2 Case 1A 19 year old male presents with a two day history of abdominal pain. He states that at onset, his pain was in the middle of his abdomen, and has since moved to the right lower side. He notes nausea, emesis, anorexia, and a low grade fever. On exam, he has rebound tenderness to the RLQ, pain with leg movement, hip rotation, and pain in the RLQ on LLQ palpation. How often do perfect clinical cases like this present to the ED?
3 Introduction 6.7% of ED visits are for abdominal pain History, physical, labs often not as helpful as Cope would have you believe.Goal is to detect life-threatening causes of abdominal pain, if not to make a solid diagnosis.The Elderly, the Young, and those who cannot get follow-up are high risk groups that may require further study and admission even in the absence of abnormal findings.
4 Pain Visceral Parietal Stretching of unmyelinated fibers that innervate walls or capsules of organs.Crampy, dull, achey pain.Localized to a sensory level, but often midlineParietalIrritaion of myelinated fibers in the parietal peritoneumLocalizable, causing guarding, reboundPatients like to stay stillVisceral fibers from appendix T10 – periumbilical pain
5 Pain Referred pain Pain that is remote from the source Caused by developmental embryologyNormally ipsilateralBoaz Sign?Kehr’s Sign?Where might renal pain get referred to?
6 Priorites Finding critical illness and stabilizing Normal vitals signs are not excluding for critical illnessResuscitate and diagnose at the same time2 LB IV’s, O2, monitorCBC, BMP, Coag, T&SDon’t neglect to do a thorough exam.Intensity of pain bears no relation to severity of illness.
7 Priorities Finding critical illness Red Flags Extremes of ageRapid onset of severe painAbnormal vitalsDehydrationPallor, vomiting, diaphoresisShock most likely hemorrhagic if of rapid onsetTemperature least helpful of vitals
8 History OPQRST What has been done Last oral intake Onset Provocations/palliationsQualityRadiationSeverityTimingWhat has been doneLast oral intake
9 History Pertinent illnesses DM HTN, CAD, PVD Liver or Renal disease Surgical historySexual historyMeds/IUDsAny traumaAny similar episodes?
10 Physical Exam Uncover as much as necessary First, inspect Check for that perirectal abscess and Fournier’sFirst, inspectDistended, stigmata of liver disease, surgical scars? Masses?Then, auscultateLow sensitivity!
11 Physical exam Finally palpate Have the patient point to where it hurts Hit that area lastMay have patient bend knees if they cannot otherwise relax abdominal wall musclesInterrater reliability 60-92% for abdominal tenderness (Yen, K, et al, Arch Ped Adol Med, 2005, Apr, 159(4):373-6)Consider early use of Ultrasound at the time of palpation.
12 Labs Should be diagnosis specific Consider pattern of pain How likely is it that an LFT will help someone with LLQ pain?Preg test – always necessary for women of childbearing age and capability
13 Labs CBC BMP WBC least useful in the panel Hemoglobin – anemia from what?Can be useful for trendingPlatelet counts – liver disease, ITP, HEELPBMPRenal function most importantCalciumCO2 level as a flag for metabolic acidosis
15 Imaging Ultrasound Many choose to use ultrasound like a stethoscope Modality of choice for RUQ painRecommended as first line for flank pain, RLQ pain in kids – operator dependentModality of choice for pelvic pain
16 Imaging Plain films Useful only for Overall, low value Free air Obstruction/volvulusPneumoniaOverall, low value
17 ImagingCTHigh sensitivityHigh specificityHigh radiation riskHigh costElderly, immune compromised, those who you are uncertain, but look ill.PO contrast – bowel obstruction, bowel massNo contrast – renal stone, renal insufficiencyIV contrast – AAA, dissection
18 Name that Story!Dull RUQ pain in a 16 year old male, worse with eating, associated with nausea and diarrhea?The four F’s are still most common, but many males are getting into the game
19 Name that Story!Low grade fever, LLQ tenderness, and rectal bleeding in a 55 year old male.
20 Name that Story!Epigastric pain which is boring and cramping, which radiates to back, and is associated with eating cheese and alchohol. Amylase and lipase are normal. This is the 6th visit for this in a year.What level of bilirubin is needed to produce scleral icterus?19 patients in a large study had normal amylase and Lipase levels on presentation, 14 had elevations on hospital day one.2-3 mg/dL
21 Name that Story55 year old diabetic with epigastric pain, weakness, nausea and vomiting. Some SOA, no diarrhea. Hx of HTN. Pain is off and on for the past week.ECG showed anteroseptal MI
22 Name that StoryPost parandial pain in a 65 year old female who has nausea, emesis, appears to be in pain, but a benign abdominal exam, trace blood on rectal exam.How many patients with mesenteric ischemia have a normal first lactate? 25%
23 Name that Story65 year old male who presents with left flank pain that is gnawing, kept him up at night, and is not associated with syncope or hypotension. His last US showed a 3.5cm AAA.US was several years ago, now has a 6cm AAA with inflammation around it… no renal stone on CT.
24 Name that Story20 year old male sharp flank pain after backing into something. Has a 1 inch laceration to left flank. Vitals signs are stable. 30 minutes later, he is dead.Type of knife – bayonet to the aorta.
25 Name that Story!16 year old virgin presents with vaginal bleeding, RLQ abdominal pain and weakness. She is tachycardic, and her rosary-holding mother (who has been in the room) is concerned about fibroids.Sexual hx with parents out of the room – HCG.
29 Treatment TRUE OR FALSE? Pain should not be treated until a surgeon has laid hands on the patient?
30 Treatment Fluids Symptom management NPO status until you know a surgeon won’t be needed anytime soonAntibioticsGram negative for gut (flagyl, AG)E.coli for gut and urine (Cipro)Gram positives for SBPSTD guidelines for PID
31 Disposition Discharge Otherwise admit Surgical consults as needed. Pain betterNasuea betterTolerates PONegative eval, or no critical findingsAdequate follow-upOtherwise admitSurgical consults as needed.
32 Gastric Bypass High risk for leak Dumping Syndrome Internal hernia Septic, abdominal pain, feverDumping SyndromeDietary changesOctreotide SQ drips for severe casesInternal herniaImmediate bowel obstruction may cause gastric rupture.Dumping Syndrome – nausea, vomiting, diaphoresis minutes after eating – rapid gastric emptying