General Surgery - Acute Abdomen & Referred Pain Flashcards
(59 cards)
What is an “acute abdomen”?
Acute abdominal pain so severe that the patient seeks medical attention
Note: NOT THE SAME AS “surgical abdomen,” because most cases of acute abdominal pain do not require surgical treatment
What are peritoneal signs?
Signs of peritoneal irritation:
extreme tenderness
percussion tenderness
rebound tenderness
voluntary guarding
motion pain
INVOLUNTARY guarding/rigidity (late)
Define rebound tenderness
pain upon releasing the palpating hand pushing on the abdomen
Define motion pain
abdominal pain upon moving, pelvic rocking, moving of stretcher, or heel strike
Voluntary guarding
Abdominal muscle contraction with palpation of the abdomen
Involuntary guarding
Rigid abdomen as the muscles “guard” involuntarily
Colic
Intermittent severe pain
Usually because of intermittent contraction of a hollow viscus against an obstruction
what conditions can mask abdominal pain?
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? (This is a LONG answer card)
Have you had this pain before?
On a scale from 1 to 10…
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/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?
Inspection (e.g. surgical scars, distention)
Auscultation (e.g. bowel sounds, bruits)
Palpation (e.g. tenderness, R/O hernia, CVAT (CostoVertebral Angle Tenderness), 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?
Point with ONE finger to where the pain is worse
What is the classic position of a patient with peritonitis?
Motionless (often with knees flexed)
What is the classic position of a patient with a kidney stone?
Cannot stay still, restless, writhing in pain
What is the best way to examine a scared child or histrionic (drama queen) adult’s abdomen?
Use stethoscope to palpate abdomen
What lab tests are used to evaluate the patient with an acute abdomen?
CBC with DIFFERENTIAL!!!, Chem-10, amylase, Type & Screen, urinalysis, LFTs (liver function tests)
What is a “left shift” on CBC differential?
Sign of inflammatory response:
Immature neutrophils (bands)
Note: Many call >80% of WBCs as neutrophils a “left shift”
Ike’s note: left shift not only bands! ALL immature forms are sent out, including not just bands, but even metamyelocytes, myelocytes, promyelocytes
What lab test should every woman of childbearing age with an acute abdomen receive?
ß-hCG (human chorionic gonadotropin)
must rule out pregnancy/ectopic pregnancy
which x-rays are used to evaluate the patient with an acute abdomen?
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?
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?
APPENDICITIS!
RUQ Differential diagnosis?
Cholecystitis, hepatitis, PUD, perforated ulcer, pancreatitis, liver tumors, gastritis, hepatic abscess, choledocholithiasis, cholangitis, pyelonephritis, nephrolithiasis, appendicitis (ESPECIALLY DURING PREGNANCY), thoracic causes (e.g. pleurisy/pneumona), PE, pericarditis, MI (ESP inferior MI)
LUQ Differential diagnosis?
PUD, perforated ulcer, 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
LLQ Differential diagnosis
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)
