Overview
Acute Abdomen
10% of ER visits or admitted patients 40% discharged from ER with pain of
unknown etiology 60% discharged from ER have wrong diagnosis The older the patient, the less accurate the diagnosis
History
Description of pain Associated symptoms Gynecologic/GU history Past medical history Family, social history
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Description of Pain
The abdominal pain checklist
Onset and duration Character and severity Location and radiation What makes it better What makes it worse Progression of pain Associated symptoms
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Associated Symptoms
Nausea, vomiting Fever, chills Anorexia, weight loss Food intolerance Pulmonary symptoms Change in bowel habits GU complaints
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Gynecologic / GU History
Last menses Contraception Sexual history Obstetric history Vaginal discharge, bleeding Previous STDs Urinary symptoms
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Cardiac or pulmonary disorders GI, vascular diseases Diabetes, HIV Medications Recent invasive procedures Trauma Recent URI or strep throat
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Inflammatory bowel disease Connective tissue disorders Bleeding diatheses Cancer Recent travel Environmental hazards Drugs, alcohol
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Physical Examination
General Examination
Chest Examination
Scars, hernia
Percussion Auscultation
Area of maximal tenderness CVA or flank tenderness Masses Hernia Peritoneal signs
involuntary guarding pain on motion
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Abdominal Exam
Special Signs
Urinalysis Amylase, lipase Pregnancy test Liver tests EKG Chest x-ray, abdominal films CBC
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Appendicitis Diverticulitis Cholecystitis Pancreatitis Bowel obstruction Perforated bowel Perforated ulcer
ischemia Nephrolithiasis
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Appendicitis
History:
periumbilical cramping pain migrating to RLQ; anorexia Exam: tenderness in RLQ and on rectal or pelvic + Rovsings sign, Psoas sign, obturator sign US useful in young women CT in doubtful cases Laparoscopy in young women and doubtful cases
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History:
PUD, NSAIDS, steroids, critical illness Exam: generalized peritonitis Free air seen on plain radiographs or CT
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Diverticulitis
History:
constipation, LLQ pain, fever, diarrhea Exam: LLQ tenderness, mass Laboratory tests Pyuria, WBC elevated CT - up to 93% sensitivity
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Pancreatitis
History:
gallstones, alcohol, epigastric pain radiating to the back Exam: generalized upper abdominal tenderness, most marked in epigastrium Increased amylase and lipase values US - detects gallstones CT - 70-100% accuracy
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Cholecystitis
History:
Exam:
cramping epigastric and RUQ pain, fatty food intolerance, + family history
RUQ tenderness, + Murphys sign, jaundice+ US - thickened GB wall, pericholecystic fluid
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Ureterolithiasis
History: Exam:
History:
intermittent cramping abdominal pain, diarrhea, low grade fever, weight loss Exam: localized abdominal tenderness, + stool for blood CT and Barium studies usually diagnostic
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Ectopic Pregnancy
History:
menstrual irregularities, + sexual history, symptoms of early pregnancy Exam: adnexal mass on pelvic; may have hypotension and tachycardia Pregnancy test + US and laparoscopy diagnostic
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PID / TOA
History:
premenopausal woman, midcycle, previous STD, vaginal discharge, dysuria, Kehrs sign Exam: cervical motion tenderness, adnexal mass Pyuria US useful to diagnose
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Gastroenteritis
History:
diarrhea, vomiting, crampy pain Exam: no localizing peritoneal signs Normal WBC
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History:
intestinal angina, arrhythmias, low flow, hypercoagulable state Exam: pain out of proportion to findings WBC and amylase elevated Acidosis, stool + for blood Thumb printing on plain film
Volvulus Cholangitis Pneumonia Acute M I Ovarian torsion / cyst Hepatitis Sickle cell disease
Diabetic
ketoacidosis Uremia Porphyria Intussusception Lupus HIV intestinal disease
Pitfalls
Summary