Professor’s Pearls: Abdominal Pain

Professor’s Pearls: Abdominal Pain




Section Review


Consider the following clinical problems and questions posed. Then refer to the professor’s discussion of these issues.


1) A 28-year-old female presents with a 2-day hx of vague peri-umbilical pain. Today the patient has lower abdominal pain (right greater than left), which is associated with new onset of urinary frequency. She also vomited twice today. She is sexually active and her menstrual cycle tends to be irregular. Her last menstrual period was 6 weeks ago (2 weeks late).

VS: T = 100.2, HR = 90, BP = 110/68.


Labs: H/H = 12.0/36.3, WBC = 11,300, U/A: 5 RBCs, 10–15 WBCs


Physical examination: RLQ tenderness, guarding, and rebound. Pelvic examination without cervical motion tenderness.


What would be your differential dx and plan for further evaluation?


2) A 44-year-old female presents to the ED with RUQ pain associated with nausea and vomiting. She states that this pain has been present for nearly a week, but she has failed to seek medical attention. She admits to having 2 to 3 “drinks” each night. Two years ago she had an episode of alcoholic hepatitis and she assumes that her current episode might be the same.

VS: T = 100.9, HR = 102, BP = 140/70


Physical examination: RUQ tenderness with guarding


Labs: H/H = 11.7/35, WBC = 14,600. Total bilirubin = 1.2, alkaline phosphatase = 92, AST = 86, ALT = 74, amylase = 47, lipase = 60


Imaging: RUQ ultrasonography shows “cholelithiasis, gallbladder wall thickening (5 mm), and a small amount of pericholecystic fluid.”


Based on the information presented, what is the most likely dx and what would you recommend?


3) A 65-year-old male presents with diffuse mid-abdominal pain that awakened him 24 hours ago. He states that the pain initially presented as a sharp stabbing sensation in his mid-abdomen but has now worsened and is generalized.

The patient is actually well known to you because you performed a colonoscopy on him 3 days ago. He had been referred to you because of a hemoglobin of 8.0 and Hemoccult-positive stools. Your colonoscopy documented a 4-cm adenocarcinoma of the cecum. You have already scheduled an elective right colectomy for next week (to be preceded, of course, by an appropriate bowel prep). The patient’s past medical hx is significant for use of NSAIDs for osteoarthritis over the past 3 years. The patient also has a hx of a single episode of acute diverticulitis 3 years ago that was treated as an inpatient with IV antibiotics.


VS: T = 99.3, HR = 110, BP = 110/70, RR = 22


Physical examination: Abdomen has diffuse rebound tenderness. The tenderness is greatest in the RLQ.


Labs: H/H = 8.3/25.2, WBCs = 18,400


Imaging: A CXR performed in the ED shows “free air under the diaphragm.”


What are the diagnostic possibilities? What further workup do you need and what would be your tx approach?


4) A 32-year-old female presents with a 2-day hx of RLQ tenderness associated with 3 loose stools. The patient describes 4 episodes of severe but self-limited diarrhea earlier this year. One such episode precipitated an ED visit without specific dx. She has had an 8-pound involuntary weight loss over the past 2 months. She is currently experiencing her menstrual period, but the pain is “not my usual menstrual cramps.”

VS: T = 99.2, HR = 90, BP = 110/68


Physical examination: RLQ tenderness, guarding, and mild rebound. Pelvic examination is unremarkable. Questionable right CVA tenderness.


Labs: H/H = 12.1/36, WBC = 11,800, U/A: many RBCs and 0–5 WBCs


What are the diagnostic possibilities? How would you work this up further?

Related posts:

  1. Hypercalcemia in a 56-Year-Old Female (Case 15)
  2. Acid-Base Balance
  3. Splenomegaly in a 40-Year-Old Female (Case 19)
  4. The Resident as Teacher: Facilitating Student Success

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Professor’s Pearls: Abdominal Pain

Full access? Get Clinical Tree
Get Clinical Tree app for offline access