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Identify the areas commonly auscultated for bruits. i.e., renal artery stenosis
Describe the significance of the abdomen in all four quadrants
Describe the common abnormalities that can cause irregular percussion notes of the abdomen, i.e. ovarian tumor, pregnant uterus or GI obstruction
Acute Abdomen objectives
Define and describe the changes associated with light and deep palpation to assess any degree of tenderness, i.e. rebound tenderness, guarding which would indicate a peritoneal irritation or distended viscous.
Acute abdomen objectives
Recognize and perform the special techniques in examining the abdomen for specific findings: (1) rebound tenderness, (2) shifting dullness in ascites, (3) Fluid wave in ascites, (4) hooking technique for palpating the liver, (5) Murphy's sign for acute cholecystitis, (6) ballottement, and (7) the techniques of assessing possible appendicitis
Differential Dx. of Acute Abdominal Pain (Understand the anatomic correlation of abdominal pain and types of abdominal pain): causes of abdominal pain by quadrants, parietal pain, visceral pain and referred pain.
Acute Abdomen definition
It has an acute onset, it can have many potential etiologies and may required immediate medical or surgical intervention, also is mostly accompany by signs of peritoneal irritation (with some exceptions) like: rigidity, tenderness (with or without rebound), involuntary guarding, also may or may not have signs of hypotension and shock.
1) H&P: obtain a complete Hx (mnemonic)OPQRST)/ Vital signs (blood pressure, with pt standing or sitting position, pulse, asses peripheral perfusion alertness, skin and extremities temperature).
Immediate management of life threatening problems: bleeding, shock, hypotension
Location of Problem: Chest, abdomen (upper, middle, lower/ sides)
Time of Onset: Date, time…?
Type of Onset: How: Sudden? Gradual?
Original Source: Triggers, what were you doing? (setting at time of occurrence)
Severity: Interfere with ADL’S?
Time Relationship: How often, when?
Duration: How long an episode?
Course: Getting better, worse?
Association: Any other manifestation?
Source of Relief: Changes in medication, diet? What makes it better?
Source of Aggravation: What makes it worse?
Relevant Data & Pertinent Negatives
Gynecological Hx for females: last menstrual period, pregnancies, STD’s.
Associated symptoms: nausea, anorexia, vomiting, change in bowel habits.
exam abdomen (gently) looking for signs of acute abdomen.(IAPP) Identify and describe the common localized abdominal masses including umbilical hernia, incisional hernia, epigastric hernia, diastases recti, and lipoma.
Pelvic(gynecological) exam for females and rectal exam for both male and female (gross blood, asses sphincter tone, and any other evidence of trauma).
Check for blood in stools: UC, diverticular ds, diverticulitis, hemorroids
Abdominal Assessment Landmarks
1. Xiphoid Process
2. Costal Margin
3. Abdominal Midline
5. Rectus Abdominis Muscle
6.Ant. Sup. Iliac Spine
7. Inguinal Ligament (Poupart’s Ligament)
8. Symphysis Pubis
Assessment of the Abdomen Inspection -- Contour
Types of abdomen:
rounded or convex
Assessment of the Abdomen Inspection -- Contour
Flat is normal
Large convex abdomen -- 7 F’s
Fluid (ascites) Fetus
Flatus Fatal growth (malignancy) Fibroid tumor
Assessment of the Abdomen Inspection -- Contour
3. Which of the following is the MOST common cause of painful rectal bleeding?
a. internal hemorrhoid
b. external hemorrhoid
d. anal fissure
e. rectal foreign body
Anal fissures result from a linear tear of the anal canal beginning at or just below the dentate line and extending distally along the anal canal.
Pt’s complain of sharp, cutting pain, most severe during and immediately after a bowel movement.
Bleeding is scant and bright red.
Anal fissures are especially painful b/c of the rich supply of somatic sensory nerve fibers located in the anoderm
All of the following are true regarding acalculous cholecystitis EXCEPT
a. it occurs in 5-10% of pt’s with acute cholecystitis
b. pt’s are frequently elderly and have a history of DM
c. it often occurs as a complication of another process
d. diagnosis is difficult due to the subtle clinical presentation
e. gallstones are absent
Acalculous cholecystitis occurs in 5-10% of pt’s c cholecystitis.
Pts frequently are elderly and have h/o DM
There are 2 distinguishing features of acalculous cholecysititis
1. it frequently occurs as a complication of another process
2. pts frequently are gravely ill on initial presentation
Which of the following drugs is NOT associated with acute pancreatitis?
Drugs and toxins are major causes of acute pancreatitis.
Some of the meds assoc c the occurrence are OCP’s, glucocorticoids, rifampin, tetracycline, isoniazid, thiazide diuretics, furosemide, salicylates, indomethacin, calcium, warfarin, and acetominophen.
Other etiologic factors contributing include infection, collagen vascular ds’s, metabolic disturbances, and trauma
In working up a patient with acute abdominal pain, which of the following etiologies is LEAST likely to represent an immediate life threat?
a. Myocardial infarction
b. Splenic rupture
c. Abdominal Aortic Aneurysm
d. Perforated duodenal ulcer
e. Ruptured ectopic pregnancy
When approaching a pt c acute abd pain, the clinician must consider conditions that can be an immediate threat to the patient’s life.
Splenic rupture, ruptured ectopic pregn, and AAA can all be associated with massive bleeding and rapid decline.
Extraabdominal conditions that present with abd pain such as MI can also be life threatening.
Perforated duodenal ulcer are serious but almost never result in significant hemorrhage, and thus are not usually an immediate threat to life.
Which of the following statements is TRUE regarding acute abdominal pain?
a. peritonitis causes visceral type of pain and is secondary to peritoneal inflammation from an irritant
b. Obstruction of a hollow viscus produces colicky, diffuse visceral pain assoc with N/V
c. Intraabdominal causes of pain include bacterial peritonitis, bowel ischemia, and tuboovarian abscess
d. referred pain from the abdomen may radiate to the back or groin, but not into the thorax
e. Metabolic disorders are rarely a significant source of acute abdominal pain
Three types of pain responses are possible with acute abd pain
Peritonitis is a somatic pain and is usually sharper, more constant, and more localized than visceral pain.
Obstruction of a hollow viscus is a common cause of visceral pain and is colicky, intermittent, and usually mid-line.
Referred pain is often felt in the back, groin, or thighs. Pt’s may also c/o pain in the supraclavicular region especially if the diaphragm is irritated by collections of blood or pus
Abd pain can arise from intraabd, extraabd, metabolic, or neurogenic origins.
Intrabd origins of pain are divided into 3 categories:
Peritoneal inflamm, obstruction of a hollow viscus, and vascular etiologies.
Extraabd sources can arise from the abd wall, thorax, or pelvis (as in the case of tubo-ovarian abscess)
Metabolic disorders such as DKA and Sickle cell crisis often present with diffuse abd pain
All of the following are TRUE regarding the evaluation of a patient with acute abdominal pain EXCEPT
a. the onset, location, and severity of pain are useful differentiating factors
b. the most important physical examination modality is palpation
c. the WBC may be normal even in inflammatory conditions such as appendicitis
d. ultrasonography is a valuable imaging tool increasingly available
e. analgesic medications should be withheld until a surgeon evaluates the patient because they may obscure the diagnosis.
The evaluation of abd pain should begin with a detailed hx.
The onset, severity, location, and character of pain and the presence of associated symptoms guide work-up and tx.
Although a complete PE is necessary, palpation of the abd is the most important modality for dx.
Lab tests are useful adjuncts, but the limitations of a CBC must be recognized.
Helpful imaging modalities include standard XR, U/S, barium contrast studies, and CT
IV opiate analgesia is humane and may actually assist in dx by facilitating PE in a pt who could otherwise not tolerate it.
Which of the following is the most common cause of upper GI bleeding?
a. Esophageal varices
b. Mallory-Weiss tear
d. Erosive gastritis
e. Arteriovenous malformations
Upper GI bleeding is defined as bleeding that originates proximal to the ligament of Treitz.
PUD, including gastric, duodenal, and stomachal ulcers, is the MC cause of upper GI bleeding (60%)
The next MC are erosive gastritis, esophagitis, and duodenitis (15%)
Gastric irritants such as ETOH, salicylates, and NSAIDS, predispose pts to upper GI bleeding.
Varices (only 6%) from portal HTN in ETOH’ers carry a high mortality rate.
Mallory-Weiss syndrome is due to a mucosal tear in the esophagus and is classically assoc c repeated bouts of retching.
AV malformations are an uncommon cause of upper GI bleed
A pt presents with what appears to be a massive lower GI hemorrhage. Which one of the following is the LEAST likely etiology?
c. Gastric varices
d. Duodenal ulcer
The MC cause of what initially appears to be lower GI bleeding is actually bleeding from an upper GI source.
Brisk bleeding from either varices or PUD can be the cause of apparent lower GI hemorrhage.
Diverticulosis and angiodysplasia are the MC causes of confirmed lower GI bleed.
Both occur more commonly in elderly, are painless, and may be massive.
Although hemorrhoids are a common etiology of minor lower GI bleed, usually not significant hemorrhage
Other less frequent sources of lower GI bleed include malignancies, IBD, polyps, infectious gastroenteritis, and Meckel’s diverticulum.
Which of the following scenarios may represent acute appendicitis?
a. a 4 y/o male with vomiting and lethargy
b. a 75 y/o female with fever and abdominal pain
c. a 26 y/o female who is 32 weeks pregnant with right upper quadrant pain
d. a 45 y/o male with AIDS and who has vomiting and diarrhea
e. All of the above
Certain groups of pts have atypical presentations and are at risk for delayed dx of acute appendicitis.
Children <6 y/o = 57% misdiagnosed; 90% perforation rates
Elderly pts, subtle sx, & high perforations
Pregnant pts pose difficulty b/c the gravid uterus changes the position of the appendix
An U/S can aid in distinguishing pelvic vs abd pathology
Immunocompromised are susceptible to delayed dx b/c of their frequent unrelated GI sx.
CT is helpful in differentiating surgical from nonsurgical conditions
What is the most common cause of large bowel obstruction?
b. incarcerated hernia
e. Sigmoid volvulus
It is important to distinguish between large and small bowel obstruction b/c tx differs
The MC cause of colonic obstruction is neoplasm
2 nd MC = diverticulitis, followed by sigmoid volvulus
MC SBO = surgical adhesions
2 nd MC SBO = hernias and primary small bowel lesions
A 40 y/o female with known gallstones presents with colicky RUQ pain and vomiting. She has a h/o similar episodes that usually resolve after 3-4 hrs. VS: BP 110/60, P 78, R 16, T 98.4*F. PE: mildly tender RUQ without signs of peritonitis. Which of the following would be LEAST appropriate in her ED management?
a. IV fluids
b. Pain control c opiate analgesics
c. pain control c ketorolac
d. antiemetic administration
e. immediate surgical consultation
Pts with uncomplicated symptomatic cholelithiasis do not require immediate surgical intervention.
ED intervention is geared toward pain relief and correction of volume deficits
Pain control can be achieved with administration of opiates or ketorolac
Antiemetics and gastric decompression with an NGT may be necessary for tx of protracted vomiting.
If the pt’s sx resolve within 4-6 hrs and she tolerates oral fluids, D/C home with outpt f/u is appropriate
Which of the following is the MOST common presentation of gallstones?
a. acute pancreatitis
b. acute cholecysitis
c. biliary colic
d. ascending cholangitis
e. gallbladder empyema
Pt’s with gallstones present in a variety of ways, and biliary colic (or symptomatic cholecystitis) is the MC.
The pain is colicky in nature, occurs after meals, and typically lasts from 1-6 hrs.
Pain lasting longer than 6 hrs that is accompanied by fever or leukocytosis suggests cholecystitis.
Biliary colic and acute cholecystitis are by far the MC manifestations of gallstone ds
Complications of gallstones may be life threatening.
Acute pancreatitis, ascending cholangitis, gallbladder empyema, and emphysematous cholecystitis all require aggressive pt resuscitation and prompt surgical consult
What is the MOST common cause of pancreatitis in an urban hospital setting?
c. abdominal trauma
d. penetrating peptic ulcer
e. salicylate poisoning
Acute pancreatitis is a common cause of abdominal pain.
In the US cholelithiasis and alcoholism account for 90%.
ETOH related ds is more common in the urban setting, and typically affects males 35-45.
Biliary ds is more frequent in the community hospital setting and typically affects females >50.
After biliary and ETOH = drugs (1/2 of remaining cases)
A 55 y/o female presents to the ED with a fever 4 days after undergoing a laparscopic cholecystectomy. What is the MOST likely cause of the fever?
c. Urinary Tract infection
d. Wound infection
e. Deep venous thrombosis
Laparoscopic procedures and early postsurgical discharge are becoming increasingly common cost-effective alternatives to laparotomy.
As a result, more pts are presenting to the ED with postoperative fever.
<24 h = atelectasis or necrotizing strept infections
24-72 h = respiratory (pneumonia), IV catheter complications (thrombophlebitis)
3-5 d = UTI’s (MC in female, and pts c cath’s)
7-10 d = wound infections
DVT’s can result in fever @ any time, pero usually >5d
A pt with suspected cholelithiasis presents to the ED. What is the initial imaging study of choice?
a. abdominal plain film
b. abdominal ultrasound
c. abdominal CT
d. Radionuclide scan (HIDA)
e. Barium contrast radiography
U/S has emerged as a valuable tool for certain conditions in the ED.
It is the initial study of choice for eval of pts with RUQ pain, and can accurately detect cholelithiasis.
Plain film is a poor imaging choice to detect gallstones (only 15%), but is useful in evaluating obstruction or suspected perforation.
CT is the diagnostic tool of choice for many abdominal conditions including pancreatitis, some trauma, and selected AAA, but is more costly and invasive than U/S for evaluating gallstones.
HIDA scan is a useful adjunct if U/S results are inconclusive or acalculous cholecysititis is suspected.
Barium studies are useful for imaging in some GI conditions, especially suspected intussusception, but not for eval of GB
Which of the following diagnostic study is most useful in the evaluation of a patient in the acute stages of diverticulitis?
a. CT scan
b. barium enema
c. ultrasound of the abdomen
Both endoscopy and barium enema are contraindicated in pts during acute stages of diverticulitis b/c of risk of perforation.
A 28 y/o man has complaints of intermittent, colicky, periumbilical, and lower-quadrant pain for 24 hours. The patient admits to nausea and decreased appetite. He is afebrile. Which of the following is the most likely diagnosis?
a. acute appendicitis
b. acute pancreatitis
e. peptic ulcer disease
The pain pattern is most consistent with a dx of gastroenteritis.
Acute appendicitis typically causes periumbilical pain that migrates to the RLQ
Acute pancreatitis radiates to the back or shoulder
Pyelonephritis is “loin to groin”
PUD is typically located in the epigastrum
A 7 y/o boy presents with c/o flank pain, fever, frequency, dysuria, and hematuria for 1 day. The UA shows >10 WBC’s per high-powered field, RBC’s, and WBC casts. Of the following, the most likely diagnosis is:
b. acute cystitis
d. renal calculi
e. urinary incontinence
Pyelonephritis is an infection of the renal parenchyma, accompanied by systemic sx such as fever, N/V and assoc with WBC casts in the urine.
In pediatric male pt, its occurrence would warrant additional eval to r/o anatomic abnormalities in the urinary tract
The most common cause of acute renal failure is:
a. prerenal azotemia
b. acute parenchymal renal failure
c. exogenous nephrotoxins
d. obstructive uropathy
Prerenal azotemia results from renal hypoperfusion and can be reversed upon restoration of blood flow.
It is not associated with structural damage to the kidney and is the most common cause of acute renal failure.
A 27 y/o woman with amenorrhea is seen for vaginal bleeding and abdominal pain. An ectopic pregnancy is suspected. Which of the following would support the suspicion?
a. enlarged boggy uterus
b. ruptured fetal membranes
c. adnexal mass
d. weak fetal heart beat
e. painless profuse bleeding
Classic features of an ectopic pregnancy are abdominal pain, bleeding, and adnexal mass in a pregnant woman.