Tummy Troubles Evaluation of the Acute Abdominal Complaint

Lacey A. Collins, MSEd, ATC, CSCS Brian G. Collins, MSPAS, PA-C, VAEMTP Housekeeping Notes Learning Objectives After this session, attendees will be able to:

● Identify surface and internal anatomy of the abdomen ● Obtain a pertinent medical history for abdominal complaints ● Evaluate acute abdominal complaints utilizing observation, inspection, auscultation, percussion and palpation ● Formulate a differential diagnosis for acute abdominal complaints based on exam history and findings ● Identify red flags for emergent referral associated with acute abdominal complaints Anatomy of the Location descriptors: abdomen 4 Quadrants (quick and dirty) 9 Regions (more descriptive)

Surface Anatomy

Muscles

Organs 4 Quadrants

RUQ LUQ - Liver - Liver (tail) - Pancreas (head) - Pancreas (body/tail) - Gallbladder - Stomach - Large intestine (hepatic flexure) - Spleen - R kidney - Large intestine (splenic flexure) - L kidney

RLQ LLQ - Appendix - L ovary - R ovary - Psoas - Psoas - Large intestine (descending) - Large intestine (ascending) From Swartz, Textbook of Physical Diagnosis, 4ed 9 Regions

R hypochondriac Epigastric L hypochondriac - Lung (RLL) - Stomach - Lung (LLL) - R kidney - Pancreas - L kidney - Liver/gallbladder - Duodenum - Liver (tail) - Aorta (supra-renal) - Spleen

R lumbar Umbilical L lumbar - Liver - Small intestine - Descending colon - Hepatic flexure - Umbilical hernia - Ascending colon - Aorta (infra-renal)

R iliac Hypogastric L iliac - R ovary/fallopian tube - Bladder - L ovary/fallopian tube - Appendix - Uterus - Descending colon - Sigmoid colon - Aorta (infra-renal) From Swartz, Textbook of Physical Diagnosis, 4ed Surface Anatomy

Borders: - Superior → 12th ribs and costal angle - Inferior → Iliac crests, inguinal ligaments, and os pubis - Lateral??

Landmarks: - Umbilicus → T10 - Iliac crests → L4-5 - Linea alba → midline Medical History

OPQRST

Associated symptoms

Context

PMH, FH, SH

Other factors OPQRST

Onset

Palloration/Provocation

Quality

Radiation

Severity

Timing Pertinent History

PMH: - Diagnoses (including any acute/new diagnoses) - Medications (rx, OTC, vitamins, supplements, BC, etc)

FH: - Diabetes, Crohn’s/UC, sickle cell, etc

SH: - Tobacco, ETOH, drug use - Sexual activity Context

Recent travel (overseas, long car/plane trip, open air markets, etc)

Recent trauma

Sick contacts (home, dorm, etc)

Similar symptoms in the past?

Menstrual cycle Other Factors

Conditioning

Recent schedule/activity

Clinician “gestalt” Evaluation Techniques ● Observation ● Inspection ● Auscultation ● Percussion ● Palpation Observation

General nutritional state

Pallor

Jaundice

Mental state Inspection

Shape and movements Swelling (6 F’s) - Fat Scars - Flatus - Fetus Distention (localized versus - Fluid generalized) - Feces - Fatal growth Striae Guarding/splinting Bruises Facial expressions (i.e. grimmace) Pigmentation

Hernias Key Findings on Inspection Cullen’s Sign - Bluish periumbilical discoloration (bruising) - Pancreatitis, ruptured ectopic, ruptured spleen, ruptured common bile duct, perforated duodenal ulcer, ...

Grey Turner’s Sign - Bruising of the flank(s) from subcutaneous blood tracking - Severe acute pancreatitis, severe abdominal trauma

Charcot’s Triad - Fever + Jaundice + RUQ Pain - Infection of the biliary tract following biliary obstruction and stasis Cullen’s sign Grey Turner’s Sign (UpToDate Graphic 95719 Version 1.0) Auscultation

ALWAYS auscultate before palpation (we don’t want to create sounds)

Diaphragm (deep pressure) → bowel sounds

Bell (gently rested) → vascular sounds Auscultation

Listen until you hear bowel sounds OR for a full minute

Normal frequency = 5-35 per minute

Bruits (aorta, renal arteries, iliacs, femorals) → blowing sound with the bell, could be related with aortic aneurysm or renal artery stenosis

Tinkling bowel sounds → high pitched sounds that are an early sign of small bowel obstruction Percussion

Percuss in all four quadrants

Tympany → gas/air

Dullness → fluid/feces Palpation Palpate in systematic fashion, avoid painful areas until last if possible (to avoid a “pan-positive” exam)

Do not be afraid to palpate areas of tenderness (you must examine in order to determine the characteristics of pain)

Liver (sometimes palpable, usually far right edge on inspiration)

Spleen (palpable spleen = enlarged spleen)

Kidneys (don’t forget to check CVA tenderness) Key Findings on Palpation

Blumberg’s Sign (aka Rebound Tenderness) - can indicate localized peritoneal irritation (i.e., appendicitis, pancreatitis, etc)

Appendiceal irritation - Psoas, Obturator, and Rovsing signs

Murphy’s Sign - cholecystitis

Markle Sign - abrupt abdominal pain and tenderness upon landing on heels from a tiptoe position - warrants urgent surgical consult (appy, SBO, perforation) RED FLAGS Sudden onset Fever

Unexplained bleeding New onset dyspepsia (hematemesis, hematuria, melena/hematochezia, Persistent unexplained non-menstrual bleeding) vomiting

Unexplained weight loss Amenorrhea

Shortness of breath Testicular pain

Dysphagia

Pre-syncope Questions? Cases Case 1: 18yo female runner

What were the key pieces? What is your differential?

● RLQ pain ● Ectopic pregnancy ● Sudden onset ● Appendicitis ● Amenorrhea ● Ovarian cyst ● Sexually active ● Other? ● Birth control +antibiotics ● Cullen’s sign positive What did you do? ● Muscle guarding RLQ A. Immediate referral B. Hold until she sees MD C. Let her play Case 2: 16yo male baseball player

What red flags did you identify? What is your differential?

● RLQ pain ● Diverticulitis ● Fever ● IBD ● Sudden onset ● Appendicitis ● Rebound tenderness/guarding ● Testicular torsion ● Positive Markle/Heel sign ● Other? ● Pain relieved with rest in flexed position What did you do? ● Positive psoas sign & Rosving A. Immediate Referral B. Hold until he sees MD C. Let him play Case 3: 18yo male football player

What red flags did you identify? What is your differential?

● Positive family history ● T1DM ● Increased life stress ● DKA ● Unexplained weight loss ● Overtraining/burnout ● Lethargy ● Dehydration ● Fruity breath ● Thirst What did you do? ● Nausea/vomiting A. Immediate Referral B. Hold until he sees MD C. Let him play Case 4: 19yo female softball player What red flags did you identify? What is your differential?

● RUQ pain ● Cholecystitis ● Hx of GERD ● Gallstone pancreatitis ● Family hx ● GERD ● Positive Murphy’s sign ● Peptic Ulcer Disease ● Hepatitis

What did you do?

A. Immediate Referral B. Hold until she sees MD C. Let her play Case 5: 22yo male basketball player

What red flags did you identify? What is your differential?

● Sudden onset ● Traveler’s diarrhea ● Severity of nausea/vomiting ● Viral illness ● Abdominal cramping ● Food poisoning ● Sick contacts ● Diverticulitis ● Low grade fever What did you do?

A. Immediate Referral B. Hold until he sees MD C. Let him play Case 6: 20yo female lax player

What red flags did you identify? What is your differential?

● Nausea ● Yeast infection ● Dysuria ● UTI ● Hematuria ● Pyelonephritis ● Urgency ● Kidney stone ● PMH ● STD

What did you do?

A. Immediate Referral B. Hold until she sees MD C. Let her play References Martin RF, Kang SK. Acute appendicitis in adults: Diagnostic evaluation. In: UpToDate, Weiser M (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Martin RF. Acute appendicitis in adults: Clinical manifestations and differential diagnosis. In: UpToDate, Weiser M (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Levitsky LL, Misra M. Epidemiology, presentation, and diagnosis of type 1 diabetes mellitus in children and adolescents. In: UpToDate, Wolfsdorf JI (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Haymond MW. Clinical features and diagnosis of diabetic ketoacidosis in children and adolescents. In: UpToDate, Wolfsdorf JI (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Bordeianou L, Yeh DD. Epidemiology, clinical features, and diagnosis of mechanical small bowel obstruction in adults. Soybel DI, Hockberger RS (Eds), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

The Abdomen, Perineum, Anus, and Rectosigmoid. In: LeBlond RF, Brown DD, Suneja M, Szot JF. eds. DeGowin’s Diagnostic Examination, 10e New York, NY: McGraw-Hill; 2014. http://accessmedicine.mhmedical.com.suproxy.su.edu/content.aspx?bookid=1192§ionid=68668433. Accessed January 01, 2018. References Tulandi T. Ectopic pregnancy: Clinical manifestations and diagnosis. In: UpToDate, Barbieri, RL, Sharp HT, Levine D (Eds), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Vakil, NB. Peptic ulcer disease: Clinical manifestations and diagnosis. In: UpToDate, Feldman M (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Pemberton JH. Clinical manifestations and diagnosis of acute diverticulitis in adults. In: UpToDate, Lamont JT (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Wanke CA. Traveler’s diarrhea: Clinical manifestations, diagnosis, and treatment. In: UpToDate, Calderwood SB (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Sharp HT. Evaluation and management of ruptured ovarian cyst. In: UpToDate, Levine D (Ed), UpToDate, Waltham, MA. (Accessed on December 27, 2017.)

Corbett SW, Stack LB, Knoop KJ. CHEST AND ABDOMEN. In: Knoop KJ, Stack LB, Storrow AB, Thurman R. eds. The Atlas of Emergency Medicine, 4e New York, NY: McGraw-Hill; . http://accessmedicine.mhmedical.com.suproxy.su.edu/content.aspx?bookid=1763§ionid=125434019. Accessed January 01, 2018.

Bass G, Gilani SNS, Walsh TN. Validating the 5Fs mnemonic for cholelithiasis: time to include family history Postgraduate Medical Journal 2013;89:638-641 THANK YOU!