What is the problem? 11/27/20141ped.emergency.Dr.Alsaif.
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Transcript of What is the problem? 11/27/20141ped.emergency.Dr.Alsaif.
ped.emergency.Dr.Alsaif 1
What is the problem?
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ped.emergency.Dr.Alsaif 2
Clinical scenario
A 5 year old girl brought by her mother to emergency room with 3 days history of abdominal pain and one episode of vomiting before arrival to the hospital.
How to approach to diagnosis?
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Anatomic origin of pain
The classic division of abdomen:
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Anatomic origin of pain Abdomen is divided into 9 regions: 2 vertical lines (RT< midclavicular) 2 horizontal lines (subcostal and intertubercular)
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History Place/Location ask child to use one finger to locate the
pain. Quality: pain can be a sharp stabbing pain (i.e. trauma)
or diffuse, poorly, localized pain (i.e. chronic or visceral pain).
Radiation: pain can radiate from its point of origin in any direction.
Severity: degree of pain on a scale of 10 Timing/Onset: onset of the pain, duration of pain,
course during the day, does it wake them at night, and the frequency of episodes.
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History
Alleviating Factors: Anything that reduces the pain like body position, movements ,medications. Aggravating Factors: Anything that increases the pain like body position, movements, relation to food intake. Associated Symptoms: Hematemesis, vomiting, nausea, melena, diarrhea,
fever, and weight loss.
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Associated symptoms for abdominal painAssociated Symptom Relevance
Diarrhea Gastroenteritis, Protein losing enteropathy
Bloody stool Ulcerative colitis, necrotizing enterocolitis, dysentery, constipation
Hematemesis Peptic Ulcer Disease, Gastritis
Bilious emesis Small bowel obstruction
Jaundice Hepatitis or Biliary obstruction
Joint pain/swelling IBD, HSP
Skin Lesions IBD, HSP, Liver disease
Testicular pain Testicular torsion
Dysuria/polyuria/hematuria Urinary tract infection/Pyelonephritis
Vaginal/Penile discharge STI
Dysmenorrhea Endometriosis
Shortness of breath Pneumonia or empyema
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History
Ask about: Bowel movement patterns and stool quality
(size, hard/soft, odour). Ingestion of toxin or foreign object accidental
or non-accidental trauma. Dietary history: in young children, too much
milk can lead to constipation.
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History
Ask about: Past medical history and medical illness:
Cystic fibrosis predisposes to gallstones.Spina bifida/cerebral palsy/developmental delay
predisposes to constipation.Sickle cell disease predisposes to splenic auto-
infarction.Recurrent respiratory tract infections suggest
mesenteric adenitis.
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History
Ask about: Family medical history, especially
inflammatory bowel disease. Travel history, social and psychiatric (potential
stressors) history.
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Physical exam
General exam: ABCDE Including vital signs and growth parameters, is there evidence of failure to thrive?. Inspection: Iook for contour, symmetry, pulsations,
peristalsis, skin markings, wall protrusions (hernias), any signs of trauma (ie. bruising, swelling), and abdominal distension.
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Physical exam
Auscultation: Auscultate before palpation in the abdominal
exam. Iisten for bowel sounds, abdominal bruits. Pressure
of the stethoscope also tests for tenderness. Percussion: (tympanic vs non-tympanic). Percuss for liver span and spleen tip. Assess for ascites.
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Physical exam
Palpation: Tenderness with light and deep palpation. Guarding and rebound tenderness Palpate for liver, spleen, kidney and abdominal
masses (including fecal mass).
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Physical exam
Digital rectal exam: First exam the anus for fissures and skin tags.
Then assess for tone, stool, and blood. Special Tests: There are a number of special tests for each
differential diagnosis.
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findings on physical exam for common differential diagnoses
Medical Condition Findings on Physical Exam
Constipation Abdominal tenderness, palpable fecal mass, look for imperforate anus or stenosis, spina bifida, developmental delay, cerebral palsy
Acute appendicitis Patient avoids movement, rebound tenderness, McBurney sign (pain at 2/3 between umbilicus and right ASIS), Rovsing sign (pain in right lower quadrant on left-sided palpation), Psoas sign (pain in right lower quadrant when child on left and right hip hyperextended), obturator sign (pain in right lower quadrant on internal rotation of flexed right thigh)
Gastroenteritis Diffuse pain with no rebound tenderness, abdominal distension, hyperactive bowel sounds
Irritable bowel syndrome Periumbilical tenderness, no rebound tenderness
Trauma Signs of bruising and tenderness
Celiac Disease Growth failure, distended abdomen, diffuse abdominal tenderness.
Inflammatory bowel disease Appears thin, abdominal tenderness, anal skin tags, possible sign of bloody stool on DRE, examine for skin lesions (erythema nodosum, pyoderma gangrenosum), iritis, and joint inflammation
Urinary tract infection Fever, suprapubic and costovertebral angle tenderness, irritability, foul-smeling urine, gross hematuria
Primary dysmenorrhea Lower abdominal tenderness
Pneumonia and Empyema Tachypnea, cyanosis, decreased breath sounds, crackles and rales, dullness on percussion, febrile
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Associated Signs
Jaundice suggests hemolysis or liver disease. Pallor and jaundice point to sickle cell crisis. Psoas & Obturator test If positive: Inflamed retrocecal appendix Ruptured appendix or Iliopsoas abscess.
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Associated Signs
Murphy's sign: (interruption of deep inspiration by pain when
the physician's fingers are pressed beneath the right costal margin).
Suggests acute cholecystitis.
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Associated Signs
Cullen's sign (bluish umbilicus) Grey Turner's sign (discoloration in the flank)
Unusual signs of internal hemorrhage.
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Associated Signs
Purpura and arthritis: Henoch-Schönlein purpura
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Laboratory investigations for common differential diagnoses
Medical Condition Relevant Diagnostic Tests
Constipation None if history does not suggest an alternative diagnosis.
Acute appendicitis CBC (WBC normal or elevated), urinalysis, urine pregnancy
Gastroenteritis Serum electrolytes, stool culture, stool for virology
Irritable bowel syndrome None, based on history and clinical findings
Trauma CBC for blood loss, abdominal CT with contrast
Celiac Disease IgA
Inflammatory Bowel Disease CBC, ESR/CRP, electrolytes, albumin, LFTs, Bilirubin, Stool culture, AXR
Urinary tract infection Urine dipstick (for leukocyte esterase and nitrite), urine microscopy, urine culture (best if suprapubic aspirate)
Primary dysmenorrhea None, based on history and clinical findings
Pneumonia and Empyema CBC, Chest x-ray, sputum culture
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Red flags in abdominal pain
Certain historical and examination findings should raise ‘‘red flags’’ that a severe life-threatening underlying abdominal process is present and prompt early triage to an emergency department.
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Red flags in abdominal pain
History Inability to maintain po intake Projectile vomiting Overt gastrointestinal blood loss Syncope Pregnancy Recent surgery or endoscopic procedure Fever Caustic or foreign body ingestion11/27/2014
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Red flags in abdominal pain
Physical examination Pathologic changes in vital signs Bloody, melenic stool Hernia (incarcerated and tender) Hypoxia Cyanosis Change in level of consciousness Jaundice Peritoneal signs Abdominal pain out of proportion to examination11/27/2014
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Red flags in abdominal pain
Laboratory results Renal failure Metabolic acidosis Leukocytosis Elevated transaminases Elevated alkaline phosphatase and bilirubin Anemia or polycythemia Hyperlipasemia/hyperamylasemia Hyperglycemia/hypoglycemia11/27/2014
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Red flags in abdominal pain
Radiography Abdominal free air Gallbladder wall thickening Pericholecystic fluid Dilated biliary tree Bowel obstruction Dilated small bowel loops ± air fluid levels Intra-abdominal abscess Bowel wall thickening Air in the portal venous system Pneumatosis intestinalis
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Indications for Surgical Consultations
Severe or increasing abdominal pain with progressive signs of deterioration
Bile-stained or feculent vomitus Involuntary abdominal guarding/rigidity Rebound abdominal tenderness Marked abdominal distension with diffuse tympany Signs of acute fluid or blood loss into the abdomen Significant abdominal trauma Suspected surgical cause for the pain Abdominal pain without an obvious etiology11/27/2014
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