Joshua Sapkin, MD
Associate Program Director
LAC+USC Internal Medicine Residency Program
Case 1
The nurse calls you because your patient who returned
from the GI suite 2 hours ago is complaining of diffuse
abdominal pain. The patient is a 55 year old man who
was admitted for symptomatic anemia. The lower
endoscopy performed earlier that demonstrated
diverticulosis without evidence of bleeding.
Case 1
What is the next best step in the management of this
patient?
A. Ask the nurse to obtain a set of vital signs.
B. Tell the nurse to call the GI fellow who
endoscoped the patient.
C. Tell the nurse to give the patient 2 mg of
morphine sulfate IV x 1 dose.
D. Immediately evaluate the patient.
Case 1
Upon arriving at the patient’s bedside, you find him slightly
diaphoretic and grimacing in pain.
Vital signs: Blood Pressure: 94/52. Heart rate 100. Respirations:
24. Temperature: 99.2. Oxygen saturation 99% on room air.
P.E. HEENT: Anicteric. No conjunctival pallor.
Cardiac: Tachycardic.
Chest: Lungs clear to auscultation
Abdomen: Mild distention. Absent bowel sounds.
Tympanitic to percussion. Diffuse tenderness to
palpation. Difficult exam secondary to guarding.
Rectal: Normal sphincter tone. No mucosal masses.
No stool in the rectal vault.
Case 1
Why are vital signs called “vital” signs?
A. They are a necessary component of the medical
documentation in order to bill health insurances
(vital for reimbursement)
B. They are important clues to the patient’s diagnosis
(vital for establishing a diagnosis).
C. The nurses consider them essential pieces of
information before paging a physician (vital for
paging a physician)
D. They reflect physiologic processes that are essential
to sustaining life.
Case 1
All of the following measures would be appropriate a this
time EXCEPT:
A. Check the patient’s blood pressure in the supine and
sitting position.
B. Ensure the patient has two large bore peripheral IV
sites.
C. Contact the GI fellow who performed the procedure.
D. STAT General Surgery consult
E. Ask the nurse if he/she would like to join you for a drink
at Barbara’s Brewery after work.
Case 1
Case 2
A 26 year-old young man with a long history of alcohol abuse complains of a 7 day
history of upper abdominal pain, nausea and vomiting. He reports gaining 30 lbs. over
the past 2 months. His skin and sclera have turned yellow during this period of time. His
last drink was 6 days ago.
P.E.
Height: 5’ 9” Weight: 240 lbs.
Vital Signs: Blood pressure: 138/82. Heart Rate: 100 Respirations: 14. Temperature: 102.0.
General: Non-toxic appearing young male who appears comfortable.
HEENT: Icteric sclera.
Tachycardic with a 2/6 systolic ejection murmur auscultated throughout the precordium
Abdomen: Distended with bulging flanks. Dull to percussion throughout. There is
tenderness to deep palpation in the mid-epigastrium and right upper quadrant. The liver
edge is palpated in the midline three finger breadths below the costal margin. It is
smooth and tender. No bruits auscultated.
Extremities: 1+ pitting edema over bilateral shins
Genitourinary: No lesions on the penile shaft. Testes descended bilaterally
without masses or tenderness. No inguinal hernias or lymphadenopathy.
Rectal: Normal sphincter tone. No mucosal masses palpated. Light brown stool
in the vault.
Case 2
All of the following should be included in the
differential diagnosis for this individual’s abdominal
pain EXCEPT:
A. Decompensated cirrhosis
B. Pancreatitis
C. Hepatic abscess
D. Sclerosing cholangitis
E. Metastatic colon cancer
Case 2
In terms of establishing a
diagnosis, which labs
would you order?
Be prepared to justify
your answer.
Case 2
In terms of establishing a
diagnosis, which
radiologic imaging study
would you order?
Be prepared to justify
your answer.
Case 2
WBC: 15,000 (82, 10, 7, 1)
Hgb: 12.7 MCV 104
Platelets: 65,000
T. Bili 16.0
D. Bili 12.5
AST: 80
ALT38
Alk Phos: 140
Pro Time: 30 seconds
INT: 2.5
Abdominal Ultrasound
Large ascites
The liver is enlarged, measuring 21
cm in diameter. There is increased
echogenicity consistent with
fatty infiltration.
Common bile duct measures 6 mm
in diameter . No intrahepatic
ductal dilatation. There is reversal
of portopedal flow, recanulization
of the umbilical vein and
splenomegaly. The pancreas is not well
visualized because of overlying bowel gas.
The kidneys are normal in size and
echoctexture. No hydronephrosis.
Case 3
A 53 year-old woman with a 25 year history of diabetes
type 2 is admitted for chronic post-prandial abdominal
pain, nausea and vomiting. She has not been able to
keep down any liquids or solid food for more than 30
minutes for the past 2 days. In between episodes, she is
asymptomatic except for mild nausea. She underwent
an open cholecystectomy 20 years ago for symptomatic
cholelithiasis. Vital signs are normal. Her abdominal
exam is only significant for minimum tenderness in
the midepigastrium and left upper quadrant. An
abdominal series performed in the DEM reveals a nonobstructive bowel gas pattern.
Case 3
Which piece of data provides the best evidence that
this woman does not have a partial small bowel
obstruction?
A. Her cholecystectomy was performed 20 years ago.
B. The timing and duration of her symptoms
C. The results of her abdominal series
D. Her abdominal exam
Case 4
A 75 year old woman with a history of Crohn’s disease
limited to the terminal ileum complains of abdominal
pain, distention and decreased flatus for the past two
days. She has no appetite and has vomited after every
attempt to drink liquids. Vital signs are normal.
Abdominal exam is significant for distention, absent
bowel sounds and diffuse mild tenderness. There is no
rebound tenderness or hepatosplenomegaly. GU and
rectal exams are normal.
Case 4
Case 4
 Obstruction is present if the small-bowel loop is greater
than 2.5 cm in diameter dilated proximal to a distinct
transition zone of collapsed bowel less than 1 cm in
diameter.
 Bowel wall thickening, pneumatosis, and portal venous gas
all suggest strangulation.
 CT differentiates between the etiologies of SBO--extrinsic
causes such as adhesions and hernia from intrinsic causes
such as neoplasms or Crohn's disease.
 CT can identify causes of acute abdominal pain such as
abscess, hernia, tumor, or inflammation. CT should be
obtained with both PO and IV contrast, unless the patient
has renal failure or IV contrast allergy.
Case 5
A 28 year old 2nd year internal medicine resident
develops low grade fever, periumbilical abdominal
pain that migrates to his right lower quadrant over a 24
hour period. On exam, obturator and Rovsing’s signs
are positive. He is admitted for presumed acute
appendicitis and given IV Abx. CT scan with oral and
IV contrast demonstrates “no evidence of
appendicitis.”
Key Points
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Rely on your own history and physical exam to
create a differential diagnosis
Stabilize the patient before proceeding with the
work-up
Be selective when ordering lab tests and imaging
studies
Consult the surgical services earlier than later
Take advantage of the radiologists
Do not be afraid to commit to a diagnosis