Abdominal Pain (acute and chronic)

Subjective

• LOCATION of pain is starting point of abdo pain evaluation

  • 

    • Is it pulm, urinary, or hepatobiliary?

    • UTI/kidney stone → urinalysis

    • colic/fever/steatorrhea/Murphy’s → u/s

  • 

    • If suspected appendicitis, also get urgent surg consult

  • 

    • Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc)

• Onset, duration, severity, quality, exacerbating/remitting factors

• Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention

  • Manning criteria (3 or more of) for IBS

• Red flags

  • New onset of pain, Change in pain, Altered bowel habits in elderly

    • Check if all 3 are particular to elderly, or just the altered bowel habits

  • Wt loss (GI malignancy)

  • Pain radiating to back (pancreatitis, AAA)

  • Appendicitis (from highest to lowest PPV)

    • RLQ PAIN, pain migration from periumbilical to RLQ, fever, anorexia

  • Pain radiating to groin (testicular torsion, hernia, renal colic)

  • Bleeding per rectum, melena stool (GI bleed, Meckel’s, malignancy in elderly)

  • Anemia

  • Supraclavicular nodes

  • personal/family hx of serious bowel patho

  • Pain waking pt at night

  • Current abx/steroids (can mask peritoneal sx’s)

  • Cardiac hx incl. Afib, HTN (ischemic bowel, AAA, MI)

  • Bowel obstruction (highest to lowest PPV)

    • CONSTIPATION, abdo distention, ↓ pain after vomiting, colic, prev abdo surg

  • Antipsychotic use (ileus, obstruction, toxic megacolon)

  • EtOH (risk factor for p

...

Można uzyskać kontrolę nad tym, jak upływa czas, prowadząc przez trzy dni spis wszystkich czynności wykonywanych w ciągu dnia. Zwróć uwagę na to, ile czasu poświęcasz łącznie na każdą czynność. Następnie, dzieląc wynik przez trzy, otrzymasz szacunkową przeciętną ilość czasu poświęcaną na każdą z czynności. Prawnicy, architekci, konsultanci i inni specjaliści stosują podobną procedurę do określenia liczby „godzin rozliczeniowych” przepracowanych dla każdego z klientów.

Back Pain (acute and chronic)

*Just use the core back tool, it’s so good*

Subjective

Objective

Plan

...

Dizziness/Vertigo

Approach to patient with Dizziness

Subjective

• “Does it feel like either the room is spinning or that you are spinning?” and/or “Is it triggered or worsened by turning your head or rolling over in bed?”

  • Yes = vertigo

    • BENIGN PAROXYSMAL POSITIONAL VERTIGO (most common)

      • brief, recurrent episodes (seconds to minutes), +/- nausea and vomiting

    • Vestibular Neuritis

      • rapid onset, severe, persistent (days), N/V, imbalance

    • Ménière’s Disease

      • recurrent episodes (minutes to hours), fluctuating hearing loss, tinnitus, and sensation of aural fullness

    • Vestibular Toxicity

      • aminoglycosides (eg. gentamycin), loop diuretics, ASA, NSAIDs, amiodarone, quinine, cisplatin

  • No = other forms of dizziness

    • Presyncopal Dizziness – “feels like nearly fainting or blacking out”

      • ECG

      • Triggered by exertion? Chest pain/palpitations? Known structural heart dz? FmHx of sudden death? Abnormal ECG? (if pt stable, fax ECG for urgent advice)

        • If yes to any, suspect cardiac etiology. Refer to Emergency

        • If no, orthostatic hypotension?

          • Yes = investigate underlying cause. meds/alcohol? Consider CBC/lytes

          • No = likely vasovagal/situational etiology. If recurrent episodes or pt is at risk of injury, consider referral for tilt test (+/- carotid sinus massage if >40 yo)

    • Disequilibrium Dizziness – “unsteadiness while walking”

      • Often multifactorial, common in elderly, risk of falls. Complete neuro and MSK exams to rule out peripheral neuropathy, Parkinsonism, MSK d/o, CVA, etc

    • Nonspecific Dizziness – “woozy”, “giddy”, “light-headed”

      • DDx: hypoglycemic (glucose), thyroid disease (TSH), pregnancy (β-HCG), meds, psychiatric disorders, alcohol/drugs, menstruation, previous head trauma

...

LOCATION of pain is starting point of abdo pain evaluation

• 

  • Is it pulm, urinary, or hepatobiliary?

  • UTI/kidney stone → urinalysis

  • colic/fever/steatorrhea/Murphy’s → u/s

• 

  • If suspected appendicitis, also get urgent surg consult

• 

  • Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc)

Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention

• Manning criteria (3 or more of) for IBS

Red flags

• New onset of pain, Change in pain, Altered bowel habits in elderly

  • Check if all 3 are particular to elderly, or just the altered bowel habits

• Wt loss (GI malignancy)

• Pain radiating to back (pancreatitis, AAA)

• Appendicitis (from highest to lowest PPV)

  • RLQ PAIN, pain migration from periumbilical to RLQ, fever, anorexia

• Pain radiating to groin (testicular torsion, hernia, renal colic)

• Bleeding per rectum, melena stool (GI bleed, Meckel’s, malignancy in elderly)

• Anemia

• Supraclavicular nodes

• personal/family hx of serious bowel patho

• Pain waking pt at night

• Current abx/steroids (can mask peritoneal sx’s)

• Cardiac hx incl. Afib, HTN (ischemic bowel, AAA, MI)

• Bowel obstruction (highest to lowest PPV)

  • CONSTIPATION, abdo distention, ↓ pain after vomiting, colic, prev abdo surg

• Antipsychotic use (ileus, obstruction, toxic megacolon)

• EtOH (risk factor for pancreatitis, varices)

• Sexually active (ectopic pregnancy, STIs)

• Cholecystitis (highest to lowest PPV)

  • RUQ pain, fever, jaundice

IBS algorithm

• 

• 

• 

Objective

• General inspection

  • Change in mental status (infection - UTI)

  • Shock (perforated viscera, GI hemorrhage, severe pancreatitis, MI, sepsis)

• Vitals

• Upper abdo pain - pay attention to Cardiac (ischemia) & lung (pneumonia) exams

  • Tachypneic (pneumonia)

• Abdo

  • peritoneal signs

  • Carnett’s sign (high ppv for abdo wall pain)

    • ↑ pain when supine pt raises head & shoulder, tensing abdo wall

  • Murphy’s sign (high ppv for choleycystitis)

  • Psoas sign (high ppv for appendicitis)

  • Sever pain out of proportion (ischemic bowel, pancreatitis)

  • restless/writhing (biliary/renal colic, testicular torsion)

  • LLQ tenderness (diverticulitis)

• Rectal & pelvic exams if lower abdo & pelvic pain

  • DRE - fecal impaction, palpable mass, occult blood in stool

    • Tenderness & fullness on R of rectum suggests retrocecal appendix

  • Pelvic - vaginal discharge (vaginitis), cervical motion tenderness & peritoneal signs (ectopic pregnancy or other gyne complications e.g. tubo-ovarian abscess)

S&S of surgical abdo

• Fever

• Protracted (prolonged) vomiting

• syncope/pre-syncope

• Evidence of GI blood loss

Assessment

• Common causes

  • IBS (discomfort/pain assc w/ altered bowel habits >3d/mo in prev 3 mo)

• Less common but important causes

  • Appendicitis

  • Acute cholecystitis

  • Diverticulitis

  • Acute pancreatitis

  • Perforated ulcer

  • Bowel infarction

Plan (for acute abdo pain) - acute abdo = sudden, non-traumatic disorder needing urgent dx & tx

• Labs

  • CBC (infection/blood loss)

  • Amylase + lipase (pancreatitis)

  • LFT (RUQ pain)

  • Urinalysis (hematuria, dysuria, flank pain - UTI/kidney stone)

  • Beta hcg (women in childbearing age)

  • Chlamydia + gonorrhea (women @ risk of STIs)

• Imaging (based on location)

  • U/S (RUQ pain)

    • abdo/transvag ultrasound for pregnant women, even for LLQ/RLQ pain

    • Transvag u/s for ectopic pregnancy

  • CT w/ IV contrast media (adults w/ acute RLQ pain)

  • CT w/ oral + IV contrast media (LLQ pain) - for sigmoid diverticulitis

  • LUQ pain (many causes so depends)

    • Suggested esophageal/gastric patho = endoscopy or upper GI series

    • Others = CT (can image pancreas, spleen, kidneys, intestines, vasculature)

  • Xray

    • Free air under diaphragm (=perforation of GI tract)

    • Abn calcifications (10% gallstones, 90% kidney stones)

    • Mult dilated loops of bowel & air-fluid lvls (bowel obstruction)

      • May see with paralytic ileus

• 

  • *occult UTI, perforated viscus, ischemic bowel ds* - potentially fatal, often missed or dx late in elderly pt

    • CONSIDER IN ALL OLDER PTS w/ abdo pain

Initial investigations & basic management for chr/recurrent abdo pain

• IBS

  • Exercise: vigorous 3-5/week (all types of IBS)

  • Laxatives: OTC ( polyethylene glycol (PEG - osmotic) - Miralax); only helps w/ constipation

  • Antidiarrheal: OTC loperamide (imodium); likely only helps diarrhea

  • Probiotics: in some OTC supplements & yogurts (lactobacillus, bifidobacterium, streptococcus)

    • To prevent worsening sx

  • Abx

    • Diarrheal/mixed: rifaximin (Xifaxan); prevent worsening global sx over 4wk

    • Constipation: neomycin; improve constipation & bloating

  • Antispasmodics: hyoscyamine (Levsin), dicyclomine (Bentyl)

  • Selective C-2 chloride channel activators: lubiprostone (Amitiza) - constipation

  • Antidepressants

    • SSRI - citalopram (celexa), fluoxetine (prozac), paroxetine (paxil)

    • TCA - amitriptyline , desipramine (norpramin), doxepin , imipramine (tofranil), trimipramine (surmontil)

  • Other: relaxation, herbals, peppermint oil

  • Not routinely recommended: CBC, lytes, thyroid, stool testing for ova & parasites, abdo img

Adult Headache Algorithm

Subjective

Objective

Plan

Non-pharm for migraine: