Abdominal Pain

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Case I Chris is a 20 year old male who presents to the emergency department complaining of lower abdominal pain and cramping. He has had this pain since last night which has been worsening throughout the morning. What are the most common causes of abdominal pain presenting to the emergency department? What is your next step in the evaluation of this patient?

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Chris has had abdominal pain now for 12 hours. It started as mild periumbilical pain but is now worse in the right lower quadrant. He has a low grade fever when taken at home. He has felt nauseated and has vomited several times. His review of systems is otherwise negative. He has no significant past medical history and has never needed surgery. He admits to binge drinking on weekend nights, but does not smoke or use illicit drugs. He is a Dartmouth undergraduate student living in campus housing. Denies sick contacts. Denies recent sexual activity. His vital signs are as follows:

Respiratory rate 16 Heart rat 94 Blood pressure 128/84 Temperature 100C

What are critical diagnoses in patience with abdominal pain? What is your differential diagnosis at this time? What additional conditions would you consider in a female patient?

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What is the differential diagnosis from abdominal pain by region of the abdomen?

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What is the classic presentation of appendicitis? What are classic signs of appendicitis? On physical exam Chris is exquisitely tender over McBurney's point. Rebound tenderness is not examined out of concern for patient comfort. He has Dunphys sign and is in noticeable pain with small movements of the bed. The remainder of his exam is on remarkable. What diagnostic tests would you consider?

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What is the role of CT in the diagnosis of appendicitis? How would you manage to patient at this time? You consult general surgery. While you await their the lab test return you order morphine. A CBC returns with a white count of 17.5. At the request of the surgeon you attain an abdominal CT which is shown below. He is reevaluated and taken to the OR.

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Case II Sharon is a 65 year old female who presents to the emergency department with abnormal bowel movements and mild abdominal discomfort. She has been feeling increasingly weak over the last couple of weeks and had a near syncope episode prior to presenting. What are common causes of the abdominal pain in the elderly? Sharon states that her pain has been intermittent, but chiefly in the left lower quadrant. The pain has waxed and waned over the last several days without any noticeable relieving or exacerbation events. It feels crampy and gassy. Her other chief complaint is the lightheadedness. It has becoming progressively worse over the last few weeks. Tonight she was clearing plates after dinner and needed to sit down because she felt faint. In the review of systems she has noticed that she has had more frequent bowel movements with dark sticky stool. She has hypertension and prediabetes which are diet controlled. She does not drink, smoke, or use drugs. She is an elementary school teacher and lives with her husband. Her vital signs are within normal limits. On physical exam she appears pale and weak. Her conjunctivae are pale. Her abdomen is mildly tender over the lower left quadrant. The remainder of the exam is normal. No invasive or private exam is conducted as she is in a hallway bed.

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How are upper and lower GI bleeding differentiated in history? In physical exam? In diagnostic procedures? She is moved into a private room. A rectal exam shows tarry heme positive stool with streaks of fresh blood. There are no obvious lesions or tears in the anus or rectum. You decide to perform orthostatic vital signs. How are orthostatic vital signs performed? What is their value? What are the common causes of upper GI bleeding?

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What are the common causes of lower GI bleeding? What workup would you like to attain? The CBC comes back first with a hemoglobin of 7.2. The ECG shows normal sinus rhythm with no ST abnormalities. While awaiting the other lab tests to return you consult GI. What are recommendations for transfusion? GI recommends against CTA as it will only pick up rapid hemorrhaging. They agree that she should be transfused as she is symptomatic and has a hemoglobin less than 9. Since she is stable you wait for the type and cross before transfusing 2 units. An urgent colonoscopy is scheduled for later this afternoon.

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Case III Angela is 53 year old female who presents to the emergency department at midnight with right upper quadrant pain. He has had crampy upper abdominal pain on and off for the last month after meals, but the current pain has been unrelenting for the last 5 hours. He has begun to feel nauseated and vomited twice. His vital signs are as follows: Respiratory rate 16 Heart rate 98 Blood pressure 150/90 Temperature 38.4C What does the pattern of her pain suggest? Define the following terms associated with biliary pathology: On physical exam the patient has a positive Murphys Sign. The remainder of the physical exam is unremarkable. What is a positive Murphys Sign? What diagnostic studies do you want to order?

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How do you use laboratory values to differentiate between biliary pathologies?

The lab results return as follows:

CBC: 15>15/45