1.5 Abd Complaint Evaluation

Question 1

Name key components of history-taking for a chief complaint of abdominal pain

Answer 1

• Complete OLDCARTS
  
  • Insidious vs acute onset
  • Progressive, constant, waxing/waning
  • Character
    
    • Visceral: dull, aching, colicky, poorly localized
    • Peritoneal: sharp, stabbing, localized
    • Referred: chest, shoulder, upper back, lower back, flank, genitalia
• Social hx
  
  • Sexual history
  • Substance abuse

Question 2

What are core components of physical exam for CC of abd pain?

Answer 2

• Vitals
• Gen appearance
• Abd/GU
• Cardiopulmonary
• Peripheral vascular
• Integumentary

Question 3

Your patient presents with CC of abd pain, and you understand the following to be “red flags”

Answer 3

• Toxic appearance
• Abnormal vitals
  
  • Fever, tachy, hotn, htn, hypoxia
• Severe, intractable pain
• Associated chest, back, flank pain
• Fever
• Intractable vomiting
• Elderly
• Recent trauma

Question 4

What risk factors may worry you in particular in a patient with CC of abdominal pain?

Answer 4

• Age > 50
• Women of childbearing age
• Heavy EtOH use
• Remote/recent abdominal surgery
• Recent hospitalization/critical illness
• Hx of smoking
• Significant PVD
• Coagulopathy
• Poor historian
• Immunocompromise
• Pregnancy

Question 5

What in particular will you be on the lookout for if your patient with CC of abdominal pain is an older adult?

Answer 5

• Atypical presentation
• Sx may be mild/non-specific
• Delay in seeking care
• Poor historian
• Multiple comorbidities
• More likely to have poor outcome
• Decreased Immune response

Question 6

Your patient presents with CC of abdominal pain, and you immediately think about these 10 never-miss diagnoses:

Answer 6

1. Ischemic bowel
2. Perforated viscus
3. Appendicitis/diverticulitis
4. Ectopic pregnancy
5. Torsion (testicular or ovarian)
6. AAA rupture
7. Solid-organ injury
8. MI
9. Ascending cholangitis/acute cholecystitis
10. PE

Question 7

Describe your general approach to diagnostic workup for CC of abdominal pain.

Then, specific tests for these scenarios:

• Epigastric pain and/or vomiting in elders
• Women under 50 years
• Pleuritic upper abd pain
• Bedside imaging?
• Concern for sepsis?

Answer 7

• Prioritize differentials, which will guide tests and mgmt
  
  • Acuity
  • Most likely
• Consider clinical value of test, imaging study
• Limit radiation when possible
• Don’t delay early surgical consult if indicated
• Specific:
  
  • Epigastric pain and/or vomiting in elders
    
    • EKG, troponin
    • CXR (r/o perf ulcer vs. pna)
    • CT w IV contrast
      
      • Large clot in mesenteric circulation
      • Hepatic vein thrombosis
      • Renal artery thrombosis
    • RUQ US
      
      • Gallbladder, kidneys, liver
      • Will miss perforated ulcer
    • CTA
      
      • Not everyone needs, but r/o mesenteric ischemia, dissection, ruptured AAA
  • Women under 50 years
    
    • HCG (even with IUD)
  • Pleuritic upper abd pain (pna vs. PE vs. diaphragmatic inflammation)
    
    • CXR
    • D-Dimer
  • Bedside imaging?
    
    • POCUS - gallbladder, kidneys, solid organ damage
  • Concern for sepsis?
    
    • Lactic acid - severity of illness

Question 8

Describe your initial management of the patient with CC: abd pain

Answer 8

• Fluid resuscitatation
• Abx
  
  • Enteric coverage
• Analgesics
• Antiemetics
• PPI
  
  • If GI bleed (bolus vs infusion)
• NGT
  
  • Life threatening hematememsis
  • SBO
• Specialty consult
  
  • Surgery
  • GI
  • Vascular
  • IR
  • Urology
  • Gyn
• Obs vs. d/c?

Question 9

What are your standard ‘belly labs’ youll want to get for your abd pain patient?

Answer 9

• CBC
• BMP
• LFTs
• Lipase
• UA

Question 10

Describe the diagnostic value of the following tests:

• UA
• D-Dimer
• POCUS
• CBC
• Abd US
• CT abd/pelv
• Abd XR

Answer 10

• UA
  
  • Ketones = dehydration
  • Blood = kidney stone, AAA
  • Protein = renal injury
  • Limitations:
    
    • Pyuria - don’t anchor to UTI
• D-Dimer
  
  • High SE, low SP
• POCUS
  
  • Dx value limited by training of operator
• CBC
  
  • Acute anemia
  • Leukocytosis/penia
    
    • Can be non-specific/reactive/inflammatory
    • Immunocompromised = wont mount white count
• Abd US
  
  • Appendicitis in young, thin adults
• CT abd/pelv
  
  • Can be falsely reassuring, even w IV contrast
  • Acute abdomen + normal CT = dont be satisfied
• Abd XR
  
  • Low SE/Sp