Key History
Acuity of onset, ± abdominal pain, relation to meals, sick contacts, possible food poisoning, possible pregnancy; neurologic symptoms (headache, stiff neck, vertigo, focal numbness or weakness); urinary symptoms; other associated symptoms (GI, chest pain); exacerbating and alleviating factors; medications; history of prior abdominal surgery.
Key Physical Exam
Vital signs; ENT; consider funduscopic exam (increased intracranial pressure); complete abdominal exam; consider heart, lung, and rectal exams.
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■ 39 yo F presents with a single 2-cm mass on the right side of her neck along with night sweats, fever, weight loss, loss of appetite, and early satiety. The mass is painless and movable and has not changed in size. She does not report heat intolerance, tremor, palpitations, hoarseness, cough, difficulty breathing, difficulty swallowing, or abdominal pain. Her husband was recently discharged from prison, and her mother has a history of gastric cancer. |
Hodgkin’s/non- Hodgkin’s lymphoma Tuberculosis Thyroid nodule Gastric carcinoma |
CBC with differential Electrolytes ESR, CRP Lymph node biopsy PPD CXR TSH U/S—thyroid Upper endoscopy |
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■ 20 yo F presents with nausea, vomiting (especially in the morning), fatigue, and polyuria. Her last menstrual period was 6 weeks ago, and her breasts are full and tender. She is sexually active with her boyfriend, and they occasionally use condoms for contraception. |
Pregnancy Gastritis Hypercalcemia Diabetes mellitus UTI Depression |
Urine hCG Pelvic exam U/S—pelvis CBC Electrolytes, calcium, glucose UA, urine culture HIV antibody |
Key History
Location, quality, intensity, duration, radiation, timing (relation to meals); associated symptoms (constitutional, GI, cardiac, pulmonary, renal, pelvic); exacerbating and alleviating factors; history of similar symptoms; history of abdominal surgeries, trauma, gallstones, renal stones, atherosclerotic vascular disease; medications (eg, NSAIDs, corticosteroids); alcohol and drug use; domestic violence, stress/anxiety, sexual history, pregnancy history.
Key Physical Exam
Vital signs; heart and lung exams; abdominal exam, including tenderness, guarding, rebound, Murphy’s sign, psoas and obturator signs, and CVA percussion; bowel sounds, aortic bruits; rectal exam; pelvic exam (women).
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■ 45 yo M presents with sudden onset of colicky rightsided flank pain that radiates to the testicles, accompanied by nausea, vomiting, hematuria, and CVA tenderness. |
Nephrolithiasis Renal cell carcinoma Pyelonephritis GI etiology (eg, appendicitis) |
UA, urine culture and sensitivity, urine cytology BUN/Cr CT—abdomen U/S—renal KUB IVP Blood culture |
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■ 60 yo M presents with dull epigastric pain that radiates to the back, accompanied by weight loss, dark urine, and clay-colored stool. He is a heavy drinker and smoker. He appears jaundiced on exam. |
Pancreatic cancer Cholangiocarcinoma Acute viral hepatitis Acute alcoholic hepatitis Chronic pancreatitis Cholecystitis/ choledocholithiasis Abdominal aortic aneurysm Peptic ulcer disease |
CBC Electrolytes Amylase, lipase AST/ALT/bilirubin/ alkaline phosphatase CT—abdomen U/S—abdomen |
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■ 56 yo M presents with severe midepigastric abdominal pain that radiates to the back and improves when he leans forward. He also reports anorexia, nausea, and vomiting. He is an alcoholic and has spent the past 3 days binge drinking. |
Acute pancreatitis Peptic ulcer disease Cholecystitis/ choledocholithiasis Gastritis Abdominal aortic aneurysm Mesenteric ischemia Alcoholic hepatitis Boerhaave syndrome |
CBC Electrolytes, BUN/Cr Amylase, lipase AST/ALT/bilirubin/ alkaline phosphatase U/S—abdomen CT—abdomen Upper endoscopy ECG |
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ABDOMINAL PAIN (cont'd) |
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■ 41 yo obese F presents with RUQ abdominal pain that radiates to the right scapula and is associated with nausea, vomiting, and a fever of 101.5°F. The pain started after she ate fatty food. She has had similar but less intense episodes that lasted a few hours. Exam reveals a positive Murphy’s sign. |
Acute cholecystitis Choledocholithiasis Hepatitis Ascending cholangitis Peptic ulcer disease Fitz-Hugh-Curtis syndrome Acute subhepatic appendicitis |
CBC AST/ALT/bilirubin/ alkaline phosphatase U/S—abdomen CT—abdomen Blood culture |
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■ 43 yo obese F presents with RUQ abdominal pain, fever, and jaundice. She was diagnosed with asymptomatic gallstones 1 year ago. She is found to be hypotensive on exam. |
Ascending cholangitis Acute gallstone cholangitis Acute cholecystitis Hepatitis Sclerosing cholangitis Fitz-Hugh-Curtis syndrome |
CBC AST/ALT/bilirubin/ alkaline phosphatase Blood culture Viral hepatitis serologies U/S—abdomen MRCP ERCP |
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■ 25 yo M presents with RUQ pain, fever, anorexia, nausea, and vomiting. He has dark urine and clay- colored stool. |
Acute hepatitis Acute cholecystitis Ascending cholangitis Choledocholithiasis Pancreatitis Acute glomerulonephritis |
CBC Amylase, lipase AST/ALT/bilirubin/ alkaline phosphatase Viral hepatitis serologies UA U/S—abdomen |
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■ 35 yo M presents with burning epigastric pain that starts 2-3 hours after meals. The pain is relieved by food and antacids. |
Peptic ulcer disease Gastritis GERD Cholecystitis Chronic pancreatitis Mesenteric ischemia |
Rectal exam, stool for occult blood Amylase, lipase, lactate AST/ALT/bilirubin/ alkaline phosphatase Upper endoscopy (including H pylori testing) Upper GI series |
ABDOMINAL PAIN (cont'd)
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■ 37 yo M presents with severe epigastric pain, nausea, vomiting, and mild fever. He appears toxic. He has a history of intermittent epigastric pain that is relieved by food and antacids. He also smokes heavily and takes aspirin on a daily basis. |
Perforated peptic ulcer Acute pancreatitis Hepatitis Cholecystitis Gallstone cholangitis Mesenteric ischemia |
Rectal exam CBC Electrolytes Amylase, lipase, lactate AST/ALT/bilirubin/ alkaline phosphatase CXR KUB CT—abdomen Upper endoscopy (including H pylori testing) Blood culture |
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■ 18 yo M boxer presents with severe LUQ abdominal pain that radiates to the left scapula. He had infectious mononucleosis 3 weeks ago. |
Splenic rupture Kidney stone Rib fracture Pneumonia Perforated peptic ulcer Splenic infarct |
CBC Electrolytes CXR CT—abdomen U/S—abdomen (if hemodynamically unstable) |
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■ 40 yo M presents with crampy abdominal pain, vomiting, abdominal distention, and inability to pass flatus or stool. He has a history of multiple abdominal surgeries. |
Intestinal obstruction Small bowel or colon cancer Volvulus Gastroenteritis Food poisoning Ileus Hernia |
Rectal exam CBC Electrolytes AXR CT—abdomen/pelvis with contrast Colonoscopy |
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■ 70 yo F presents with acute onset of severe, crampy abdominal pain. She recently vomited and had a massive dark bowel movement. She has a history of CHF and atrial fibrillation, for which she has received digitalis. Her pain is out of proportion to the exam. |
Mesenteric ischemia/ infarction Diverticulitis Peptic ulcer disease Gastroenteritis Acute pancreatitis Cholecystitis |
Rectal exam CBC Amylase, lipase, lactate ECG AXR CT—abdomen Mesenteric angiography Barium enema |
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ABDOMINAL PAIN (cont'd) |
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■ 21 yo F presents with acute onset of severe RLQ pain, nausea, and vomiting. She has no fever, urinary symptoms, or vaginal bleeding and has never taken OCPs. Her last menstrual period was regular, and she has no history of STDs. She has been told that she had a cyst on her right ovary. |
Ovarian torsion Appendicitis Nephrolithiasis Ectopic pregnancy Ruptured ovarian cyst Pelvic inflammatory disease Bowel infarction or perforation |
Pelvic exam Urine hCG Doppler U/S—pelvis Rectal exam UA CBC CT—abdomen Laparoscopy Chlamydia and gonorrhea testing, VDRL/RPR |
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■ 68 yo M presents with LLQ abdominal pain, fever, and chills for the past 3 days. He also reports recent onset of alternating diarrhea and constipation. He consumes a low-fiber, high-fat diet. |
Diverticulitis Crohn’s disease Ulcerative colitis Gastroenteritis Abscess |
Rectal exam CBC Electrolytes CXR AXR CT—abdomen Blood culture |
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■ 20 yo M presents with severe RLQ abdominal pain, nausea, and vomiting. His discomfort started yesterday as a vague pain around the umbilicus. As the pain worsened, it became sharp and migrated to the RLQ. McBurney’s and psoas signs are positive. |
Acute appendicitis Gastroenteritis Diverticulitis Crohn’s disease Nephrolithiasis Volvulus or other intestinal obstruction Perforation Acute cholecystitis |
CBC Electrolytes CT—abdomen AXR U/S—abdomen Blood culture |
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■ 30 yo F presents with periumbilical pain for 6 months. The pain never awakens her from sleep. It is relieved by defecation and worsens when she is upset. She has alternating constipation and diarrhea but no nausea, vomiting, weight loss, or anorexia. |
Irritable bowel syndrome Crohn’s disease Celiac disease Chronic pancreatitis GI parasitic infection (amebiasis, giardiasis) Endometriosis |
Rectal exam, stool for occult blood Pelvic exam Urine hCG CBC Electrolytes Colonoscopy CT—abdomen/pelvis Stool for ova andparasitology, Entamoeba histolytica antigen |
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ABDOMINAL PAIN (cant'd) |
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■ 24 yo F presents with bilateral lower abdominal pain that started with the first day of her menstrual period. The pain is associated with fever and a thick, greenish-yellow vaginal discharge. She has had unprotected sex with multiple sexual partners. |
Pelvic inflammatory disease |
Pelvic exam |
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