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44yo lady. Epigastric pain for 4 weeks (Visceral pain ~vaguely localized…
44yo lady. Epigastric pain for 4 weeks
Generalized peritonitis
~severe pain exacerbated by movement in a toxic, septic, hypotensive pt. + guarding
DKA
~S/S usually rapid (24hrs), N/V, kussmaul breathing, dehydration (dec skin tugor, dry axillae & orla mucosa, tachycardia), fruity odor breath
~Hx of T1DM, alcohol, cocaine abuse
Hypercalcemia
~wide range of abnl
~neuro (anxiety, depression, cognitive dysfunction), GI (constipation, anorexia, nausea, pancreatitis, peptic ulcer), renal (polyuria, RTA), cardio (shortened QT), MSK (weakness)
Visceral pain
~vaguely localized +/- referred to midline (foregut - epigastrium, midgut - umbilicus)
~pt tosses about
Peptic ulcer
~Gastric ulcer = pain exacerbated by food, relieved by vomiting
~Duodenal ulcer = pain relieved by food
~possible melena/hematemesis. take drug hx (NSAIDs, steroids), RF for H. pylori (travel/contact/pass hx, smoking)
Gastritis
~mild dyspepsia (bloating, epi pain)
Gastric cancer
~vague constant epi pain w no relationship to meals
~early satiety, vomiting undigested food (intermittent in gastric outlet obstruction, post-meal in linitis plastica), dysphagia, LOA, LOW
~virchow's nodes
Pancreatitis
~steady pain lasting for days, radiate to back, relived on bending forward a/w by frequent N/V. Symptoms often out of proportion to signs
~Etiology: gallstones (prior dyspepsia), alcohol (hx of binge drinking), Hx of ERCP..
Pancreatic cancer
~chronic progressive pain radiating to back
~if tumor is @ head, obstructive jaundice
~Sig. weight loss (temporal wasting, sunken eyes, prominent clavicles)
Chronic pancreatitis
~epi pain (episodic -> continuous), steatorrhea (pancreatic insufficiency), new/worsening DM
GERD
~epi/retrosternal discomfort, exacerbated by lying flat, sour taste at back of throat
Mesenteric ischemia
~Chornic 'gut claudication' - post-prandial pain, weight loss, N/V, diarrhoea
Gastroparesis
~N/V, abdo pain, early satiety, bloating, weight loss. vomitus may contain undigested food
~pain is burning/vague/crampy
~may have epi distension/tenderness but not guarding/rigidity
Biliary colic
~intense dull discomfort @ RUQ/epi
~a/w N/V, diaphoresis, usually lasting at least 30mins plateaus in an hr
Benign abdo exam
Referred pain
~usually central & w/o tenderness on palpation
Cardiovascular
~ AMI (SOB, exertional dyspnea), endocarditis
Respi:
~pneumonia, pneumothorax affecting lung bases
Localized peritonitis
~steady, localized pain exacerbated by palpation (guarding, rebound), movement and coughing
Chronic abdo wall pain
~anterior cutaneous nerve entrapment
~maximal tenderness over small area (right lateral edge of rectus abdominis muscle). may be muultifocal/diffused (to affected dermatome)
~pain aggravated by tensing abdo muscles/sitting/lying on affected side; least in supine position
~+ve Carnett's sign
Perforations/ruptured abscess/perforated ulcers
Others/to rule out:
Ectopic pregnancy
Psychogenic:
~Hx of PTSD, abuse, somatisation, anxiety, depression
Functional GI disorder