NURS8026 1st Edition Lecture 2Current LectureAbdominal pain differential diagnosisImportance of demographics of abdominal pain:- ETOH at risk for pancreatitis - Sickle cell predisposing factor for acute abdomen in AA- S/p abdominal surgery increases risk of obstruction- Duodenal ulcers rare before age 15, appendicitis is not Intestinal obstruction d/t malignance is more often in patients>40 - Bowel ischemia is more prevalent in the elderly- Pelvic pain in the 75yo think diverticulitis/carcinoma pelvic pain in 25yo think PID, ectopic, ruptured cyst Abdominal pain in childrenFlu/gastroenteritis Food poisoning/food allergies Poisoning AppendicitisDifferential w/children Duration >24 hours, location, appearance, duration & type of emesis, diarrhea that persists beyond 3 days or is bloody, groin pain, urination problems Abdominal Pain Pathophysiology: Pain impulses originate w/in the abdominal cavity Transmitted via the autonomic & anterior/ lateral spinothalamic tracts. 3 major causes of pain Colic (spasm) Ischemia (loss of flow) Peritoneal inflammationAnatomy of Pain Right Upper Quadrant: Cholecystitis, biliary colic, hepatitis, hepatic abcess, hepatomegaly secondary to CHF, right lower lobe pneumonia, colitis Epigastric: Aortic aneurysm, MI, pancreatitis, PUD, early appendicitis, gastritisLeft Upper Quadrant: Gastritis, pancreatitis, splenomegaly, left lower lobe pneumonia, splenic rupture or infarct Right or Left Flank: Nephrolithiasis, pylonephritis Right Lower Quadrant: Appendicitis, ectopic, salpingitis, testicular torsion, mittleschmertz,ovarian torsion/cyst, inguinal hernias, Psoas abcess, and ureteral calculiUmbilical: AAA, early appendicitis, bowel obstruction, gastroenteritis, IBD, mesenteric ischemia/infarct enteritis, umbilical hernia Left Lower Quadrant: Colon ca, diverticulitis, ectopic, salpingitis, IBD, mittleschmertz, ovarian torsion/cyst, testicular torsion, inguinal hernias, Psoas abscesses, ureteral calculi Hypogastric: Cystitis, endometriosisNURS8026 1st Edition Lecture 2Diffuse: Hemolytic crisis (sickle cell), gastroenteritis, peritonitis, endocrine disorders (DKA, Addison’s, HPT), intestinal obstructionHistory: Women: Regardless of age inquire about? Vaginal bleeding – LMP Sexual history Obstetric history Ectopic risk factors: PID, IUD, previous ectopic, tubal surgery (or ligation), infertility, h/o endometriosis,History for Man Men: Hesitancy Nocturia Low urinary volume/lower abd distention Sexual historyHistory: PMH- Previous abd surgery, CV disease Analgesic use (acute & chronic)- ETOH/tobacco/substance abuse - Weight change, bowel habit change- Chronic illness - Risk factors- Recent travel Environmental exposures - Allergies - H/o domestic violenceRed Flags for Abdominal Pain (Adults): - Pain that changes location- Pain that awakens from sleep- Weight loss- Pain that persists for >6 hours or worsens - Pain followed by vomitingRed Flags for Abdominal Pain (Childerns): - Pain location distant from umbilicus- Pain that awakens from sleep - Weight loss or deceleration of weight gain - Elevated sed rate - Projectile vomiting- Current jelly stool - Bulky foul-smelling clay colored stoolsHistory - FH Appendicitis = increased risk- Medication history Anticoagulant – development of abd hematomas- OC – hepatic adenomas w/mesenteric infarctionNURS8026 1st Edition Lecture 2- Steroids – mask the symptoms of peritonitisHistory of PI - Location Onset- what were they doing when it started? - Radiation - Duration: how long has it lasted? >6 hours maybe a surgical abdomen - Aggravating factors (movement, coughing) - Relieving factors (position, vomiting, meds) - Mode of onset? W/progression: Better, same, worse, abruptness- Previous similar episodes Infant may become fussy, draw his or her legs up toward the belly, and eat poorlyAcute Abdominal Pain: Timing Abrupt onset -instant GI Causes: - Perforated ulcer- Ruptured abscess/ hematoma- Intestinal infarct - Ruptured esophagusAcute Abdominal Pain: Timing Abrupt onset –Non- GI Causes: - Ruptures/dissecting aneurysm- Ruptures ectopic - Pneumothorax - MI- Pulmonary infarct Acute Abdominal Pain Timing Rapid-onset minutes-GI-Causes- Perforated viscus - Strangulated viscus - Volvulus - Pancreatitis- Biliary colic- Mesenteric infarct- Diverticulitis- Penetrating peptic ulcer- High intestinal obstructionAcute Abdominal Pain Timing Rapid-onset minutes-NON-GI-Causes- Ureteral colic - Renal colic- EctopicAcute Abdominal Pain Timing Gradual onset – hours-GI-causes- Appendicitis - Strangulated hernia - Low intestinal obstruction- CholecystitisNURS8026 1st Edition Lecture 2- Pancreatitis - Gastritis- Peptic ulcer- Crohn’s disease- Ulcerative colitisAcute Abdominal Pain Timing Gradual onset – hours-NON-GI-causes- Cystitis- Pyelonephritis- Prostatitis- Salpingitis - Threatened abortion - Urinary retentionVomiting – R/t pain (before/after): Pain before vomiting = more acute situation - Vomiting before pain more suggestive of gastroenteritis- Character & pattern: Intermittent, steady, colicky - Severity - Stool: Last, color, consistency- Urinary Pattern :Frequency, urgency, dysuria, flank/back painHistory of PI Associated symptoms - Acute surgical abdomen – pain occurs before vomiting, no desire for food, rarely appear calm - Medical abdomen – pain occurs after vomiting, diarrhea is associated - Constipation - ?true obstipation (absence of stool & flatus) = mechanical bowel obstruction - Fever & chills - Early satietyPhysical Examination: General appearance: pallor, restlessness, stillness, diaphoresis Temperature, RR, HR BP w/orthostatics (especially w/elderly) Pulmonary CardiovascularAbdomen - Inspection Abnormal pulsations Scars Skin Color Temperature Cullen’s sign; periumbilical ecchymosis (hemoperitoneum d/t pancreatitis, ectopic) Grey Turner’s sign; flank ecchymosis (hemoperitoneum d/t pancreatitis)Auscultation : Bruits, bowel sounds, character Percussion: Abdominal distention, shifting dullness, Palpation: Involuntary guarding, rebound tenderness, organomegaly, abnormal massesRectal :Occult blood, fecal impaction, prostatic enlargement, tenderness, hemorrhoids (anoscopic) Pelvic :CMT, adnexal tenderness, abnormal masses, organ sizePhysical Examination : Special- Maneuvers Murphy’s : Gallbladder cholecystitis, cholelithiasisNURS8026 1st Edition Lecture 2- Iliopsoas : Psoas muscle Peritoneal irritation - Rebound tenderness/Rovsings: Peritoneal