Abdominal Pain

You are going to observe and participate in a clinical encounter of a patient who comes to the office with a complaint of abdominal pain. As you observe the encounter, you will be asked to answer questions while the image on the screen freezes. Such questions will allow you to practice history taking and physical examination skills as well as your clinical reasoning skills in developing an assessment or differential diagnosis, and a plan—that is, an appropriate next diagnostic workup.

Health History
You will have the opportunity to record your findings and receive immediate feedback. So, what brings you in today?
Well actually I’m a little worried. I had this pain about two days ago in the upper, middle section of my abdomen and it seems to be spreading to my back.
What possible causes of abdominal pain are you considering? Gastritis.
Peptic ulcer.

Acute pancreatitis. GERD.
Abdominal aortic aneurysm. Do you have the pain now?
Yeah, and it seems to be getting worse. It’s like a burning in my belly and then when I cough it just seems to get worse.
How severe would you say the pain is, on a scale of 1 to 10, with 1 being faint and 10 being very severe? Oh, I’d say at least an 8 out of 10.
What does it feel like?

Well its steady, I mean it never seems to go away. It’s sharp through to my back. And it just seems to be burning all the time.

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When did you first get this pain?

Two days ago. And I remember that. That was the day that I was served my divorce papers at work. Man, I guess I’m having some luck.
So the pain happened at work then?

No, no I left work, and I stopped had a drink…or two…well…more than two I guess. But the pain came on that night. And um…so I took some Tums and I did feel a little better for a little while. But then it came on again and it was worse. It went to my back. I guess it lasted for about an hour or two then it stopped.
Have you ever had a pain like this before?

Well, I’ve had, you know, stomach pain off and on for the past 6 months. Are there any triggers for the pain, like stress or specific foods?
Well, you know I’m a stock broker, so that’s pretty stressful. And this whole thing about separating from my wife right now, that isn’t helping. But I tell you, I do try and avoid spicy foods because that tends to kind of like, stir up my stomach.
Is there anything that makes the pain better?

Well, I find if I lie still and maybe draw my legs up. And I have tried Motrin and Advil but that doesn’t help too much.
Is there anything that makes the pain worse?

Oh, just any movement. I mean, just even walking.

Have you had any dark stools or any with bright red blood in them? I haven’t noticed anything.
How about any blood in the urine? Not that I’ve noticed.
What about smoking? Oh…probably…a pack and a half a day.
Well, you mentioned having a few drinks earlier. What would you say is your normal intake?
Maybe…probably 4 or 6 beers a day. Or…maybe 2 to 4 drinks a day. I mean it’s been a pretty tough 6 months. I just need to relax at night.
What further questions would you have in light of this drinking pattern? The following questions would be helpful:
Have you ever had a drinking problem?

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When was your last drink?

Do you feel you have a problem with drinking now?

These questions from the CAGE questionnaire are highly sensitive and specific for problem drinking. Two or more affirmative answers to all four questions have a sensitivity of 43%−84% and specificity of 70%−96% for alcohol misuse.
Are you at all concerned about your drinking? Have you ever had a drinking problem?

Well, I know I drink too much but I can’t deal with that right now. Well, I did have a problem in college but…and I guess I did have a DWI.
Well, how would you say your spirits are in general? I’d say…pretty down right now.
Have you had any other medical problems? Hmmm…no. I didn’t even have any surgeries.
Well, let’s do your physical examination and then we can talk more.

With the patient’s health history in mind, and after good hand hygiene, you are ready for the physical examination.

Physical Examination
Well, I can see that your blood pressure is 140 over 88. You have a heart rate of 110. And you’re running a little bit of a temperature at about 100.8.
Can you give me something for this pain?

Well, first we need to further evaluate the cause of the pain. Can you go ahead and lay back on the exam table for me here?
What areas of the physical examination are most important for this patient? Vital signs.
And the following:

Perform a lung exam.

Perform a cardiovascular exam. Auscultate the abdomen.
Palpate the abdomen.

Oh, that does hurts when you press in the middle.

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What about when I press over here?

Well it’s tender but it doesn’t hurt as much as when you pressed in the middle. Perform a neurological exam, namely check for alcohol withdrawal signs.
Can you just follow my finger with your eyes only, please?

Now if you can just stretch out your arms and hold up your palms, like you are stopping traffic.

Sudden, brief, non−rhythmic flexion of the hands and fingers indicates asterixis, seen in liver disease, uremia, and hypercapnia.

Diagnostic Considerations
List your diagnostic considerations in order of importance and explain your rationale. Press pause and list your answers. Resume when you are ready to receive feedback
Alcoholic gastritis. The patient exceeds the recommended drinking level for men of less than 14 drinks a week and less than 4 drinks on any one occasion. Patient has heart rate of 110, suggesting possible withdrawal.
Peptic ulcer. The patient has pain radiating to the back, seen in posterior penetrating ulcers. Alcohol intake is a risk factor. There is no melena or bright red blood per rectum on the history.
Acute pancreatitis. The patient’s alcohol intake is a risk factor and his temperature is slightly elevated. The pain is persisting and radiates to the back but the location of the pain is not typical. Severe left upper quadrant pain is more typical in pancreatitis, at times causing the patient to double over. Patients typically stop eating and drinking.
GERD. The patient has a history of alcohol use which can cause relaxation of the lower esophageal sphincter pressure, leading to symptoms of reflux. He has nausea and epigastric tenderness, which can be present in GERD. However, the lack of heartburn, a burning sensation in the retrosternal area particularly in the post prandial period, coupled with the absence of dysphagia and regurgitation, make this diagnosis less likely.
Angina. The patient has cardiac risk factors of smoking, now with mild hypertension in a setting of high alcohol intake. Although he reports burning pain at times into the chest, his pain is primarily in the epigastric area with radiation into the back. Given the patient’s age and known risk factors, CAD should be considered in the differential.
Other considerations not pursued here include abdominal aortic aneurysm (however, no change in aortic width is noted and there is no pulsatile mass) and right renal stone, although severe flank pain is not present and there is no history of hematuria.

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Diagnostic Workup
List 5 next steps in your diagnostic workup.

Press pause and list your answers. Resume when you are ready to receive feedback.

CBC, complete metabolic panel, to assess hemoglobin and hematocrit for anemia from possible bleeding. Amylase and lipase liver function tests, for possible pancreatitis.
Serum alcohol level and urine toxicology due to prevalence of mixed substance abuse.

Esophageal−gastric endoscopy (EGD) with mucosal biopsy is one of the most accurate tests to detect presence of mucosal irritation (gastritis) or the presence of a peptic ulcer. A trial of antacids for 4−6 weeks could be considered first, followed by EGD if there is no improvement. Counseling the patient about alcohol use is important.
Abdominal ultrasound to assess the size of the liver. Or perform an abdominal CT scan. These would also show increased aortic width and hydroureter, if present.
Order an electrocardiogram, given the age and cardiac risk factors.

Summary
In sum, this is a 64−year−old stock broker, recently separated from his wife, who presents with increased epigastric pain over the prior two days and excess drinking. On examination, his blood pressure is slightly elevated to 140 over 88 and his heart rate is elevated to 110. His temperature is slightly elevated, suggesting alcohol withdrawal. His heart and lung examinations are normal. His abdominal examination shows epigastric tenderness and liver tenderness. There is no CVA tenderness. He has no nystagmus, tremor, or asterixis also often seen in alcohol withdrawal.
This patient is most likely to have alcohol−induced gastropathy; however, peptic ulcer disease cannot be excluded. An endoscopy would differentiate these two entities. It also includes acute pancreatitis, GERD, and angina.
The diagnostic workup includes CBC, amylase and lipase liver function tests, serum alcohol level, urine toxicology, EGD, a trial of antacids for 4−6 weeks with EGD if no improvement, counseling the patient about alcohol use, abdominal ultrasound, abdominal CT scan, and an electrocardiogram.