Acute Abdomen and Referred Pain, C35 P203-209 Flashcards
(59 cards)
What is an “acute
abdomen”?
P203
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)
What are peritoneal signs?
P203
Signs of peritoneal irritation: extreme tenderness, percussion tenderness, rebound tenderness, voluntary guarding, motion pain, involuntary guarding/ rigidity (late)
Define the following terms:
Rebound tenderness
P203
Pain upon releasing the palpating hand
pushing on the abdomen
Define the following terms:
Motion pain
P203
Abdominal pain upon moving, pelvic
rocking, moving of stretcher, or heel
strike
Define the following terms:
Voluntary guarding
P203
Abdominal muscle contraction with
palpation of the abdomen
Define the following terms:
Involuntary guarding
P203
Rigid abdomen as the muscles “guard”
involuntarily
Define the following terms:
Colic
P203
Intermittent severe pain (usually because
of intermittent contraction of a hollow
viscus against an obstruction)
What conditions can mask
abdominal pain?
P203
Steroids, diabetes, paraplegia
What is the most common
cause of acute abdominal
surgery in the United
States?
Acute appendicitis (7% of the population
will develop it sometime during their
lives)
What important questions should be asked when obtaining the history of a patient with an acute abdomen? P204
“Have you had this pain before?”
“On a scale from 1 to 10, how would you
rank this pain?”
“Fevers/chills?”
“Duration?” (comes and goes vs. constant)
“Quality?” (sharp vs. dull)
“Does anything make the pain better or
worse?”
“Migration?”
“Point of maximal pain?”
“Urinary symptoms?”
“Nausea, vomiting, or diarrhea?”
“Anorexia?”
“Constipation?”
“Last bowel movement?”
“Any change in bowel habits?”
“Any relation to eating?”
“Last menses?”
“Last meal?”
“Vaginal discharge?”
“Melena?”
“Hematochezia?”
“Hematemesis?”
“Medications?”
“Allergies?”
“Past medical history?”
“Past surgical history?”
“Family history?”
“Tobacco/EtOH/drugs?”What should the acute
abdomen physical exam
include?
P204
Inspection (e.g., surgical scars,
distention)
Auscultation (e.g., bowel sounds, bruits)
Palpation (e.g., tenderness, R/O hernia,
CVAT, rectal, pelvic exam, rebound,
voluntary guard, motion tenderness)
Percussion (e.g., liver size, spleen size)
What is the best way to have
a patient localize abdominal
pain?
P204
“Point with one finger to where the pain
is worse”
What is the classic position
of a patient with peritonitis?
P204
Motionless (often with knees flexed)
What is the classic position
of a patient with a kidney
stone?
P205
Cannot stay still, restless, writhing in pain
What is the best way to
examine a scared child or
histrionic adult’s abdomen?
P205
Use stethoscope to palpate abdomen
What lab tests are used to
evaluate the patient with an
acute abdomen?
P205
CBC with differential, chem-10,
amylase, type and screen, urinalysis,
LFTs
What is a “left shift” on CBC
differential?
P205
Sign of inflammatory response:
Immature neutrophils (bands)
Note: Many call >80% of WBCs as
neutrophils a “left shift”
What lab test should every woman of childbearing age with an acute abdomen receive? P205
Human chorionic gonadotropin (-hCG)
to rule out pregnancy/ectopic pregnancy
Which x-rays are used to
evaluate the patient with an
acute abdomen?
P205
Upright chest x-ray, upright abdominal
film, supine abdominal x-ray (if patient
cannot stand, left lateral decubitus
abdominal film)
How is free air ruled out if
the patient cannot stand?
P205
Left lateral decubitus—free air collects
over the liver and does not get confused
with the gastric bubble
What diagnosis must be
considered in every patient
with an acute abdomen?
P205
Appendicitis!
What are the differential
diagnoses by quadrant?
RUQ
P205
Cholecystitis, hepatitis, PUD, perforated
ulcer, pancreatitis, liver tumors, gastritis,
hepatic abscess, choledocholithiasis,
cholangitis, pyelonephritis, nephrolithiasis,
appendicitis (especially during
pregnancy); thoracic causes (e.g.,
pleurisy/pneumonia), PE, pericarditis,
MI (especially inferior MI)
What are the differential
diagnoses by quadrant?
LUQ
P206
PUD, 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
What are the differential
diagnoses by quadrant?
LLQ
P206
Diverticulitis, sigmoid volvulus, perforated colon, colon cancer, urinary tract infection, small bowel obstruction, inflammatory bowel disease, nephrolithiasis, pyelonephritis, fluid accumulation from aneurysm or perforation, referred hip pain, gynecologic causes, appendicitis (rare)
