FRCEM FINAL SBA eBook 1(Preview)

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4 <strong>FRCEM</strong> Final • Common examples of referred pain are scapular pain due to biliary colic, groin pain due to renal colic, and shoulder pain due to blood or infection irritating the diaphragm. 5. CLINICAL ASSESSMENT HISTORY • When possible, the history should be obtained from a nonsedated patient. The initial differential diagnosis can be determined by a delineation of the pain's location, radiation, and movement (e.g., appendicitis-associated pain usually moves from the periumbilical area to the right lower quadrant of the abdomen). After the location is identified, the physician should obtain general information about onset, duration, severity, and quality of pain and about exacerbating and remitting factors. • Associated symptoms often allow the physician to further focus the differential diagnosis. • For bowel obstruction, constipation is the symptom with the highest positive predictive value. • For appendicitis, right lower quadrant pain has the highest positive predictive value, although migration from periumbilical to right lower quadrant pain and fever also suggest appendicitis. Some conditions that were historically considered useful in diagnosing abdominal pain (e.g., anorexia in patients with appendicitis) have been found to have little predictive value. • Colic (i.e., sharp, localized abdominal pain that increases, peaks, and subsides) is associated with numerous diseases of hollow viscera. The mechanism of pain is thought to be smooth muscle contraction proximal to a partial or complete obstruction (e.g., gallstone, kidney stone, small bowel obstruction). Although colic is associated with several diseases, the location of colic may help diagnose the cause. The absence of colic is useful for ruling out diseases such as acute cholecystitis; less than 25 percent of patients with acute cholecystitis present without right upper quadrant pain or colic. • Peptic ulcer disease is often associated with Helicobacter pylori infection (75 to 95 percent of duodenal ulcers and 65 to 95 percent of gastric ulcers), 3 although most patients do not know their H. pylori status. In addition, many patients with ulcer disease and serology findings negative for H. pylori report recent use of nonsteroidal anti-inflammatory drugs. • Other symptoms of peptic ulcer disease include concurrent, episodic gnawing or burning pain; pain relieved by food; and nighttime awakening with pain. 3 Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol. 2002;97(4):824–830. • Symptoms in patients with abdominal pain that are suggestive of surgical or emergent conditions include fever, protracted vomiting, syncope or presyncope, and evidence of gastrointestinal blood loss. CLINICAL FEATURES SUGGESTING PARTICULAR CAUSES OF ABDOMINAL PAINCLINICAL FEATURES Abdominal pain in patients with AF or Atherosclerotic disease. Abdominal pain out of proportion to clinical findings. Flank pain radiating to the groin. Severe abdominal pain radiating through to back. Abdominal pain associated with shoulder tip pain (due to diaphragmatic irritation). Abdominal pain with collapse or signs of shock. Abdominal distension Evidence of GI bleeding (haematemesis or melena). Abdominal bruising Constipation DIFFERENTIAL DIAGNOSIS • Aortic aneurysm • Mesenteric infarction (embolic or thrombotic) • Aortic aneurysm • Mesenteric infarction • Renal colic • Renal colic • Pyelonephritis • Testicular torsion • Aortic aneurysm • Aortic aneurysm • Acute cholecystitis • Ascending cholangitis • Acute pancreatitis • Peptic ulcer disease • Ectopic pregnancy • Acute pancreatitis • Acute cholecystitis • Ascending cholangitis • Aortic aneurysm • Bowel perforation • Aortic aneurysm • Ectopic pregnancy • Massive GI bleed • Myocardial infarction • Bowel obstruction • Pregnancy • Ascites • Cancer • Peptic ulcer • Diverticular disease • Malignancy • Varices • Angiodysplasia • Trauma • Aortic aneurysm • Acute pancreatitis Haemorrhagic fluid collecting in the paracolic gutters (Grey Turner’s sign) or around umbilicus (Cullen’s sign) • Bowel obstruction • Bowel ischaemia • Diverticular disease Acute & Major Presentations Moussa Issa Bookstore
Section I: Major and Acute Presentations 5 PHYSICAL EXAMINATION • The patient's general appearance and vital signs can help narrow the differential diagnosis. • Patients with peritonitis tend to lie very still, whereas those with renal colic seem unable to stay still. • Fever suggests infection; however, its absence does not rule it out, especially in patients who are older or immunocompromised. Tachycardia and orthostatic hypotension suggest hypovolemia. • A rectal examination may reveal fecal impaction, a palpable mass, or occult blood in the stool. Tenderness and fullness on the right side of the rectum suggest a retrocecal appendix. • A pelvic examination may reveal vaginal discharge, which can indicate vaginitis. The presence of cervical motion tenderness and peritoneal signs increase the likelihood of ectopic pregnancy 5 or other gynecologic complications, such as salpingitis or a tuboovarian abscess. 6. INVESTIGATION STRATEGIES Investigations of Associated Symptoms Investigations in the Emergency Department MUST include the following simple tests: • Urinalysis: This should be performed in ALL patients with abdominal pain and if significant infection suspected an urgent gram stain should be arranged • Urinary hCG: This MUST be performed in all females of child-bearing age to rule out ectopic pregnancy • BM Stix: Do not FORGET this, as diabetic ketoacidosis (DKA) can present with abdominal pain • The location of pain guides the remainder of the physical examination. Physicians should pay close attention to the cardiac and lung examinations in patients with upper abdominal pain because they could suggest pneumonia or cardiac ischemia. • There are several specialized maneuvers that evaluate for signs associated with causes of abdominal pain. When present, some signs are highly predictive of certain diseases. These include: o Carnett's sign (i.e., increased pain when a supine patient tenses the abdominal wall by lifting the head and shoulders off the examination table) in patients with abdominal wall pain 4 ; o Murphy's sign in patients with cholecystitis (although it is only present in 65 percent of adults with cholecystitis and is particularly unreliable in older patients); o Psoas sign in patients with appendicitis. • Other signs such as rigidity and rebound tenderness are nonspecific. • Rectal and pelvic examinations are recommended in patients with lower abdominal and pelvic pain. 1) Blood Tests Tests Reason WCC CRP • This may be raised in many causes of abdominal pain, including nonsurgical causes. • These tend to be more accurate if combined but cannot rule out serious pathology, generally helpful but low sensitivity and specificity. U&E • Urea raised if dehydrated/GI Bleed LFT • Suspected liver or gallstone pathology Amylase • Suspected pancreatitis (Lipase is more specific) G&S +/- • If bleeding suspected or Crossmatch laparotomy possible ABG • If patient unwell or pancreatitis or ischaemic bowel suspected 4 Srinivasan R, Greenbaum DS. Chronic abdominal wall pain: a frequently overlooked problem. Practical approach to diagnosis and management. Am J Gastroenterol. 2002;97(4):824–830. 5 Buckley RG, King KJ, Disney JD, Gorman JD, Klausen JH. History and physical examination to estimate the risk of ectopic pregnancy: validation of a clinical prediction model. Ann Emerg Med. 1999;34(5):589–594. Acute & Major Presentations Moussa Issa Bookstore
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