Advanced Practice Provider Academy

(1)

CaseStudiesinAbdominalPain:Performingthe High‐YieldHistoryandPhysicalExamination

Abdominal pain accounts for approximately 5 percent of ED visits. Most patients do well but some patients have a life‐threatening illness that can’t be missed. During this case‐based lecture, the speaker will emphasize the key points in the history and physical examination that will allow you to recognize the seriously ill patient.

Objectives:

 Discuss the typical and atypical presentations of acute pyelonephritis, cholecystitis, pancreatitis, abdominal aortic aneurysm, testicular torsion and appendicitis.

 Describe specific questions that if answered affirmatively increase the likelihood of serious abdominal disease.

 Describe findings on physical examination (including the GU exam) that should alert the practitioner to the possibility of serious abdominal pathology.

 List key elements that should be included on each chart in the patient presenting with abdominal pain. Date: 4/15/2014

Time: 11:45 AM ‐ 12:15 PM Course Number: TU‐23

April

14 ‐

18

SanDiego,CA

Advanced

Practice

Provider

(2)

Dean T Harrison , M.P.A.S, P.A.‐C, D.F.A.A.P.A San Diego , April 15,2014

Agenda

 At the end of this presentation you should be able to

recognize the following patient presentations

 Acute Pyelonephritis

 Cholecystitis

 Pancreatitis

 Abdominal Aortic Aneurysm

 Testicular Torsion

(3)

Case

1

 34 year old female – negative past medical history

 1‐2 days of intractable nausea vomiting

 Past 24 hours low grade fever – chills –and back pain

 Exam – HR – 112 – BP ‐110/70 – RR – 18

‐right sided CVAT

‐TTP – RLQ/LLQ

What do you want to do ? What is you diagnosis

Case

2

 55 year old obese female – acute onset of RUQ pain

a/w n/v after eating at work party

Past Hx : HTN DM CAD

 Exam – distressed due pain

RUQ tenderness with guarding

(4)

Case

3

 24 year old male – diffuse abdominal pain after a night

of drinking celebrating graduation

 Past 12 hrs now has nausea/vomiting

 Exam – 38.2 C – HR ‐120 – BP 120/90 rr ‐20

 ‐Abd – diffuse tenderness

 What to you want to do? – what is your diagnosis ?

Case

4

 78 year old male with stabbing abdominal pain to his

back past 2 hours

 PHX – CAD  ‐HTN  ‐DM  ‐PVD  Exam – Bp – 80/40 – HR 130 – RR ‐24  Abdomen – Diffuse TTP

(5)

Presentations

 Non‐specific abd pain 34%

 Appendicitis 28%  Biliary tract dz 10%  SBO 4%  Gyn disease 4%  Pancreatitis 3%  Renal colic 3%  Perforated ulcer 3%  Cancer 2%  Diverticular dz 2%  Other 6%

Determining

the

Correct

Diagnosis

CAN

BE

(6)

 Gastritis, ileitis, colitis, esophagitis

 Ulcers: gastric, peptic, esophageal

 Biliary disease: cholelithiasis, cholecystitis

 Hepatitis, pancreatitis, Cholangitis

 Splenic infarct, Splenic rupture

 Pancreatic psuedocyst

 Hollow viscous perforation

 Bowel obstruction, volvulus

 Diverticulitis

 Appendicitis

 Ovarian cyst

 Ovarian torsion

 Hernias: incarcerated, strangulated

 Kidney stones

 Pyelonephritis

 Hydronephrosis

 Inflammatory bowel disease: crohns, UC

 Gastroenteritis, enterocolitis

 pseudomembranous colitis, ischemia colitis

 Tumors: carcinomas, lipomas

 Meckels diverticulum

 Testicular torsion

 Epididymitis, prostatitis, orchitis, cystitis

 Constipation

 Abdominal aortic aneurysm, ruptures aneurysm

 Aortic dissection

 Mesenteric ischemia

 Organomegaly

 ACS

 Pneumonia

 Abdominal wall syndromes: muscle strain, hematomas, trauma,

 Neuropathic causes: radicular pain

 Non‐specific abdominal pain

 Group A beta‐hemolytic streptococcal pharyngitis

 Rocky Mountain Spotted Fever

 Toxic Shock Syndrome

 Black widow envenomation

 Drugs: cocaine induced‐ischemia, erythromycin, tetracyclines,

NSAIDs

 Mercury salts

 Acute inorganic lead poisoning

 Electrical injury

 Opioid withdrawal

 Mushroom toxicity

 AGA: DKA, AKA

 Adrenal crisis

 Thyroid storm

 Hypo‐and hypercalcemia

 Sickle cell crisis

 Vasculitis

 Irritable bowel syndrome

 Ectopic pregnancy

 PID

 Urinary retention

 Ileus, Ogilvie syndrome

How

Do

You

Approach

the

patient

with

Abdominal

Pain

?

 ‐Knowing the location and type of pain

 ‐History and Physical Examination

 ‐Laboratory Analysis

 ‐Imaging Studies

 ‐High Risk Patients

 ‐Knowing the potential ‘Land Mines”

(7)

OLD

CARS

‐

Mnemonic

for

Pain

 O – Onset  L ‐ Location  D‐ Duration  C‐ Character  A‐ Alleviating/Aggravating Factors  R ‐ Radiation  S‐ Severity  Visceral

 Involves hollow or solid organs; midline pain due to bilateral innvervation

 Steady ache or vague discomfort to excruciating or colicky pain

 Poorly localized

 Epigastric region: stomach, duodenum, biliary tract

 Periumbilical: small bowel, appendix, cecum

 Suprapubic: colon, sigmoid, GU tract

 Parietal

 Involves parietal peritoneum

 Localized pain

 Causes tenderness and guarding which progress to rigidity and rebound as peritonitis

develops

 Referred

 Produces symptoms not signs

 Based on developmental embryology

(8)

(9)

Relevant

Associated

ROS

 General ‐Fever – weight loss – dizziness

 Cardiac ‐chest pain – palpitations – lightheadedness

 GI – nausea –vomiting‐hemetemesis –anorexia – diarrhea –melena‐constipation

 GU – urgency –dysuria‐hematuria – incontinence

 GYN – vaginal bleeding – vaginal discharge – dysprunia

History

– Taking

– IMPORTANT

!!

 ‐Similar episodes ?

 ‐Other Medical Conditions ‐DM/CAD/HIV/Cancer

 ‐Past Surgical History – Think Adhesions /Infections

 ‐Past GU History – UTI/Pyelonephritis/Kidney Stones

(10)

History

– Taking



Social

History

‐ Drugs – Tobacco – ETOH –

Work Environment ‐? Physical Abuse



Medications

‐NSIDS – PPI’s –

Immunosuppressive Agents – Anti‐coagulants

Physical

Examination

 Start at the Door – General Appearance

 Vitals Signs – Can tell you a lot

 Make sure you include Cardiac /Pulmonary Exam

 Make sure patent is undressed

(11)

Consistent

Approach

to

Exam



Inspection

‐ Distention/scars/masses



Auscultation

‐All 4 Quadrants – BS – Absent –

Hyper/Hypo



Palpation

– Tenderness – Masses –AA –Organomegaly –

Rebound – Guarding – Rigidity



Percussion

‐Check for Tympany

Acute

Pyelonephritis

What is it ?

‐Sudden and Severe kidney infection

What are the bacterial etiologies ?

‐E‐coli – 75‐95% ‐Proteius ‐Klebsiella ‐Pseudomonas ‐Serraitia ‐Enterocci

(12)

How

Do

They

Present

?

‐ Fever > 38 degree C ‐ Chills ‐ Back/Flank Pain ‐ Nausea/Vomiting ‐ Anorexia

‐ May Mimic PID/STD in Female Patients ‐Especially in Inner City

Locations

‐ Dysuria/Pyuria/Urgency/Hematuria

Physical

Findings

 Febrile

 May be dehydrated from vomiting

 CVA tenderness

 Diffuse or localized pain on abdominal exam

 Remember to perform Pelvic Examination to R/O Gyn

(13)

Laboratory

Evaluation

 Elevated WBC with Left shift

 Urine positive for LE/Nitrates

 May have WBC cast ‐? Renal origin

 Electrolytes may reflect dehydration

 Imaging – CT with contrast if concern about altercations in renal

perfusion/abscesses

 Imaging – CT without contrast – concerned about obstructive process – ie. – infected stone

 Ultra sound – if unable to have CT

Treatment

Plan

 Urine cultures

 Antibiotics –extend coverage as clinically indicated

 Hydration

 Antiemetic

 Pain Management

 Complications

 ‐Renal Abscess

 ‐Peri‐Nephric Abscess

 ‐Papillary Necrosis

(14)

Take

Home

Points

!

 Assume all females or pregnant until proven they are not

 Inner city patients may have GYN process

 Always perform a Pelvic Exam – you may have two

processes simultaneously

 If patient is not improving as expected – Your initial

diagnosis may not be correct !

 Easily treated ‐significant complications if missed !

Acute

Cholecystitis

– What

is

it?

 The gallbladder neck or cystic duct is obstructed

 Increased intraluminal pressure along with irritation

from bile and stones can lead to mucosal damage and

inflammation of the gallbladder wall

(15)

Acute

Cholecystitis

(16)

How

Do

They

Present

?

 RUQ Pain

 Radiation to back or shoulder

 Nauseated /Vomiting

 Low grade fever

 Tachycardia

 Pain lasting greater than 6 hours

(17)

What

do

you

Find

on

Examination?

 Patient appears sick

 May be febrile

 May have tachycardia

 RUQ pain with positive Murphy’s sign (place hand RU Costal

Margin‐ask pt to take deep breath –pt will experience pain and

catch their breath as the GB descends and contacts the palpating

hand )

 Peritoneal signs may signify perforation

What

will

the

labs

show

?

 Leukocytosis

 If CBD obstruction – elevated bilirubin /LFTs

 Elevated lipase suggestive of gallstone pancreatitis

 Gallbladder Ultra Sound ‐ Thicken GB wall

‐Pericholecystic fluid

‐Gallstones or sludge

‐Sonographic Murphy Sign

(18)

What

Do

I

Do

?

 Surgical Consult  NPO  IV Fluids  Pain Management  NG if indicated  Antibiotics ‐ Ceftriaxone 1 gm IV

‐ If septic –broaden coverage –

Take

Home

Points

!

 Most people with asymptomatic gallstones remain

asymptomatic

 Patients that develop Acute Cholecystitis will present with

pain

 Acute Cholecystitis and its complications are potentially

life‐threatening and require prompt diagnosis

 Bedside GB /US with positive Murphy's sign can help

(19)

Acute

Pancreatitis

– What

is

it

?

 Usually a relatively mild disease may become a life‐

threatening illness characterized by infection and

necrosis of pancreatic tissue

How

do

They

Present

?

 Abdominal pain is the most common complaint

 Usually is severe and constant

 Pain may be diffuse but may be localized to epigastric

region and LUQ

 Nausea/Vomiting

 H/O ETOH abuse is common – 1‐10%

(20)

What

do

Find

on

Physical

Exam

?

 Pain is exacerbated by recumbency and relieved by sitting up and flexing forward – due

to retroperitoneal irritation

 May have Guarding LUQ and epigastric region

 May have signs of peritoneal irritation

 Cullen sign – Bluish discoloration around the umbilicus (hemorrhagic process)  Grey Turner sign – Bluish discoloration of the flanks (hemorrhagic process)

 May be febrile  May have tachycardia  May also be diaphoretic

 Dehydrated from vomiting

What

will

the

Labs

Show

?

 Elevated WBC

 Elevated Lipase – high specificity

 Elevated Amylase – others processes can elevate –do not rely

only on this test

 US can show pancreatic edema/pseudo cyst – can be difficult to

visualize due to adipose tissue or distended loops of bowel

 CT – NOT necessary to diagnose pancreatitis – useful to evaluate

(21)

What

Do

I

Do

?

 90 % of cases can be treated with supportive care

 “Rest the pancreas”

 IVF

 Advance diet as tolerated

 NG tube if indicated

 Pain management

 Correct electrolyte imbalance

 Antiemetic

 Trend lipase

Take

Home

Points!

 High suspicion with patients with ETOH dependency

 Significant Physical Exam findings – LUQ

 Elevated Lipase – isolated value – is it trending upward or

downward ?

 Chronic pancreatitis is usually manifested by recurrent

(22)

Abdominal

Aortic

Aneurysm

What

it

Is

 The most frequent catastrophic event involving the

aorta

 Starts with a tear in the inner most layer of the vessel

 Tear allows blood to penetrate down to the middle

(23)

 Often asymptomatic and unknown prior to

presentation

 Rupture is the worry

 Presents with midline abdominal pain with tearing

sensation to the back

 Patients often present in shock

 Exam revels pustule abdominal mass

Aortic

Dissection

– What

to

Think

About

it

– You

Do

NOT

want

to

miss

this

Diagnosis

!!

 Chest pain with associated back pain/abdominal pain

 H/O Hypertension

 H/O Connective Tissue Diseases

 H/O Atypical Chest Pain

 H/O Atypical Back Pain

(24)

Physical

Exam

 Pt will present in 3 ways

‐asymptomatic

‐symptomatic

50% of asymptomatic AAA are palpable

‐ruptured

Classic triad in ruptured patients

‐back pain

‐hypotension

‐pulsatile mass

What

to

do

 Laboratory studies not usually helpful for diagnosis but

helpful for baseline references

 Coagulations studies should be evaluated

 Type and Cross

 US is quick and accurate for presence of AAA

 CT provides greater detail and more accurate measurement

(25)

Take

Home

Points

 High Suspicion in an unstable patient requires emergent

surgical consultation and surgery

 Aggressive resuscitation of shock with fluids and blood

products as necessary

 US is helpful in establishing the presence or absence of

AAA ‐but it cannot provide evidence that the AAA is not

ruptured ,leaking, or expanding

 AAA are frequently misdiagnosed in obese patients

(26)

Testicular

Torsion

How

do

they

Present

?

 Sudden onset of severe testicular pain

 If torsion is repaired within 6 hoursof the initial insult, salvage rates

of 80‐100% are typical. These rates decline to nearly 0% at 24 hours.  Approximately 5‐10% of torsed testes spontaneously detorse, but the

risk of retorsion at a later date remains high.

 Most occur in males less than 20yrs old but 10% of affected patients are

(27)

What

will

I

see

on

exam

?

What

do

I

do

?

 Stat Ultrasound – Stat Urology Consult

 “Time is Testicular Survival “

 True Urological Emergency

 Pain Management

 Prep for OR

(28)

Take

Home

Points

 50% of testes lost because of misdiagnosis at

presentation

 Scrotal erythema and swelling usually associated with

infection

 Do not delay consultation with Urologist

 Manual detorsion is the most rapid means of

establishing blood flow

Acute

Appendicitis

 Classic Presentation ( How often do you see that ?)

 ‐Anorexia , nausea, vomiting ‐Periumbilical pain

‐ Pain localized to RLQ

‐ This presentation occurs in majority of patients . 26% of appendices are retrocecal and cause pain in the

flank – 4% patients will present with RUQ pain . Males may present with pain in their testicles

(29)

Physical

Exam

 Varied – depends on duration of symptoms

 Can have rebound , voluntary guarding ,rigidity,

tenderness on rectal exam

 Positive Psosas sign

 Positive Obturator sign

(30)

Psoas

Sign

(31)

Laboratory

Findings

 CBC not sensitive or specific –

 Abdominal x‐ray – may see localized ileus ,blurred

right psoas muscle , free air

 US ‐+/‐

 CT – pericecal inflamation – abscess, periappendiceal

(32)

What

do

I

do

?

 Positive CT – call surgeon

 NPO –IVF –

 Cover anaerobes, gram negative and eterococci

 Zosyn 3.375 grams iv or Unasyn 3 grams iv

 Suspect – but have not pulled the CT trigger ‐Place in

(33)

Take

Home

Points

.

 Abdominal Pain and tenderness are present in nearly

100% of patients with acute appendicitis

 Use caution in your evaluation of the young – elderly – pregnant female ! And don’t forget the intoxicated

male !

 Do not rely on the CBC

(34)

Case

1

 34 year old female – negative past medical history

 1‐2 days of intractable nausea vomiting

 Past 24 hours low grade fever – chills –and back pain

 Exam – HR – 112 – BP ‐110/70 – RR – 18

‐right sided CVAT

‐TTP – RLQ/LLQ

What do you want to do ? What is you diagnosis

Case

1

 Lab – WBC ‐15,000 with left shift  U/A ‐positive nitrates

 ‐positive LE  ‐positive Ketones  ‐micro 200‐300 wbc/HPF  Electrolytes – normal  Pregnancy ‐negative DX : Acute Pyelonephritis Treatment plan ‐ antibiotics

 ‐antiemetic  ‐fluids  ‐pain management  ‐urine c/s   

(35)

Case

2

 55 year old obese female – acute onset of RUQ pain

a/w n/v after eating at work party

Past Hx : HTN DM CAD

 Exam – distressed due pain

RUQ tenderness with guarding

What do you want to do ? What is your diagnosis

Case

2

 Lab ‐ WBC – 20,000 with left shift

 Electrolytes – normal

 U/A – normal

 LFTS – T‐Bilirubin ‐ 1.9

 GB /US – positive for obstructive stones /CB

dilatation  DX: Acute Cholecystitis  Plan : Admission  Antibiotics  Surgical Consult  Supportive Care

(36)

Case

3

 24 year old male – diffuse abdominal pain after a night

of drinking celebrating graduation

 Past 12 hrs now has nausea/vomiting

 Exam – 38.2 C – HR ‐120 – BP 120/90 rr ‐20

 ‐Abd – TTP over McBurney point

 What to you want to do? – what is your diagnosis ?

Case

3

 Lab – WBC ‐13000

 Electrolytes – K+ ‐3.1

 Bun – 28/Creat.– 1.6

 CT – positive for dilated appendix with stranding

 Diagnosis – Acute Appendicitis / Mild dehydration

 Plan: ‐NPO  ‐Surgical Consult  ‐Antibiotics  ‐Pain Management  ‐IVF  ‐K replacement 

(37)

Case

4

 78 year old male with stabbing abdominal pain tearing

sensation radiating to his back past 2 hours

 PHX – CAD

 ‐HTN

 ‐DM

 ‐PVD

 Exam – Bp – 80/40 – HR 130 – RR ‐24

 Abdomen – Diffuse TTP – palpable pulsating

mass – decreased distal pulses

What do you want to do ? What is your diagnosis

Case

4

 Bedside US – positive for AAA –

 DX – Rupturing AAA

 p/ Stat Surgical Page

Aggressive Management

(38)

Assessment

and

Management

 ‐Always perform genital examination when lower abdominal pain is

present in males and females

 ‐Females are pregnant until proven otherwise  ‐Sudden , severe pain suggest serious disease

 ‐Pain awakening the patient from sleep should be taken as an indicator

of serious disease

 ‐In older patents – remember to think about AAA

 Significant abdominal tenderness should never be attributed to

gastroenteritis

Documentation

MUST

!!!

‐

or

it

will

come

back

to

“bite

you

latter”

Remember – if it is not documented – it wasn’t done

Remember – to document you medical decision process

Pitfalls ‐ Incomplete exams (rectal‐pelvic‐genital)

‐ Incomplete histories ‐ Missing lab results/VS

‐Not performing serial exams and documenting

‐“Gastroenteritis” Diagnosis !!!

‐Change of shifts dilemma

‐The Intoxicated or altered patient

(39)