Acute abdomen

Dr Alaa Osman MDSurgeon

The termlsquoacute abdomenrsquo

designates symptoms and signs ofintra-abdominal disease usually treated best

by surgical operation

Acute Abdomen If I operate and the problem is not

surgical patient exposed to unnecessary risk anesthetic etc

Risks greater with concomitant illness older age

If I do not operate and problem is surgical patient at risk because of wrong therapy

Again the older patient is under greater burden

Continue

Characteristics of patients need surgery

Acute pain Septic amp toxic Board-like abdomen Absent bowel sounds WBC 25000 Free air under diaphragm

Characteristics of patients need NO surgery

Trivial pain Robust appearance Soft abdomen with no guarding Normal bowel sounds Normal WBC Normal plain and upright films of

abdomen

Acute Abdominal PainNon-surgical Emergencies

Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually)

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

The termlsquoacute abdomenrsquo

designates symptoms and signs ofintra-abdominal disease usually treated best

by surgical operation

Acute Abdomen If I operate and the problem is not

surgical patient exposed to unnecessary risk anesthetic etc

Risks greater with concomitant illness older age

If I do not operate and problem is surgical patient at risk because of wrong therapy

Again the older patient is under greater burden

Continue

Characteristics of patients need surgery

Acute pain Septic amp toxic Board-like abdomen Absent bowel sounds WBC 25000 Free air under diaphragm

Characteristics of patients need NO surgery

Trivial pain Robust appearance Soft abdomen with no guarding Normal bowel sounds Normal WBC Normal plain and upright films of

abdomen

Acute Abdominal PainNon-surgical Emergencies

Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually)

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Acute Abdomen If I operate and the problem is not

surgical patient exposed to unnecessary risk anesthetic etc

Risks greater with concomitant illness older age

If I do not operate and problem is surgical patient at risk because of wrong therapy

Again the older patient is under greater burden

Continue

Characteristics of patients need surgery

Acute pain Septic amp toxic Board-like abdomen Absent bowel sounds WBC 25000 Free air under diaphragm

Characteristics of patients need NO surgery

Trivial pain Robust appearance Soft abdomen with no guarding Normal bowel sounds Normal WBC Normal plain and upright films of

abdomen

Acute Abdominal PainNon-surgical Emergencies

Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually)

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Characteristics of patients need surgery

Acute pain Septic amp toxic Board-like abdomen Absent bowel sounds WBC 25000 Free air under diaphragm

Characteristics of patients need NO surgery

Trivial pain Robust appearance Soft abdomen with no guarding Normal bowel sounds Normal WBC Normal plain and upright films of

abdomen

Acute Abdominal PainNon-surgical Emergencies

Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually)

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Characteristics of patients need NO surgery

Trivial pain Robust appearance Soft abdomen with no guarding Normal bowel sounds Normal WBC Normal plain and upright films of

abdomen

Acute Abdominal PainNon-surgical Emergencies

Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually)

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Acute Abdominal PainNon-surgical Emergencies

Mesenteric Adenitis Acute Enteric Infections Acute Enteric Poisonings Inflammatory Bowel Disease Pancreatitis (usually)

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Acute Abdominal PainMetabolic Causes

Diabetic Ketoacidosis Heavy Metal Poisoning Acute Porphyria Tabes dorsalis Sickle Cell Crisis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

The Physiology of Abdominal Pain

1048713 Abdominal pain from any cause is mediated by either visceral or somatic afferent nerves

1048713 Several factors can modify expression of pain

1048713 Age extremes

1048713 Vascular compromise (pain lsquoout of proportionrsquo) 1048713 Pregnancy 1048713 CNS pathology 1048713 Neutropenia

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Visceral Pain

1048713 Stimuli 1048713 Distention of the gut or other hollow

abdominal organ 1048713 Traction on the bowel mesentery 1048713 Inflammation 1048713 Ischemia

1048713 Sensation 1048713 Corresponds to the embryologic

origin of the diseased organ (foregut midgut hindgut)

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Somatic Pain Stimuli 1048713 Irritation of the peritoneum

1048713 Sensation 1048713 Sharp localized pain 1048713 Easily described

1048713 Cardinal signs 1048713 Pain ldquotendernessrdquo 1048713 Guarding 1048713 Rebound 1048713 Absent bowel sounds

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Pattern of referred pain

Gastric pain

Liver and biliary pain

Colonic pain

Ureteral or kidney pain

Diaphragmatic irritation

Biliary colic

Pancreatic and renal pain

Uterine and rectal pain

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

Where does it hurt Know locations of major organs But realize abdominal pain locations do

not correlate well with source

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

What does pain feel like Steady pain - inflammatory process Crampy pain - obstructive process

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

Was onset of pain gradual or sudden Sudden = perforation hemorrhage

infarct Gradual = peritoneal irrigation hollow

organ distension

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

Does pain radiate (travel) anywhere Right shoulder angle of right scapula =

gall bladder Around flank to groin = kidney ureter

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History Duration

gt 6 hour duration = surgical significance Nausea vomiting Bloody ldquoCoffee

Groundsrdquo

Any blood in GI tract = Emergency until proven otherwise

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

Change in urinary habits Urine appearance

Change in bowel habits Appearance of bowel movements Melena

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

Regardless of underlying cause vomiting or diarrhea can be a problem because of associated volume loss

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

History

Females Last menstrual period Abnormal bleeding

In females abdominal pain = Gyn problem until proven otherwise

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Physical Exam

General Appearance Lies perfectly still inflammation

peritonitis Restless writhing obstruction

Abdominal distension Ecchymosis around umbilicus flanks

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Physical Exam

Vital signs Tachycardia Early shock (more

important than BP) Rapid shallow breathing peritonitis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Physical Examination The Quadrants

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Special physical signs

Murphyrsquos sign Boasrsquos sign Grey turnerrsquos and Cullens sign Rovsingrsquos sign

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Diagnosis Right Upper Quadrant (RUQ) Pain

Investigations 1048713 X-Ray Upright chest Upright and supine abdominal 1048713 Complete Blood count 1048713 Urinalysis 1048713 Amylase Creatinine BUN

Electrolytes

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Differential Diagnosis RUQ PainConditionclues

Biliary colic acutecholecystitis

Recurrent attacks tender over gall bladderarea

Acute hepatitisAlcohol history jaundice medications

Right pyelonephritisDysuria fever costovertebral angletenderness

Congestive heart failureEdema dyspnea elevated JVP

Retrocecal appendicitisShift of pain tenderness

Right lower lobe pneumonia

Fever tachypnea bronchial breathing

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Diagnosis Left Upper Quadrant (LUQ) and Epigastric Pain

Investigations 1048713 Upright chest XR 1048713 Upright and supine abdominal XR 1048713 CBC 1048713 Amylase and lipase (if available

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Differential Diagnosis LUQ and Epigastric Pain

ConditioncluesSplenic ruptureHistory of trauma or splenic disease

Fractured ribsHistory of trauma gross deformity extremetenderness on palpation

PancreatitisHistory of alcohol consumption history ofsimilar event elevated labs

Gastritis Peptic ulcerdisease

Recurrent relationship to mealsrelationship to posture

PneumoniaFever XR findings bronchial breathing

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Diagnosis Right Lower Quadrant (RLQ) Pain

Investigations 1048713 Urinalysis (to exclude obvious urinary

causes) 1048713 Pregnancy test 1048713 Ultrasound 1048713 Complete blood count

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Differential Diagnosis RLQ Pain

ConditioncluesAcute appendicitisShift of pain anorexia localized

tenderness

Mesenteric adenitisFever inconstant signs

Right renal colicColicky pain hematuria

Torsed right testisTender swollen testis usually young age

Crohnrsquos diseaseRecurrent several days history

Gynecologic causeshellipsee next

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Gynecologic Causes of RLQ Pain

CONDITIONCLUES

Ruptured follicleFever cervical excitation discharge

Torsion of ovaryMidcycle sudden onset

Ruptured ectopicpregnancy

Severe pain vomiting

Pelvic inflammatorydisease

Sudden onset amenorrhea shock

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Diagnosis Left Lower Quadrant (LLQ) Pain

1048713 Pregnancy test1048713 Urinalysis to exclude unsuspected

urinary source1048713 Ultrasound1048713 Complete blood count1048713 Upright and supine abdominal XR1048713 CT scan if diverticular disease is

suspected

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Differential Diagnosis LLQ PainCONDITIONCLUES

Diverticular diseaseElderly patient recurrent

Acute urinary retention

Palpable bladder difficulty passing urine

Urinary tract infectionDysuria frequency

Inflammatory bowel disease

Recurrent attacks diarrhea (+- mucus blood)

Large bowel obstruction

Colicky pain constipation

Left renal colicColicky pain hematuria

Torsion of testisTender swollen testis young age

Gynecologic causes as for RLQ pain

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis

Immediate Treatment of the Acute Abdomen1-Start large bore IV with either saline or lactated Ringerrsquossolution2-IV pain medication3-Nasogastric tube if vomiting or concerned about obstruction4-Foley catheter to follow hydration status and to obtainurinalysis5-Antibiotic administration if suspicious of inflammation orperforation6-Definitive therapy or procedure will vary with diagnosis

Remember to reassess patient on a regular basis