PLEASE PAY ATTENTION TO THE CASE STUDY

ZERO PLAGIARISM

FIVE REFERENCES

ABDOMINAL ASSESSMENT

Subjective:

CC: “My stomach hurts, I have diarrhea and nothing seems to help.”
HPI: JR, 47 yo WM, complains of having generalized abdominal pain that started 3 days ago. He has not taken any medications because he did not know what to take. He states the pain is a 5/10 today but has been as much as 9/10 when it first started. He has been able to eat, with some nausea afterwards.
PMH: HTN, Diabetes, hx of GI bleed 4 years ago
Medications: Lisinopril 10mg, Amlodipine 5 mg, Metformin 1000mg, Lantus 10 units qhs
Allergies: NKDA
FH: No hx of colon cancer, Father hx DMT2, HTN, Mother hx HTN, Hyperlipidemia, GERD
Social: Denies tobacco use; occasional etoh, married, 3 children (1 girl, 2 boys)
Objective:

VS: Temp 99.8; BP 160/86; RR 16; P 92; HT 5’10”; WT 248lbs
Heart: RRR, no murmurs
Lungs: CTA, chest wall symmetrical
Skin: Intact without lesions, no urticaria
Abd: soft, hyperactive bowel sounds, pos pain in the LLQ
Diagnostics: None
Assessment:

Left lower quadrant pain
Gastroenteritis
C H A P T E R 3

Abdominal pain Abdominal pain is a subjective feeling of discomfort in the abdomen that can be caused by a variety of problems. The goal of initial clinical assessment is to distinguish acute life­threatening conditions from chronic/recurrent or acute mild, self­limiting conditions. Assessment is complicated by the dynamic rather than static nature of acute abdominal pain, which can produce a changing clinical picture, often over a short period of time. In addition, both children and older adults tend to deviate from the usual and anticipated clinical pattern of abdominal pain. The following three processes can produce abdominal pain: (1) tension in the gastrointestinal (GI) tract wall from muscle contraction or distention, (2) ischemia, and (3) inflammation of the peritoneum. Pain can also be referred from within or outside the abdomen.

Colic is a type of tension pain. It is associated with forceful peristaltic contractions and is the most characteristic type of pain arising from the viscera. Colicky pain can be produced by an irritant substance, from infection with a virus or bacteria, or by the body’s attempt to force its luminal contents through an obstruction. Another type of tension pain is caused by acute stretching of the capsule of an organ, such as the liver, spleen, or kidney. The patient with this visceral pain is restless, moves about, and has difficulty getting comfortable.

Ischemia produces an intense, continuous pain. The most common cause of intestinal ischemic pain is strangulation of the bowel from obstruction.

Inflammation of the peritoneum usually begins at the serosa covering the affected and inflamed organ, causing visceral peritonitis. The pain is a poorly localized aching. As the inflammatory process spreads to the adjacent parietal peritoneum, it produces localized parietal peritonitis. The pain of parietal peritonitis is more severe and is perceived in the area of the abdomen corresponding to the inflammation. A patient with parietal pain usually lies still and does not want to move.

Pain can be referred from within the abdomen or from other parts of the body (Box 3.1).

Box 3.1

Some Causes of Pa in Perce ived in Anatomica l Regions

Right upper quadrant

• Duodenal ulcer • Hepatitis • Hepatomegaly • Pneumonia • Cholecystitis

Right lower quadrant

• Appendicitis • Salpingitis • Ovarian cyst • Ruptured ectopic pregnancy • Renal or ureteral stone • Strangulated hernia • Meckel diverticulitis

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• Regional ileitis • Perforated cecum

Periumbilical

• Intestinal obstruction • Acute pancreatitis • Early appendicitis • Mesenteric thrombosis • Aortic aneurysm • Diverticulitis

Left upper quadrant

• Ruptured spleen • Gastric ulcer • Aortic aneurysm • Perforated colon • Pneumonia

Left lower quadrant

• Sigmoid diverticulitis • Salpingitis • Ovarian cyst • Ruptured ectopic pregnancy • Renal or ureteral stone • Strangulated hernia • Perforated colon • Regional ileitis • Ulcerative colitis

Modified from Judge R, Zuidema G, Fitzgerald F: Clinical diagnosis, ed. 5, Boston, 1988, Little Brown.

Referral of pain occurs because tissues supplied by the same or adjacent neural segments have the same common pathways inside the central nervous system. Thus, stimulation of these neural segments produces the sensation of pain. For example, nerves that supply the appendix are derived from the same source as those that supply the small intestine, resulting in the onset of appendicitis pain in the epigastric area.

Abdominal pain in adults can be classified as acute, chronic, or recurrent. The term “acute abdomen” refers to any acute condition within the abdomen that requires immediate attention because surgical intervention may be required. Acute abdominal pain refers to a relatively sudden onset of pain that is severe or increasing in severity and has been present for a short duration. Chronic pain is characterized by its persistent duration or recurrence. Recurrent episodes of pain can be either acute or chronic in nature.

In adults, acute pain requiring immediate surgical intervention is commonly caused by appendicitis, perforated peptic ulcer, intestinal obstruction, peritonitis, perforated diverticulitis, ectopic pregnancy, or dissection of aortic aneurysm. Other common causes of acute pain include cholelithiasis, gastroenteritis, peptic gastroduodenal syndrome, pancreatitis, pelvic inflammatory disease (PID), or urinary tract infection (UTI). Chronic or recurrent pain can be caused by GI disorders, such as Crohn disease, irritable bowel syndrome (IBS), diverticulitis, or esophagitis; pelvic disorders, such as dysmenorrhea or uterine fibroids; genitourinary disorders, such as recurrent UTI or chronic prostatitis; or conditions outside the abdomen, such as costochondritis, hip disease, or hernia.

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In children, abdominal pain can be classified as acute or recurrent. Common causes of acute pain include appendicitis, food poisoning, UTI, viral gastroenteritis, and bacterial enterocolitis. Recurrent abdominal pain (RAP) is defined as more than three episodes of pain in 3 months in children older than 3 years. It affects 10% to 15% of children between the ages of 3 and 14 years; of these children, 90% will not have an organic etiology.

Diagnostic reasoning: Focused history Is this an acute condition? Key Questions

• How long ago did your pain start? • Was the onset sudden or gradual? • How severe is the pain (on a scale of 1–10)? • If a child: What is the child’s level of activity? • Does the pain wake you up from sleep? • What has been the course of the pain since it started? Is it getting worse or better? • When was your last bowel movement? • Have you ever had this pain before? What was diagnosed? How was it treated?

Onset and duration Acute onset of pain that is getting progressively worse could signal a surgical emergency. In general, patients who present with severe pain 6 to 24 hours from the onset probably have an acute surgical condition. Acute abdominal pain can signal a few potentially life­threatening conditions that must be considered first. The following are possible surgical emergencies that require immediate evaluation and intervention:

• Perforation or ruptured appendix: look for signs and symptoms of peritonitis (Box 3.2) • Ectopic pregnancy: suspect in any woman of childbearing age

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• Obstruction: sudden onset of crampy pain usually in umbilical area • Ruptured abdominal aortic aneurysm: when back pain is present • Intussusception: in infants • Malrotation: in infants usually younger than 1 month old

Box 3.2

Features of Per i toni t i s

P Pain: front, back, sides, shoulders

E Electrolytes fall; shock ensues

R Rigidity or rebound of anterior abdominal wall

I Immobile abdomen and patient

T Tenderness with involuntary guarding

O Obstruction

N Nausea and vomiting

I Increasing pulse rate, decreasing blood pressure

T Temperature falls and then rises; tachypnea

I Increasing girth of abdomen

S Silent abdomen (no bowel sounds)

Modified from Shipman JJ: Mnemonics and tactics in surgery and medicine, ed. 2, Chicago, 1984, Mosby.

Pain of sudden onset is more likely associated with colic, perforation, or acute ischemia (torsion, volvulus). Slower onset of pain generally is associated with inflammatory conditions, such as appendicitis, pancreatitis, and cholecystitis.

Acute pain that comes and goes can be related to intestinal peristalsis. The onset of pain in relation to food ingestion provides diagnostic clues: pain occurring several hours after a meal suggests a duodenal ulcer (pain with stomach empty), but pain immediately after eating occurs with esophagitis.

In children, RAP occurs in attacks usually lasting less than 1 hour and rarely longer than 3 hours and frequently interferes with daily routines. Between episodes, the pain resolves completely. When interviewing a child, remember that the child might not be old enough to have a clear sense of time.

Severity and progression Severity is the most difficult symptom to evaluate because of its subjective quality. It is helpful to use a scale of 1 to 10 in adults. Children often respond to the use of the FACES pain scale or the Oucher pain scale (Fig. 3.1).

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