free air collects over the liver and does not get confused with the gastric bubble |
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What diagnosis must be considered in every patient with an acute abdomen? |
Appendicitis |
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What is the differential diagnosis for RUQ pain? |
- Cholecystitis - Hepatitis - Peptic ulcer disease - Perforated ulcer - Pancreatitis - Liver tumors - Gastritis - Hepatic abscess - Choledocholithiasis - Cholangitis - Pyelonephritis - Nephrolithiasis - Appendicitis (especially during pregnancy) - Thoracic causes (eg, pleurisy / pneumonia) - PE - Pericarditis - MI (especially inferior MI) |
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What is the differential diagnosis for LUQ pain? |
- Peptic ulcer disease - 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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What is the differential diagnosis for LLQ pain? |
- Diverticulitis - Sigmoid volvulus - Perforated colon - Colon cancer - UTI - Small bowel obstruction - Inflammatory bowel disease - Nephrolithiasis - Pyelonephritis - Fluid accumulation from aneurysm or perforation - Referred hip pain - Gynecologic causes - Appendicitis (rare) |
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What is the differential diagnosis for RLQ pain? |
- Appendicitis - Same as LLQ
Also - Mesenteric lymphadenitis - Cecal diverticulitis - Meckel's diverticulum - Intussusception |
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What is the differential diagnosis of epigastric pain? |
- Peptic ulcer disease - Gastritis - MI - Pancreatitis - Biliary colic - Gastric volvulus - Mallory-Weiss tear |
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What is the differential diagnosis of gynecologic pain? |
- Ovarian cyst - Ovarian torsion - Pelvic Inflammatory Disease - Mittelschmerz - Tubo-ovarian abscess (TOA) - Uterine fibroid - Necrotic fibroid - Pregnancy - Ectopic pregnancy - Endometriosis - Cancer of cervix / uterus / ovary - Endometrioma - Gynecologic tumor - Torsion of cyst or fallopian tube |
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What is the differential diagnosis of thoracic causes of abdominal pain? |
- MI (especially inferior) - Pneumonia - Dissecting aorta - Aortic aneurysm - Empyema - Esophageal rupture / tear - Pneumothorax - Esophageal foreign body |
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What is the differential diagnosis of scrotal causes of lower abdominal pain? |
- Testicular torsion - Epididymitis - Orchitis - Inguinal hernia - Referred pain from nephrolithiasis or appendicitis |
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What are non-surgical causes of abdominal pain? |
- Gastroenteritis - DKA - Sickle cell crisis - Rectus sheath hematoma - Acute porphyria - PID - Kidney stone - Pyelonephritis - Hepatitis - Pancreatitis - Pneumonia - MI - C. difficile colitis |
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What is the unique differential diagnosis for the patient with AIDS and abdominal pain? |
In addition to all common abdominal conditions: - CMV (most Common) - Kaposi's sarcoma - Lymphoma - TB - MAI (Mycobacterium Avium Intracellulare) |
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What are the possible causes of suprapubic pain? |
- Cystitis - Colonic pain - Gynecologic causes - Appendicitis! |
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What causes pain limited to specific dermatomes? |
Early zoster before vesicles erupt |
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What is referred pain? |
Pain felt at a site distant from a disease process; caused by convergence of multiple pain afferents in the posterior horn of the spinal cord |
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What is gastroenteritis? |
Viral or bacterial infection of the GI tract, usually with vomiting and diarrhea, pain (usually after vomiting), non-surgical |
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What is classically stated to be the "great imitator"? |
Constipation? |
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What is the classic location of referred pain for cholecystitis? |
Right subscapular pain (also epigastric) |
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What is the classic location of referred pain for appendicitis? |
Early: peri-umbilical Rarely: testicular pain |
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What is the classic location of referred pain for diaphragmatic irritation (from spleen, perforated ulcer, or abscess)? |
Shoulder pain (+ Kehr's sign on the left) |
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What is the classic location of referred pain for pancreatitis / cancer? |
Back pain |
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What is the classic location of referred pain for rectal disease? |
Pain in the small of the back |
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What is the classic location of referred pain for nephrolithiasis? |
Testicular pain / flank pain |
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What is the classic location of referred pain for rectal pain? |
Midline small of back pain |
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What is the classic location of referred pain for small bowel? |
Periumbilical pain |
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What is the classic location of referred pain for uterine pain? |
Midline small of back pain |
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What is the classic diagnosis for "abdominal pain out of proportion to the exam"? |
Rule out mesenteric ischemia |
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What is the classic diagnosis for "hypotension and pulsatile abdominal mass"? |
Ruptured AAA; go to OR |
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What is the classic diagnosis for "fever, LLQ pain, and change in bowel habits"? |
Diverticulitis |
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What is the test of choice to diagnose cholelithiasis? |
Ultrasound |
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What is the test of choice to diagnose bile duct obstruction? |
Ultrasound |
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What is the test of choice to diagnose mesenteric ischemia? |
Mesenteric angiogram |
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What is the test of choice for a ruptured abdominal aortic aneurysm? |
NONE - emergent laparotomy |
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What is the test of choice for an AAA? |
Abdominal CT scan or ultrasound |
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What is the test of choice for an abdominal abscess |
Abdominal CT scan |
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What is the test of choice for severe diverticulitis? |
Abdominal CT scan |
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What is the most common cause of RUQ pain? |
Cholelithiasis |
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What is the most common cause of surgical RLQ pain? |
Acute appendicitis |
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What is the most common cause of GI tract LLQ pain? |
Diverticulitis |
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Classically, what endocrine problems can cause abdominal pain? |
1. Addisonian crisis 2. DKA (Diabetic KetoAcidosis) |
