Abdominal Pain Initial management: 1 st 20 sec there are only 3 option: o Very ill: Going to die?

Ask for help and start resuscitation. o Ill: Stable for couple hours? Urgent investigations, initial diagnosis & management o Reasonably well: Investigate as appropriate, formulate diagnosis.

Initial management: ABCDE Resuscitation & analgesia (opioid IV) Full monitoring Low threshold in seeking senior help

PMSH: Previous episodes of AP, Investigations, Operations, Chronic disease, Immunosuppressant, Medication (NSAIDs) Key point on history: Site Nature & character Duration Intensity Precipitating & reliving factors Associate symptoms

Systematic Examination: Abdomen: Inspection: Scaphoid or flat (in peptic ulcer), Distended (in ascites or intestinal obstruction), Visible peristalsis (in a thin or malnourished patient) Palpation: Check for Herni sites, Tenderness, Rebound tenderness, Guardinginvoluntary spasm of muscles during palpation, Rigidity-when abdominal muscles are tense & board-like. (indicates peritonitis) Systematic Examination: Local Right Iliac Fossa tenderness (in Acute appendicitis a), Low grade, poorly localized tenderness (in Intestinal Obstruction), Tenderness out proportion to examination (Mesenteric Ischemia, Acute Pancreatitis), Flank Tenderness (in Perinephric Absess or Retrocaecal Appendicitis)

Important Sings in Patients with Abdominal Pain English Village, Gulan Street, Erbil, Kurdistan Region of Iraq www.bcm-medical.com

Signs Cullens sign Khers sign McBurneys sign

Finding Severe left shoulder pain Severe left shoulder pain Tenderness located 2/3 distance from anterior iliac spine to umbilicus on right side Abrupt interruption of inspiration on palpation of right upper quadrant Hyperextension of right hip causing abdominal pain Internal rotation of flexed right hip causing abdominal pain Discoloration of the flank Manipulation of cervix causes patient to lift buttocks of table Right lower quadrant pain with palpation of the left lower quadrant

Association Retroperitoneal haemorrhage Splenic rupture Appendicitis

Murphys sign Iliopsoas sign Obturators sign Grey-Turners sing Chandelier sign Rovsings sign

Acute cholecystitis Appendicitis Appendicitis Retroperitoneal haemorrhage Pelvic inflammatory disease Appendicitis

Generalized Acute Pain: Perforation AAA DM Bilateral pleurisy

Central AP: Early appendicitis, SBO, Acute gastritis, Acute pancreatitis, Ruptured AAA, Mesenteric thrombosis

Epigastric pain: DU/GU, Oesophagitis, Acute pancreatitis, AAA Right Upper Qadrant: Gallbladder disease, DU, Acute pancreatitis, Pneumonia, Subphrenic abscess LUO pain: GU, Pneumonia, Acute pancreatitis, Spontaneus splenic rupture, Acute perinephritis, Subphrenic abscess Puprapubic pain: Acute urinary retention, UTIs, Cistitis, PID, Diverticulitis English Village, Gulan Street, Erbil, Kurdistan Region of Iraq www.bcm-medical.com

RIF pain: Acute appendicitis, Mesenteric adenitis, Perf DU, Diverticulitis, PID, Ureteric colic, Meckels diverticulum, Biliary colic (low-lying gall bladder) Loin pain: Muscle strain, UTIs, Renal stones, Pyelonephritis LIF pain: diverticulitis, Constipation, IBS, PID, Rectal CA, UC, Casification by nature: Colicky pain: Baseline of no pain in true colic, IBS, Bowel obstruction Nagging & Grumbling: Bliliary colic, Cholecystitis, PID, UTI Stabbing: AAA Burning or boring: PUD, Oesophagitis Gnawing: Pancreatitis, Pancreatic Ca

Associated symptoms: Fever, Genitourynary, Vascular Investigations: FBC (Hb&WCC) Amylase (Pancreatitis) U&Es, LFTs Clotting (acute pancreatitis, sepsis, DIC, liver disease) Glucose (BM) G&S (X-match if necessary) ABG ECG Cardiac enzymes (if appropriate) Urinalysis Radiology

English Village, Gulan Street, Erbil, Kurdistan Region of Iraq www.bcm-medical.com