Abdominal Pain Lesson Notes

Abdominal Pain Site of the pain Radiation Severity Character Time course: Onset Offset Duration Episodic Change over time. Previous episodes and compare to previous episodes. Context Contributing factors Aggravating factors Relieving factors Associated features Fever Jaundice Nausea Vomiting Scrotal pain Skin lesions Rash Red eye Anal pain Appetite changes Urinary symptoms Abdominal distension Altered bowel habits: Stool colour. Frequency Constipation Diarrhoea Stool contents. Urgency Shock features -> dizziness and palpitations. Medications Prescription medications Non-prescription medications Past medical history Past surgical history Allergies Vaccinations Family history Social history: Diet Smoking Alcohol Recreational drugs Specific Differentials Questions Diseases Questions and Physical Examination Findings Fever Shock Nausea Vomiting Appetite changes Appendicitis Altered bowel habits: Ask generally. Constipation Diarrhoea Past medical history Past surgical history Fever Nausea Jaundice Vomiting Appetite changes Cholecystitis Urinary symptoms Altered bowel habits. Social history: Diet Smoking Alcohol Itch Fever Nausea Jaundice: Yellow eyes Yellow skin Cholangitis Vomit Abdominal pain Altered bowel habits. Pale stools Social history: Diet Past medical history Fever Nausea Jaundice Vomit Choledocholithiasis Family history Social history: Diet Past medical history Past surgical history Fever Nausea Abdominal pain Cholelithiasis Family history Social history: Diet Past medical history Fever Vomit Joint pain Abdominal distension Usually, RLQ Palpable mass due to adhesions caused by inflammation. Altered bowel habits: Ask generally. Constipation. Defecating blood Diarrhoea (general patient presents with chronic diarrhoea) Faecal urgency Low grade fever Crohn’s disease Weight loss Lower GI bleed -> uncommon Fatigue Features of Crohn’s disease complications: Malabsorption: weight loss, anaemia and failure to thrive. Enterocutaneous or perianal fistulas often associated with abscess formation. Extra-intestinal manifestations Enteropathy arthritis -> serogenerative sponadylaorthopay Eyes: uveitis, iritis, episcleritis Liver/bile duct: cholelithiasis Skin rashes Social history: Smoking Blood diarrhoea with mucus Often very loose and watery stools Blood is a rare manifestation in ulcerative colitis. The bloody diarrhoea tends to happen with belly cramps a sudden urgent to have a bowel movement and sometimes fever. Faecal urgency Abdominal pain with cramps Ulcerative colitis Tenesmus Extraintestinal features: Fatigue and fever Skeletal (most common extra-intestinal manifestations) -> osteoarthritis, ankylosing spondylitis, sacroiliitis Ocular: uveitis, episcleritis, iritis Primary sclerosing cholangitis Cutaneous: erythema nodosum, pyoderma gangrenous, aphthous stomatitis Abdominal discomfort or pain. Severe pain in left iliac fossa, as mainly affects the sigmoid colon. Chronic constipation Diverticular bleeding May be febrile and with tachycardia. Palpable mass may be felt in the left iliac fossa. Diverticulosis Complications: Perforation Fistula formation Intestinal obstruction Bleeding Mucosal inflammation Low grade fever Sigmoid colon most affected -> left quadrant pain Possibly a tender, palpable mass (peri colonic inflammation) Diverticulitis Change in bowel habits -> constipation in 50% of cases and diarrhea in 25-35% of cases. Increase in urinary urgency and frequency in 50% of cases and sterile pyuria (irritation of the bladder is cause by the proximity to an inflamed sigmoid colon). Acute abdomen -> indicates possible perforation and peritonitis. Rarely hematochezia. Fever Nausea Vomit Altered bowel habits: Ask generally. Gastroenteritis Diarrhoea Defecating blood Social history -> diet: Ask generally. Contaminated water Expired food. Abdominal pain Frequency Intensity Localisation generally widely varies from a patient to another. Typically related to defecation. Abdominal distension Altered bowel habits: Ask generally. Diarrhoea Constipation Mucus in stools. Faecal urgency Painful defecation Other GIT symptoms: Irritable Bowel Syndrome Nausea Reflux Early satiety Passing of mucus Abdominal bloating. Extraintestinal symptoms: Generalised somatic symptoms -> pain or fatigue as in fibromyalgia. Disturbed sexual function. Increased urinary frequency and urgency. Dysmenorrhea Physical examination: Normal Past medical history: GIT disease history Mental health history Abdominal pain Fatigue Weight loss Abdominal distension Altered bowel habits. Ability to flush. Chronic or recurring diarrhoea -> steatorrhea Flatulence Changes to appetite Malabsorption symptoms: Fatigue Coeliac Diseases Weight loss Vitamin deficiency Osteoporosis Hypocalcaemia Family history: Autoimmune disease Coeliac diseases Social history: Diet Past medical history: Autoimmune disease history Gastrointestinal disease history Abdominal pain Fever Nausea Vomit Pelvic Inflammatory Disease Urinary symptoms Ask generally. Painful urination. Social history Smoking history Acute ischemic colitis: Abdominal pain out of proportion to physical examination. Diarrhoea: bloody in the later stages. Nausea and vomit Abdominal bloating. Systemic signs of sepsis. Peritonitis and acute abdomen in the later stages. Onset and intensity may vary with the aetiology: AMI due to atrial embolism: most acute onset and most severe pain of all AMI aetiologies -> classic triad (seen in 80% of patients) -> severe pain with unremarkable physical examination, bloody diarrhoea and atrial fibrillation Ischemic Colitis . Patients may also present with symptoms suggestive of an embolic source. (such as AF, mitral or aortic valve reg murmur in endocarditis). AMI due to atrial thrombosis: subacute onset, less severe pain and occurs in patients with a history of abdominal angina. AMI due to non-occlusive AMI: gradual onset of symptoms over several days -> patients may be asymptomatic. AMI due to mesenteric venous thrombosis: mild, non-specific symptoms that worsen gradually. Chronic: Postprandial abdominal pain -> begins 10 to 30 minutes after eating -> lasts for 1-2 hours. Food aversion (sitophobia): fear of eating due to pain. Nonspecific symptoms: nausea, diarrhoea and bloating. Abdominal bruit on auscultation. Complete bowel obstruction: Total obstruction of the intestinal lumen -> prevents passage of air and fluid. Rapid progression of clinical features. Can be associated with obstipation -> complete inability to pass stool or gas. Partial bowel obstruction: Partial obstruction of the intestinal lumen -> allows a small amount of air and fluid to pass through. Clinical features can ne les severe than in complete bowel obstruction. Can be associated with intermittent passage of flatus and overflow diarrhoea. Abdominal pain Relived by vomiting. Colicky and periumbilical pain. Fever Nausea Fatigue Vomit Small Bowel Obstruction Early onset Large volume than LBO Bilious Has food in it. Abdominal distension Less than in LBO. Altered bowel habits: Constipation -> late onset especially is proximal SOB. Most recent bowel movement Medical history Past surgical history Examination findings: Signs of dehydration -> hypotension and dry mucus membranes. Diffuse abdominal tenderness. Tympanic percussion -> due to gaseous distension of the bowel. Increased high-pitched bowel sounds (early) and absence of any bowel sounds (late). Collapsed empty rectum on DRE in complete bowel obstruction. Abdominal pain: Colicky Constant Progressively worse Fever Nausea Vomit Late onset Initially bilious Progresses to faecal vomiting in the presence of faeces in the vomit. Weight loss Large Bowel Obstruction Night sweats Abdominal distention Altered bowel habits. Constipation -> early onset -> especially in distal LBL. Past medial history Past surgical history Examination findings: Signs of dehydration -> hypotension and dry mucus membranes. Diffuse abdominal tenderness. Tympanic percussion -> due to gaseous distension of the bowel. Increased high-pitched bowel sounds (early) and absence of any bowel sounds (late). Collapsed empty rectum on DRE in complete bowel obstruction. Nausea Vomit Ileus Abdominal distension Altered bowel habits. Past surgical history Itch Nausea and vomit Fever Brusing Jaundice Vomit Abdominal pain Constant Severe epigastric pain Radiates to the back. Improves upon leaning forwards. Appetite change Abdominal distention If pulmonary complications are present: chest pain and dyspnoea. Family history medications Relieving factors: Ask generally. Pancreatitis Medications Defecating or flatulating Medications: Prescription medications Non-prescription medications Positional or movements Vomiting Social history: Diet Alcohol history Examination findings: Signs of shock: tachycardia, hypotension, oliguria/anuria. Possibly jaundice in patients with biliary pancreatitis. Abdominal tenderness, distension and guarding. Ileus secondary to inflammation with reduced bowel sounds and tympani on percussion. Ascites Nausea Vomit Testicular Torsion Scrotal pain Past medial history relating to testicular disease Fever Nausea Vomiting Abdominal pain Ovarian torsion Altered bowel habits. Social history: Exercise Past medical history: Gynaecological disease history Right sided diverticular Consider when the appendix has been removed based on Hx