Approach to the Patient with an Abdominal Complaint - SRS

Question 1

If I say: •medical jargon that refers to any acute condition within the abdomen that requires immediate medical or surgical attention.

You say?

Answer 1

Acute abdomen

Question 2

Riddle me some common symptoms of abdominal disease.

Answer 2

1. –Pain
2. –Nausea and vomiting
3. –Change in bowel habits (constipation & diarrhea)
4. –Rectal bleeding
5. –Jaundice
6. –Abdominal distention
7. –Abdominal mass
8. –Anorexia
9. –Dysphagia
10. –Indigestion
11. –Hematemesis
12. –Melena
13. –Change in stool size
14. –Weight loss

Question 3

What are the three types of abdominal pain?

Answer 3

1. Visceral pain (colic pain)
2. Parietal Pain
3. Referred pain

Question 4

Describe the source and character of colic pain.

Answer 4

Usually from a hollow organ being distended or stretched.

Comes and goes, crescendo/decrescendo pattern with poorly localized cramping.

Question 5

Describe the cause and character of parietal pain.

Answer 5

Inflammation of the peritoneum.

Steady aching pain that is usually well localized.

Question 6

What are 7 causes of RUQ pain?

Answer 6

1. Acute cholecystitis
2. duodenal ulcer
3. hepatitis
4. congestive hepatomegaly
5. pyelonephritis
6. appendicitis
7. pneumonia (right sided)

Question 7

What are four causes of epigastric pain?

Answer 7

MI

Peptic ulcer

Acute cholecystitis

Perf. esophagus

Question 8

What does ERCP stand for?

Answer 8

Endoscopic retrogrades cholangiopancreatography

Question 9

What is melena?

Where is it typically from?

Answer 9

–Black tarry stools

–50-60 ml of blood in the stomach can produce melena

–Above the “Ligament of Treitz” (very general rule)

Question 10

Hematochezia is what?

From where?

What if blood is mixed into stool? Outside stool?

Answer 10

–Blood unchanged by passage through the gut usually at the level of the colon or lower

–Blood mixed with stool suggests upper colon, blood outside the stool suggests sigmoid or rectum.

Question 11

What are five signs/symptoms of jaundice? (three bold)

Answer 11

–Yellow skin

–Scleral yellowing

–Pruritus

–Urine color – darken urine from conjugated

–Acholic feces – malodorous, gray to light colored stools

Question 12

What are five possible etiologies for Unconjugated hyperbilirubinemia?

Answer 12

1. •Hemolysis
2. •Red cell defects – sickle cell
3. •Ineffective erythropoiesis
4. •Deficient hepatic uptake
5. •Deficient hepatic conjugation – hepatitis

Question 13

What causes conjugated hyperbilirubinemia?

Answer 13

–Impaired excretion of conjugated bilirubin from hepatocytes in the bile canaliculi or obstruction of biliary flow.

Question 14

What will be seen on the liver function testing that indicates conjugated hyperbilirubinemia?

Answer 14

–Serum alkaline phosphatase is elevated out of proportion to the transaminases.

Question 15

If you see painless jaundice, that is indicative of what?

Answer 15

pancreatic cancer.

(apparently very important to know)

Question 16

What are two general mechanisms of conjugated hyperbilirubinemia?

Answer 16

–Intrahepatic cholestasis – hepatocellular disease, drugs, sepsis, primary biliary cirrhosis

–Extrahepatic obstruction – gallstones, biliary carcinoma, sclerosing cholangitis, parasites, pancreatic cancer, pancreatitis

Question 17

What are the four signs of free fluid? (ascites)

Answer 17

1. –Bulging flanks
2. –Tympany at the top of the abdomen
3. –Fluid wave
4. –Shifting dullness

Question 18

What are the nine regions of the abdomen?

Answer 18

Right hypochondrium

epigastrium

left hypochondrium

right lumbar

umbilical

left lumbar

right inguinal

suprapubic

left inguinal

Question 19

On auscultation of the abdomen you hear: –high pitched “tinkle” about every 3-5 seconds.

What is this?

Answer 19

Normal bowel sounds

Question 20

What is Borborygmi?

Answer 20

–Increased, hyperactive bowel sounds,

–Low pitched rumbling

–Hyperperistalsis

Question 21

What are the common locations for abdominal bruits?

Answer 21

Aorta

Renal arteries

Iliac Arteries

Femoral Arteries

Question 22

How should the lungs, liver and intestine sound to percussion?

Answer 22

–Resonant (lungs) to dull (liver) to tympanic (intestine)

Question 23

You have hepatomegaly if your liver is greater than what in size?

Answer 23

10 cm

Question 24

What are the important tests for liver health?

Answer 24

Enzymes

• ALT
• AST
• ALP

Function

• Bilirubin
• Albumin
• PT

Question 25

If AST and ALT are significantly elevated, where is the problem likely to be?\>

Answer 25

Intrahepatic

Question 26

If Alk phos is super high, where is the problem?

Answer 26

Likely extrahepatic

Question 27

What are some possibilities for the DDX of CVA tenderness?

Answer 27

1. •Nephrolithiasis 2. •Pyelonephritis 3. •Renal cell carcinoma 4. •DJD 5. •Pneumonia – lower lobe 6. •SLE 7. •Perinephric abscess 8. •AAA 9. •Glomerulonephritis

Question 28

What is the most important component of the rectal exam?

Answer 28

Inform the patient what is going on. No surprises.

Question 29

What are four components of the appendicitis history to pick up on?

Answer 29

1. –Pain starts peri-umbilical then shifts to the right lower quadrant. 2. –Nausea and vomiting 3. –Anorexia 4. –Fever

Question 30

What is described here? ## Footnote –place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.

Answer 30

Obturator sign

Question 31

What is described here? ## Footnote –turn patient on left side and extend the right leg to check for psoas muscle inflammation.

Answer 31

Psoas sign

Question 32

What are the F's of acute cholecystitis?

Answer 32

–The 5 “f’s” – female, fat, fertile, fair, flatulent.

Question 33

What are some elements of history that should point to acute cholecystitis?

Answer 33

–RUQ postprandial pain. Biliary colic pain. –Pain radiating to the right shoulder. –Nausea and vomiting. –Anorexia –Obesity –Fever –The 5 “f’s” – female, fat, fertile, fair, flatulent.

Question 34

What is the diagnostic triad for acute cholecystitis?

Answer 34

–RUQ pain, fever and leukocytosis.

Question 35

What are the big causes of acute pancreatitis?

Answer 35

–Alcohol use –Obstruction – gallstones, cancer –Hyperlipidemia –Drugs and medications –Infection

Question 36

What are some common history elements for acute pancreatitis?

Answer 36

–Acute onset –Nausea/vomiting –Pain radiating to the back –Constant pain

Question 37

In acute pancreatitis, you may see... ## Footnote –Low grade fever –Hypotension –Decreased or absent bowel sounds –Epigastric tenderness –Turner’s sign –Cullen’s sign What are the last two things? What are they due to?

Answer 37

–Turner’s sign – discoloration around the flanks –Cullen’s sign – discoloration around the umbilicus • D/T Hemorrhagic pancreatitis