(+)DeanT.Harrison,MPAS,PA‐C,DFAAPA
DirectorofMid‐LevelPractitioners;Assistant
MedicalDirector‐ClinicalEvaluationUnit,Division
ofEmergencyMedicine,DepartmentofSurgery,
DukeUniversityMedicalCenter
AdvancedPracticeProvider
Academy
April14‐18
SanDiego,CA
CaseStudiesinAbdominalPain:Performingthe
High‐YieldHistoryandPhysicalExamination
Abdominalpainaccountsforapproximately5percentof
EDvisits.Mostpatientsdowellbutsomepatientshavea
life‐threateningillnessthatcan’tbemissed.Duringthis
case‐basedlecture,thespeakerwillemphasizethekey
pointsinthehistoryandphysicalexaminationthatwill
allowyoutorecognizetheseriouslyillpatient.
Objectives:
 Discussthetypicalandatypicalpresentationsofacute
pyelonephritis,cholecystitis,pancreatitis,abdominal
aorticaneurysm,testiculartorsionandappendicitis.
 Describespecificquestionsthatifanswered
affirmativelyincreasethelikelihoodofserious
abdominaldisease.
 Describefindingsonphysicalexamination(including
theGUexam)thatshouldalertthepractitionertothe
possibilityofseriousabdominalpathology.
 Listkeyelementsthatshouldbeincludedoneach
chartinthepatientpresentingwithabdominalpain.
Date:4/15/2014
Time:11:45AM‐12:15PM
CourseNumber:TU‐23
(+)Nosignificantfinancialrelationshipstodisclose
4/24/2014
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  Appendicitis 1
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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 What do you want to do ? What is your diagnosis 2
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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
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‐ 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
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‐ HTN
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‐ DM
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‐ PVD
 Exam – Bp – 80/40 – HR 130 – RR ‐24 
Abdomen – Diffuse TTP What do you want to do ? What is your diagnosis 3
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Most Common Abdominal Pain Presentations 
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Non‐specific abd pain
Appendicitis
Biliary tract dz
SBO
Gyn disease
Pancreatitis
Renal colic
Perforated ulcer
Cancer
Diverticular dz
Other
34%
28%
10%
4%
4%
3%
3%
3%
2%
2%
6%
Determining the Correct Diagnosis CAN BE CHALLENGING !!!!
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Differential Diagnosis
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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
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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”  ‐ Knowing when to engage consultants 5
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OLD CARS ‐ Mnemonic for Pain  O – Onset
 L ‐ Location
 D‐ Duration
 C‐ Character  A‐ Alleviating/Aggravating Factors
 R ‐ Radiation
 S‐ Severity  Visceral
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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
 Ureteral obstruction → testicular pain
 Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
 Gynecologic pathology → back or proximal lower extremity
 Biliary disease → right infrascapular pain
 MI → epigastric, neck, jaw or upper extremity pain
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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
 ‐ Past GYN – Sexual Activity /Contraception /PID/STD
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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  Don’t forget Gent/Pelvic exam when indicated 9
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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 10
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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 process 11
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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 
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Urine cultures
Antibiotics –extend coverage as clinically indicated Hydration Antiemetic
Pain Management  Complications
 ‐ Renal Abscess
 ‐ Peri‐Nephric Abscess
 ‐ Papillary Necrosis
 ‐ Urosepsis 12
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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
 Potentially can lead to ischemia 13
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Acute Cholecystitis Acute Cholecystitis 14
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How Do They Present ?
 RUQ Pain
 Radiation to back or shoulder  Nauseated /Vomiting
 Low grade fever
 Tachycardia  Pain lasting greater than 6 hours
 Look sick 15
4/24/2014
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 HIDA scan more sensitive/specific 16
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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 expedite the diagnosis 17
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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%
 In non ETOH patients – 60% will have gallstones
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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 complications 19
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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 episode of acute pancreatitis
 Adequate pain management
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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 layer causing separation
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Ruptured AAA
 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  Diminished or Absent Peripheral Pulses
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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  Management is tailored to the patients presentation 23
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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 Testicular Torsion 24
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Testicular Torsion How do they Present ?
 Sudden onset of severe testicular pain
 If torsion is repaired within 6 hours of 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 older than 30 years. 25
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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  No Urology available – Manual detorsion 26
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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 27
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Physical Exam
 Varied – depends on duration of symptoms
 Can have rebound , voluntary guarding ,rigidity, tenderness on rectal exam
 Positive Psosas sign  Positive Obturator sign Obturator sign 28
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Psoas Sign
Appendicitis: Psoas Sign
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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 phlegmon, fluid collection , localized fat stranding 30
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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 Observation – trend exam and clinical changes 31
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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 Back to the Cases
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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
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U/A ‐ positive nitrates 
‐ positive LE
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‐ positive Ketones 
‐ micro 200‐ 300 wbc/HPF
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Electrolytes – normal
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Pregnancy ‐ negative DX : Acute Pyelonephritis
Treatment plan ‐ antibiotics
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‐ antiemetic
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‐ fluids
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‐ pain management 
‐ urine c/s
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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
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LFTS – T‐Bilirubin ‐ 1.9
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GB /US – positive for obstructive stones /CB dilatation  DX: Acute Cholecystitis  Plan : Admission
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Antibiotics
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Surgical Consult
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Supportive Care 
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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
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‐ Abd – TTP over McBurney point  What to you want to do? – what is your diagnosis ?
Case 3
 Lab – WBC ‐ 13000
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Electrolytes – K+ ‐ 3.1
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Bun – 28/Creat.– 1.6
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CT – positive for dilated appendix with stranding  Diagnosis – Acute Appendicitis / Mild dehydration  Plan: ‐ NPO
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‐ Surgical Consult 
‐ Antibiotics
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‐ Pain Management 
‐ IVF
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‐ K replacement 
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Case 4
 78 year old male with stabbing abdominal pain tearing sensation radiating to his back past 2 hours  PHX – CAD
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‐ HTN
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‐ DM
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‐ 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 Prep for OR 36
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Summary Bullets – Patient 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 ‐ Documentation of Consultants Recommendations 37
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Thank You for Your Time and Attention !!
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