Presentation on theme: "Case #1 24 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He."— Presentation transcript:
1Case #124 yo healthy M with one day hx of abdominal pain. Pain was generalized at first, now worse in right lower abd & radiates to his right groin. He has vomited twice today. Denies any diarrhea, fevers, dysuria or other complaints. No appetite today. ROS otherwise negative.PMHx: negativePSurgHx: negativeMeds: noneNKDASocial hx: no alcohol, tobacco or drug useFamily hx: non-contributoryBasic cases to go through the most common abd pain complaints we see in the ED
2Abdominal pain What else do you want to know? What is on your differential diagnosis so far?(healthy male with RLQ abd pain….)How do you approach the complaint of abdominal pain in general?Let’s review in this lecture:Types of painHistory and physical examinationLabs and imagingAbdominal pain in special populations (Elderly, HIV)Clinical pearls to help you in the ED
3“Tell me more about your pain….” LocationQualitySeverityOnsetDurationModifying factorsChange over time
4What kind of pain is it? Visceral Parietal Referred Involves hollow or solid organs; midline pain due to bilateral innvervationSteady ache or vague discomfort to excruciating or colicky painPoorly localizedEpigastric region: stomach, duodenum, biliary tractPeriumbilical: small bowel, appendix, cecumSuprapubic: colon, sigmoid, GU tractParietalInvolves parietal peritoneumLocalized painCauses tenderness and guarding which progress to rigidity and rebound as peritonitis developsReferredProduces symptoms not signsBased on developmental embryologyUreteral obstruction → testicular painSubdiaphragmatic irritation → ipsilateral shoulder or supraclavicular painGynecologic pathology → back or proximal lower extremityBiliary disease → right infrascapular painMI → epigastric, neck, jaw or upper extremity pain
6And don’t forget the history GIPast abdominal surgeries, h/o GB disease, ulcers; FamHx IBDGUPast surgeries, h/o kidney stones, pyelonephritis, UTIGynLast menses, sexual activity, contraception, h/o PID or STDs, h/o ovarian cysts, past gynecological surgeries, pregnanciesVascularh/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAAOther medical historyDM, organ transplant, HIV/AIDS, cancerSocialTobacco, drugs – Especially cocaine, alcoholMedicationsNSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
7Physical Examination General Vital Signs Cardiac Lungs Abdomen Back Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying still or moving around in the bedVital SignsOrthostatic VS when volume depletion is suspectedCardiacArrhythmiasLungsPneumoniaAbdomenLook for distention, scars, massesAuscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise not very helpfulPalpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidityPercuss for tympanyLook for hernias!rectal examBackCVA tendernessPelvic examCMTVaginal discharge – CultureAdenexal mass or fullnessOrthostatic VS are less reliable in the diabetic, elderly, those on beta-blocker. Pulse increase of 30 or presyncope on standing are highly sensitive for loss of 1 L of blood or 3L of fluid. BP changes are less reliable. Patient must be standing at least one minute before measurements are taken.
8Abdominal Findings Guarding Rebound VoluntaryContraction of abdominal musculature in anticipation of palpationDiminish by having patient flex kneesInvoluntaryReflex spasm of abdominal musclesaka: rigiditySuggests peritoneal irritationReboundPresent in 1 of 4 patients without peritonitisPain referred to the point of maximum tenderness when palpating an adjacent quadrant is suggestive of peritonitisRovsing’s sign in appendicitisRectal examLittle evidence that tenderness adds any useful information beyond abdominal examinationGross blood or melena indicates a GIBHeme positive stool – 10% of people over the age of 50 sent home with diagnosis of NSAP and heme positive stools were found to have cancer within a year.Heme positive stool in the setting of suspected PUD should elicit more urgent referral for further evaluation
10Appendicitis Diagnosis Treatment WBC Clinical appendicitis – call your surgeonMaybe appendicitis - CT scanNot likely appendicitis – observe for 6-12 hours or re-examination in 12 hoursTreatmentNPOIVFsPreoperative antibiotics – decrease the incidence of postoperative wound infections
11Case #268 yo F with 2 days of LLQ abd pain, diarrhea, fevers/chills, nausea; vomited once at home.PMHx: HTN, diverticulosisPSurgHx: negativeMeds: HCTZNKDASocial hx: no alcohol, tobacco or drug useFamily hx: non-contributory11
12Case #2 Exam T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99% room air Gen: uncomfortable appearing, slightly palePulmonary: normal heart and lung exam, no LE edema, normal pulsesAbd: soft, moderately tender in LLQWhat is your differential diagnosis & what next?
13Diverticulitis Risk factors Clinical features Physical Exam DiverticulaIncreasing ageClinical featuresSteady, deep discomfort in LLQChange in bowel habitsUrinary symptomsTenesmusParalytic ileusSBOPhysical ExamLow-grade feverLocalized tendernessRebound and guardingLeft-sided pain on rectal examOccult bloodPeritoneal signsSuggest perforation or abscess rupture
14Diverticulitis Diagnosis Treatment CT scan (IV and oral contrast) Pericolic fat strandingDiverticulaThickened bowel wallPeridiverticular abscessLeukocytosis present in only 36% of patientsTreatmentFluidsCorrect electrolyte abnormalitiesNPOAbx: gentamicin AND metronidazole OR clindamycin OR levaquin/flagylFor outpatients (non-toxic)liquid diet x 48 hourscipro and flagyl
15Case #346 yo M with hx of alcohol abuse with 3 days of severe upper abd pain, vomiting, subjective fevers.Med Hx: negativeSurg Hx: negativeMeds: none; Allergies: NKDASocial hx: homeless, heavy alcohol use, smokes 2ppd, no drug use
16Case #3 ExamVital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat: 95% room airGeneral: ill-appearing, appears in painCV: tachycardic, normal heart sounds, pulses normalLungs: clearAbdomen: mildly distended, moderately TTP epigastric, +voluntary guardingRectal: heme neg stoolWhat is your differential diagnosis & what next?