TRAINING PROBLEM #2: ABDOMINAL PAIN
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1 TRAINING PROBLEM #2: ABDOMINAL PAIN RATIONALE: Abdominal pain is a common symptom that can be attributed to a wide variety of acute and chronic disease processes, many of which may represent serious medical problems. Mastery of the approach to patients with abdominal pain is important to third year medical students. PREREQUISITES: Prior knowledge, skills, and attitudes acquired during the pre-clerkship experience should include: Ability to perform a complete medical history and physical exam. Ability to communicate with patients of diverse backgrounds. Knowledge of gastrointestinal and gynecologic anatomy, physiology, and pathophysiology. SPECIFIC LEARNING OBJECTIVES: A. KNOWLEDGE: Students should be able to define, describe, and discuss: 1. three principal types of abdominal pain: Visceral pain: (MK) o Poorly localized but site roughly corresponds to dermatome that innervates the affected organ. o Characteristics may vary (dull, cramping, burning). o Frequently accompanied by secondary autonomic effects (nausea, vomiting, pallor, diaphoresis, restlessness). o Patient moves around in an attempt to alleviate discomfort. Somatoparietal or peritoneal pain: (MK) o More localized and more intense than visceral pain. o Arises from peritoneal irritation. o Aggravated by movement (patient attempts to lie still). Referred pain: (MK) o Usually well localized but felt in areas remote to affected organ. o May be felt in skin or in deeper tissues. o Results from convergence of visceral afferent neurons with somatic neurons from different anatomic regions. 2. Relative likelihood of the common causes of abdominal pain based on the pain pattern and the quadrant in which the pain is located. (MK) 3. Diagnostic discrimination between common causes of abdominal pain based on history, physical exam, laboratory testing, and imaging procedures. (MK) 4. Symptoms and signs indicative of an acute/surgical abdomen. (MK)
2 5. The influence of age, gender, menopausal status, and immunocompetency on the prevalence of different disease processes that may result in abdominal pain. (MK) B. SKILLS: Students should be able to demonstrate specific skills, including: 1. History-taking skills: Students should be able to obtain, document, and present an appropriately complete medical history that differentiates among etiologies of disease, including: Chronology. (PC, CS) Location. (PC, CS) Radiation. (PC, CS) Character. (PC, CS) Intensity. (PC, CS) Duration. (PC, CS) Aggravating or alleviating factors. (PC, CS) Associated symptoms. (PC, CS) Pertinent information about previous abdominal or pelvic surgeries, chronic medical conditions, sexual activity, medications, and family history. (PC, CS) 2. Physical exam skills: Students should be able to perform a focused physical exam in patients who present with abdominal pain in order to: Establish a preliminary diagnosis of the cause. (PC) Assess the severity of the patient s presenting symptoms and signs. (PC) Determine the urgency of implementing diagnostic and treatment plans. (PC) The initial physical examination of the patient should include: A general assessment of the patient s appearance, position, and degree of discomfort. (PC) Measurement of vital signs, including temperature, pulse, blood pressure, and, when indicated, orthostatic blood pressure and pulse. (PC) Correct order and technique for examining the abdomen. (PC) Inspection of the abdomen for surgical scars, distension, asymmetry or cutaneous abnormalities (dilated veins, ecchymoses, etc.). (PC) Auscultation of the abdomen for abnormal bowel sounds, bruits. (PC) Percussion of the abdomen for detection of hepatomegaly, splenomegaly, abdominal masses, or the presence of ascites. (PC) Palpation of the abdomen for areas of tenderness, signs of peritoneal inflammation, hepatomegaly, splenomegaly, abnormal masses, pulsations, or hernias. (PC) Performance of rectal and pelvic exams (under supervision). (PC) 3. Differential diagnosis: Students should be able to generate a prioritized differential diagnosis of the most important and likely causes of a patient s
3 abdominal pain and recognize specific history, physical exam, and laboratory findings that distinguish between the following diagnoses or conditions: Appendicitis. (PC, MK) Cholecystitis (biliary colic). (PC, MK) Pancreatitis. (PC, MK) Diverticulitis. (PC, MK) Peptic ulcer disease including perforation. (PC, MK) Gastroenteritis. (PC, MK) Hepatitis. (PC, MK) Irritable bowel syndrome. (PC, MK) Small bowel obstruction. (PC, MK) Acute mesenteric ischemia. (MK, PC) Inflammatory bowel disease. (PC, MK) Ruptured abdominal aortic aneurysm. (PC, MK) Ureteral stones (renal colic). (PC, MK) Pelvic inflammatory disease. (PC, MK) Ruptured ectopic pregnancy. (PC, MK) Abdominal wall pain. (PC, MK) Referred pain. (PC, MK) 4. Laboratory interpretation: Students should be able to interpret specific diagnostic tests and procedures that are commonly ordered to evaluate patients who present with abdominal pain. Test interpretation should take into account: Important differential diagnostic considerations including potential diagnostic emergencies. (PC, MK) Pre-test and post-test likelihood of disease (probabilistic reasoning). (PC, MK) Performance characteristics of individual tests (sensitivity, specificity, positive and negative predictive value, likelihood ratios). (PC, MK) Laboratory and diagnostic tests should include, when appropriate: CBC with differential. (PC, MK) UA. (PC, MK) Pregnancy test. (PC, MK) Stool for occult blood. (PC, MK) Hepatic function panel. (PC, MK) Amylase and lipase. (PC, MK) Abdominal obstructive series. (PC, MK) Students should be able to define the indications for, and interpret (with consultation) the results of: Abdominal ultrasound. (PC, MK) Abdominal CT scan. (PC, MK) Paracentesis fluid studies. (PC, MK) Upper gastrointestinal endoscopy. (PC, MK) Sigmoidoscopy/colonoscopy. (PC, MK) Barium contrast studies. (PC, MK)
4 Radionuclide scan of the hepatobiliary system. (PC, MK) 5. Communication skills: Students should be able to: Communicate the diagnosis, treatment plan, and subsequent follow-up to the patient and his or her family. (PC, CS) Elicit questions from the patient and his or her family about the management plan. (PC, CS) Communicate in lay terms the indications, risk/benefits, and expected outcomes essential to obtaining informed consent for diagnostic and therapeutic procedures commonly used to evaluate and treat patients who present with abdominal pain. (PC, CS) 6. Basic and advanced procedural skills: Students should be able to: Insert a nasogastric tube. (PC) Perform stool occult blood testing. (PC) Assist in performing a paracentesis after explaining the procedure to the patient. (PC, CS) 7. Management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients that includes: Recognizing the role of narcotic analgesics and empiric antibiotics in treating selected patients who present with acute abdominal pain. (PC, MK) Determining when to consult a gastroenterologist or a surgeon. (PC, SBP) Involving a surgeon as soon as possible when a patient is identified as having an acute abdomen. (PC, SBP) Selecting various tests and procedures commonly used to diagnose patients who present with symptoms of abdominal pain. ( PC, MK) Recommending basic initial management plans for the various causes of abdominal pain listed in the differential diagnosis. (PC, MK) Considering the potential value of addressing psychosocial issues in the management of chronic abdominal pain. (PC, MK) Accessing and utilizing appropriate information systems and resources to help delineate issues related to abdominal pain. (PC, PLI) Using a cost-effective approach based on the differential diagnosis. (PC, SBP) Incorporating patient preferences. (PC, P) C. ATTITUDES AND PROFESSIONAL BEHAVIORS: Students should be able to: 1. Demonstrate commitment to using risk-benefit, cost-benefit, and evidencebased considerations in the selection of diagnostic and therapeutic interventions for abdominal pain. (PLI, P) 2. Recognize the importance of patient needs and preferences when selecting among diagnostic and therapeutic options for abdominal pain. (P) 3. Recognize the importance and demonstrate a commitment to the utilization of other healthcare professions in the treatment of abdominal pain. (P, SBP)
5 D. REFERENCES: Silen W. Cope s Early Diagnosis of the Acute Abdomen. 20 th ed. New York: Oxford University Press; Wagner JM, McKinney WP, Carpenter JL. The rational clinical exam. Does this patient have appendicitis? JAMA. 1996;276: Lederle F, Simel D. The rational clinical exam. Does this patient have an abdominal aortic aneurysm? JAMA. 1999;281: Trowbridge RL, Rutkowski NK, Shojania KG. The rational clinical exam. Does this patient have acute cholecystitis? JAMA. 2003;289:
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