Key Feature 7c: In a patient with chronic or recurrent abdominal pain: Always consider cancer in a patient at risk.
Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis In a previous post I wrote something that I thing is important to elaborate on with regards to chronic or recurrent abdominal pain: "Sometimes serious diseases first present in a benign way, and only the passage of time and development of more serious symptoms or signs will provide information that declares them." In particular this is as true for the presentation of cancer as any other etiology. Cancer can be a master of presenting subacutely, often only causing problems because it's grown large enough to have consequences due to the space or the energy it consumes (ex: constipation from a bowel obstruction caused by a growth or weight loss secondary to increased energy needs of a growing mass). In the 13 year old female who I wrote the source post about, cancer would be utterly unlikely, but in those patients who are older or who have a family history that increases their risk, this would be something to always keep in the back of your mind. My general approach to avoid missing a cancer when patients present with symptoms that could be caused by a cancer (but for which my pretest probability is still fairly low):
The Canadian Task Force on Preventative Health Care provides a multitude of guidelines to support screening efforts. Here are their recommendations for colorectal cancer screening:
0 Comments
By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient’s cultural and gender contexts, will be able to...
Key Feature 6a: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Recognize the life-threatening situation. Skill: Selectivity Phase: Diagnosis Key Feature 6b: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Make the diagnosis Skill: Clinical Reasoning Phase: Diagnosis Key Feature 6c: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Stabilize the patient Skill: Selectivity, Clinical Reasoning Phase: Treatment Key Feature 6d: Given a patient with a life-threatening cause of acute abdominal pain (ex: a ruptured abdominal aortic aneurysm or a ruptured ectopic pregnancy): Promptly refer the patient for definitive treatment. Skill: Selectivity Phase: Diagnosis, Referral I have not had the unfortunate experience of ever encountering a patient with an acutely life-threatening cause of abdominal pain. In fact, over the duration of my residency and my only occasional training in critical care/emergency, I may never encounter this. So I don't want to cop out on this, but I also don't want to delve into detail that will probably never be too clinically relevant for me. What I do want to know is what I would need to do to help try to save a patient's life if I am the physician who encounters a patient with an acutely life-threatening cause of abdominal pain. Here is what I feel I need to know to manage such a situation:
Key Feature 7a: In a patient with chronic or recurrent abdominal pain: Ensure adequate follow-up to monitor new or changing symptoms or signs.
Skill: Clinical reasoning Phase: Follow-up Key Feature 7b: In a patient with chronic or recurrent abdominal pain: Manage symptomatically with medication and lifestyle modification (ex: for irritable bowel syndrome). Skill: Clinical reasoning, Communication Phase: Treatment Let's return one more time to the case of the 13 year old female who presented to the office with abdominal pain. In my assessment of her pain I applied a broad differential diagnosis to thinking about what could be going on: She described a recurrent pattern of this pain over the past month or so, maybe once a week, but this new episode started this same morning, so I had to keep both chronic and acute causes on my differential. I also needed to keep the differential for pediatric abdominal pain at the forefront, given differences in incidence and prevalence of diseases in pediatric compared to adult populations. This patient was otherwise well, but if she had been previously diagnosed with a chronic disease that can manifest with abdominal pain, I would've needed to consider an exacerbation of that disease as a possible contributor to the pain as well. As a female who was now postmenarchal, I needed to consider the possibility of gynecological causes of pain, including the possibility of pregnancy. Given the details of the account her pain story, and her localisation of pain in her abdomen as generalised rather than localised to the lower abdominal area, my suspicion for gynecological etiologies, and pregnancy in particular, was low. Given this diminutive pretest probability, and the fact that she appeared well on general physical examination, I deferred performing a pelvic exam. As I clinically worked through my differential, finding facts on history and exam to make my suspicion of different etiologies more or less pronounced, I arrived at my working diagnosis, which was constipation.* Now constipation in and of itself is not a diagnosis, but rather a symptom, and it is important to address the underlying reason(s) for this. Given this patient's history and physical exam, my working diagnosis was functional constipation rather than constipation secondary to an organic etiology. The management for this centres on patient education and recommendations for behavioural and specific dietary interventions, and so we chatted and came to a shared understanding of lifestyle modifications that could be realistically adopted by this patient. No investigations needed to be ordered, at least not yet. In the setting of constipation that is seemingly functional and without alarm features, lifestyle changes are the first-line intervention. But this also means that as a clinician I must arrange followup to assess whether or not the intervention was successful, and to further intervene and possibly investigate if indicated. According to the UpToDate article Constipation in infants and children: Evaluation (2017), "Organic causes are responsible for fewer than 5 percent of children with constipation." Given her clinical assessment, this patient was unlikely to be in that 5%, but not definitively so. With any disease presentation, it is important to keep the possible worrisome diagnoses it could represent in your mind, to be able to counsel patient on associated symptoms to watch for. Sometimes serious diseases first present in a benign way, and only the passage of time and development of more serious symptoms or signs will provide information that declares them. My general approach to the closing any patient encounter, including followup recommendations, is as follows:
For the patient with constipation, I explained that her presentation was in keeping with a diagnosis of functional constipation. I asked what she knew about this and explained what it means (not a default diagnosis, but actually having criteria that she met). I explained that it was a clinical diagnosis, which was great because it meant we wouldn't have to wait for the results of any investigations before starting treatment. I presented that the most evidence-based treatment for this diagnosis is lifestyle modifications, specifically by increasing physical activity and consumption of dietary fibre and water. We discussed what she thought she could do to get more physical activity and what sorts of foods she could see herself eating to increase the fibre intake. I gave her a number for how many grams of fibre in a day to shoot for, to help her get a sense of just how much fibre is recommended**, and explained what the expected benefits (decreased constipation), risks and how to mitigate them (increasing fibre quickly can cause bloating, so I recommended she go up gradually in her daily consumption of fibre), and logistics (taking time to think about packing her lunch differently for school, for example) of these lifestyle interventions would be. If these changes were to be effective, we would likely see a benefit in 2 weeks or so, so we planned for follow up then. I also warned her that if she develops worsening or new symptoms not to hesitate to make an appointment sooner. (There was nothing I was seriously worried about in her case to provide more specific anticipatory advice.) I then provided a handout on Constipation in Children as published by UpToDate and said that I looked forward to seeing how she would be doing at the follow-up appointment :) *You may be thinking, but what about irritable bowel syndrome?? Let's explore that a little bit. Like functional constipation, irritable bowel syndrome is also a functional disease in that there is no organic findings of disease on physical exam or investigations. (The best way I've heard someone explain functional disease is to use a headache for analogy. We can see evidence of a headache on physical exam, nor are there any tests we can use to prove that it is there, but we certainly experience the pain as real regardless. It is not just "in one's head.") Sometimes patient's may seem to have what could be considered functional constipation and irritable bowel syndrome, at least if they have the IBC-C (for constipation) subtype. But the diagnostic criteria are different, and patients will fall into one or the other. This is has important ramifications, as labelling a patient with a particular diagnosis sticks to their medical chart like superglue, and more importantly it affects their understanding of their body and what they need to do to keep it functioning. So what are the diagnostic criteria for functional constipation and irritable bowel syndrome? Rome IV criteria for functional constipation
Rome IV criteria for irritable bowel syndrome
**A general rule of thumb: For children 2 years and older, take the age and add 5-10 for the number of grams of daily fibre to incorporate in the diet. For example, a 13 year old patient would be advised to consume between 18-23 g of fibre daily. Once people reach adulthood, the rule of thumb is to aim for 20-35 g per day. Key Feature 3c: In a woman with abdominal pain: Do a pelvic examination, if appropriate.
Skill: Clinical Reasoning Phase: Physical, Diagnosis In my last blog post I described my encounter with a 27 year old female patient presenting with abdominal pain. The cause of her pain was ultimately felt to be a combination of a flare-up of ulcerative colitis along with secondary acute opioid withdrawal. But during my first assessment of her, and with pain that she localised to her right lower quadrant, I had to consider that there was a gynecological etiology contributing to her pain. (As a female of childbearing age, this would be indicated regardless, but on top of that, she had significant risk factors including past history of a ruptured ovarian cyst and pelvic inflammatory disease.) A pelvic examination was warranted as part of this patient's workup, and my findings were reassuring in that there were no specific signs of gynecological pathology on exam. My approach to a general pelvic examination is as follows:
The end! Abdominal Pain
Key Feature 2: In a patient with diagnosed abdominal pain (ex: gastroesophageal reflux disease, peptic ulcer disease, ulcerative colitis, Crohn’s disease), manage specific pathology appropriately (ex: with. medication, lifestyle modifications). Skill: Clinical Reasoning Phase: Treatment Key Feature 8: Given a patient with a diagnosis of inflammatory bowel disease (IBD) recognize an extra intestinal manifestation. Skill: Clinical Reasoning Phase: Hypothesis generation, Diagnosis Chronic Disease Key Feature 1: In a patient with a diagnosed chronic disease who presents with acute symptoms, diagnose:
Phase: Diagnosis When I was on rotation on the Family Practice Teaching Service at St Paul's Hospital I was managing a 27 year old female inpatient admitted with abdominal pain NYD (not yet diagnosed). Her past medical history was significant for ulcerative colitis, intravenous drug use now on opioid agonist therapy, pelvic inflammatory disease, and a ruptured ovarian cyst. Prior to the onset of the pain that brought her into the emergency department, she had not been taking any medications for the ulcerative colitis (the disease had been in remission) and she was on opioid agonist therapy to help manage her opioid use disorder. When she presented to the ED with acute abdominal pain she did not have a clear etiology to blame, and she was certainly unwell, so she was admitted to our service so we could manage her pain and figure out what was going on to resolve the underlying issue. After a couple of days into her admission and many investigations later, the team surmised that her pain was likely secondary to a flare up of the ulcerative colitis compounded with the pain of acute opioid withdrawal - the opioid agonist therapy she was taking was in the form of ingested slow-release oral morphine, which was likely not getting absorbed in her gut given its disposition. She was started back up on her antiinflammatory medication, her pain was temporarily managed with hydromorphone, and soon she was feeling back to her baseline. The list of possible aetiologies for abdominal pain is - as I've highlighted in previous blog posts - extensive. I will outline here the general management of selected aetiologies of abdominal pain that I must be familiar with as a family doctor. My information was gathered from Bugs & Drugs and the following UpToDate articles:
Overview of the management of gastroesophageal reflux disease (GERD) For uncomplicated GERD without alarm features*
Overview of the management of peptic ulcer disease (PUD) The patient will have already been seen by a gastroenterologist, as endoscopy would've been done to detect the presence of ulceration. Although this means the gastroenterologist almost certainly will have developed a treatment plan for the patient to follow, it is important for family doctors to understand what needs to be done so they can ensure patient compliance.
Overview of the management of inflammatory bowel disease [IBD] (ulcerative colitis [UC] or Crohn's disease [CD]) As with patients diagnosed with PUD, patients diagnosed with IBD will be seen and likely will continue to be seen by a gastroenterologist. It is important for family doctors to understand the management of IBD because they will be actively involved in helping patients manage the disease as well as their overall health, which can be impacted in numerous ways by IBD.
*Interestingly, the patient I was managing who had ulcerative colitis had an outbreak of lesions on her arms and legs, which she said started only a few days before she went in to the ED with abdominal pain. The two common types of extraintestinal skin manifestations associated with IBD are erythema nodosum and pyoderma gangrenosum. According to the UpToDate article, Dermatologic and ocular manifestations of inflammatory bowel disease, "Erythema nodosum typically appears as raised, tender, red or violet subcutaneous nodules on the extensor surfaces of extremities. As erythema nodosum usually parallels intestinal disease activity, treatment is directed at the underlying IBD. If skin nodules precede any bowel symptoms or occur during quiescent phases of IBD, therapy with other medications, including prednisone, may be required." I looked up pictures of erythema nodosum, and the lesions the patient had certainly fit the look, along with the fact that they were nodular and tender to palpation, and were located on the extensor surfaces of her arms and legs. How interesting that they erupted at the same time or possibly right before the concomitant flare-up in her bowel disease! In summary, this has been another long but not even very detailed post that provides an overview of important elements in the management of common and occasionally serious causes of abdominal pain. Key Feature 1c: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Investigate in an appropriate and timely fashion.
Skill: Clinical Reasoning, Selectivity Phase: Investigation In a couple of weeks I will be starting my rotation in the pediatric emergency department at the BC Children's Hospital and I am pretty well guaranteed to encounter a pediatric patient presenting with abdominal pain. A few months later, I'll be on my emergency medicine rotation at St Paul's Hospital and I am also certainly going to need to work up a patient presenting with abdominal pain there too. About a year after this, I will be an independent physician practicing in the community, and I will be fully responsible for knowing what to do if a patient walks into my office complaining of abdominal pain, be it acute or chronic, focal or generalised, in a pediatric or elderly patient, who is otherwise healthy or with multiple comorbidities. So no better time than now to have an approach to my workup of abdominal pain. Per the differential diagnosis to acute, chronic, and pediatric abdominal pain (see previous blog post), here is my (UpToDate) approach to ordering investigations to working up the causes and consequences of abdominal pain. The UpToDate articles that have informed this approach are "Evaluation of the adult with abdominal pain in the emergency department," "Evaluation of the adult with abdominal pain," "Emergent evaluation of the child with acute abdominal pain," and "Chronic abdominal pain in children and adolescents: Approach to the evaluation." Acute Abdominal Pain
Chronic Abdominal Pain The natural history of chronic abdominal pain usually indicates there is less acutely worrisome pathology that in turn can be worked up in less of a shotgun approach
Pediatric Abdominal Pain A repeated note on investigations in general in the setting of acute abdominal pain: If a patient is otherwise healthy, investigations should only be ordered to confirm a clinically suspected diagnosis or to investigate for abdominal pain of unclear etiology. The threshold for ordering a broader range of tests should be lower for immunosuppressed patients and those with significant comorbidities.
There is so much to know about when and when not to order specific tests, far more than I've included here, and this doesn't even include how to interpret them! But this is a place to start, to capture the most worrisome and most common causes of abdominal pain. Key Feature 3b: In a woman with abdominal pain: Suspect gynecologic etiology for abdominal pain.
Skill: Clinical Reasoning Phase: Hypothesis generation In the 13 year old female per the last two posts, I suspected gynecologic etiology for her abdominal pain as my ddx for paediatric (and nonpediatric) abdominal pain is inclusive of this possibility. My generic gynecological history-taking mnemonic is (one of those silly mnemonics that for whatever reason just sticks): MC HAMMER M - Menarche/last menstrual period/menopause C - Cycle (regularity and length of time [number of days of entire cycle and subset of days having flow]) H - Hemorrhage (qty of flow and any intermittent spotting) A - Aches associated with menstruation (dysmenorrhea) M - Motherhood (GTPALM history, at what age the events occurred, if there were any associated complications, be it in the labour, delivery, or abortion as relevant) M - Mishaps/miscarriages (usually this is obtained during my "motherhood" questioning, but there have been times where I've been happy to have a dedicated mnemonic letter for this as it gets me to think twice about explicitly asking about abortions, be they spontaneous or induced, and there has been a time I can remember when asking again deliberately prompted a patient to clarify that she indeed had had an abortion) E - Evading pregnancy (use of contraception or fertility difficulties) R - Risk factors (if pregnancy is being considered or not actively being prevented, such as folic acid supplementation, substance use, achieving or maintaining a healthy weight and lifestyle) I gathered clinical information on the possibility of a gynaecological etiology in my 13 year old female patient by asking if she had reached menarche (yes), when the first date of her last menstrual period was (a few days before Christmas), if her cycles were typically regular (yes) and if there had been any alteration in this pattern recently (no). I asked her if she had any recent abnormal vaginal bleeding in terms of the pattern or quantity (no), and if she has had cramping associated with menstruation (not really), or any other pattern of pelvic/abdominal cramping (no). I asked if she is on or has ever been started on any sort of contraception (no), and opportunistically if she was considering that she might want to be prescribed contraception (not yet). I then went on to obtain a sexual history using the 5 Ps (as I have adapted, for my own purposes, the original format as advocated by the CDC). **Always start with a statement regarding confidentiality, particularly when taking a sexual history from adolescents, and the reasons why I am about to ask these sexual health questions.** P - Practices (when was the last time that the patient was sexually active, and if they say "never," clarify that this includes oral-genital activity and not just penetrative intercourse) P - Partners (how many partners has the patient had in the past month or year, and have they been males, females, or both?)* P - Protection (does the patient use protection and if not, why not, or if yes, what and how often) (opportunity to ask if they have any questions about protection) P - Past STI history (have they ever been diagnosed +/- treated for an STI, and if not, have they ever been tested and would they like to be at this time?) P- Pregnancy prevention (are they using contraception, and if not, are they trying to conceive and would they be concerned if conception occurred? [prenatal counselling may be indicated]) (opportunity to ask if they have any questions about contraception) Obtaining my sexual history with this patient revealed that she had never been sexually active (at all), and that she didn't feel she needed to explore methods of protection or contraception at this visit. I made sure to tell her that she can always return to the clinic at any time to discuss anything regarding sexual health, and told her about my favourite website she could explore for general sexual health information. *Disclaimer: When I originally adapted the 5Ps for my own sexual history taking in medical school, appreciation of the gender spectrum as more than binary was lacking. Exploring the sexual and gender identities of their previous partners may or may not be indicated. This patient had no pertinent positives on gynecological and sexual history. If there were any pertinent positives suggesting gynecological or STI-related pathology, relevant investigations may have included: B hCG to rule out pregnancy, STI testing, and an ultrasound of the pelvis. Key Feature 3a: In a woman with abdominal pain: Always rule out pregnancy if she is of reproductive age.
Skill: Clinical Reasoning Phase: Hypothesis generation, Investigation In assessing the 13 year old female who presented to clinic today concerned about abdominal pain, with my trusted pediatric ddx and its generalised inclusion of gynaecological causes in pubertal children, I was indeed prompted to first ask if she has had her first period (she had been having them for "awhile"), and then to obtain some pertinent gynaecological and sexual health history information, including when her last menstrual period was, if she has been sexually active yet, and if she has any symptoms in keeping with a sexually transmitted infection. She denied being sexually active yet, without any symptoms suggestive of an STI (ex: genital discharge or pruritus), and with consistently regular cycles that were free of dysmenorrhea. Because she characterised her pain as mild, along with the fact that she clinically appeared well without signs suggestive of genitourinary pathology, and because I had increased suspicion of nongenitourinary aetiologies for her pain, I trusted her, without any beta hCG backup. This is also taking into consideration the reliability of this patient and her family: that they were concerned enough to bring her to see her family doctor on the same day her self-reportedly minor pain started probably meant I could trust she would return for medical attention if her symptoms were not improving. Going from practically zero to instead a low pretest probability of GU related pathology would prompt me to screen her in my clinic for urine beta hCG, which is an extremely sensitive test for pregnancy (UpToDate, 2017). If I was in a position in which I was ordering bloodwork to investigate the possibility of other diagnoses, I would instead throw in a serum beta hCG (as long as the expected time to get the bloodwork was quick, such as in a hospital or emergency department setting), and I would certainly do this if I had a higher than low pretest probability of possible pregnancy. A note on sexual history taking in adolescents (and probably applicable to any demographic in general): A sexual history taken with other people present, be it parents, friends, or partners, may be as inconsequential as not taking a sexual history at all. It takes a total of probably 30 seconds to get the parent or whoever else out of the room, and although you may just get the same response, the privacy, along with a statement regarding confidentiality, increases the sensitivity in gathering important pieces of clinical information. Even if you think it is unlikely that a young adolescent has been sexually active yet, if you're a family doctor, you'll likely recognize this as an opportunity to broach the subject of contraception and practicing safe(r) sexual activity. By the end of postgraduate training, using a patient-centred approach and appropriate selectivity, a resident, considering the patient's cultural and gender contexts, will be able to...
Key Feature 1b: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Generate a complete differential diagnosis (ddx). Skill: Clinical reasoning Phase: Hypothesis generation, Diagnosis Key Feature 4: In a patient with acute abdominal pain, differentiate between a surgical and a non-surgical abdomen. Skill: Clinical reasoning, Selectivity Phase: Physical, Diagnosis Key Feature 5: In specific patient groups (ex: children, pregnant women, the elderly), include group-specific surgical causes of acute abdominal pain in the ddx. Skill: Clinical Reasoning, Selectivity Phase: Hypothesis generation, Diagnosis A 13 year old female presented to clinic with her mother today concerned about acute abdominal pain. She localised the pain as being midline in the lower abdomen. What is my ddx? Like my previous post regarding the categorisation of acute vs chronic abdominal pain, sometimes (oftentimes) we encounter patients who challenge our clinical ability to categorise symptoms. Certainly this is true with pediatric patients, as their report of symptoms, if they are even old enough to verbally report symptoms, can be challenging to decode. Their inexperience with the pain of a headache may be entirely new, and perhaps associating feeling sick with feeling sick to their stomach, they may point to their tummy when you ask them where there pain is. Or maybe some kiddos actually feel sick to their stomach when they have a headache. The possibilities are endless, and without a reliable way to confidently know where pain or other manifestations of disease is originating from on history, as treating physicians we need to maintain a healthy dose of suspicion in searching for the culprit(s). As their own demographic, children also present with different probabilities of disease, and when it comes to abdominal pain, this is as true as any other undifferentiated symptom. My abbreviated ddx for pediatric abdominal pain (informed by the LMCC learning objectives) depending on the area to which the pain is localised (if they are old enough to be able to localise and communicate this information) is as follows:
Of course, this list is not exhaustive, but it does prompt me to consider some of the most common diagnoses in pediatric patients, as well as important ones not to miss, including the ones that require urgent or emergent surgery. And when I encountered that 13 year old female in clinic today who was able to reliably tell me that she was having midline lower abdominal pain, I was able to use this ddx to inform my clinical data collection, my springboard to collect pertinent negatives to arrive at a working diagnosis (which for this patient was constipation). I don't know that I was correct in reaching this conclusion, or that it was the only thing contributing to the pain, but my attending concurred with this conclusion, and it helped me look for the absence of findings suggesting a worrisome not-to-miss condition. If I cannot feel confident about localisation in a pediatric patient, then I can simply broaden my ddx to include all common and worrisome pediatric diagnoses. And if that still is unsatisfactory, I can consider the more extensive ddx I have for adult abdominal pain (which is still relatively abbreviated, but does take into consideration most bodily systems that may be sources of pain). For completeness, here is my ddx for acute abdominal pain (adult patient, also informed by the LMCC objectives):
And my ddx for chronic abdominal pain (adult patient, also informed by the LMCC objectives):
To elaborate a bit further on inclusion of surgical causes of acute abdominal pain, it is important to know which diagnoses require surgical referral, be it after a bit of a workup to confirm the diagnosis, or more urgent or emergently if the patient is seriously unwell or with signs of peritonitis*. In the pediatric patient, for example, this could mean first doing an ultrasound** to rule out appendicitis if you think it is possible but not highly likely as the cause of the abdominal pain, or it could mean ordering imaging concurrently as you urgently consult general surgery if you think an acute appendicitis is in fact likely to be the underlying etiology for the pain. For any case in which a patient is presenting with peritonitis and a broad working differential for acute abdominal pain, a consult to general surgery is indicated. If the working differential is more focused, given the clinical presentation and patient-specific risk factors, then the surgeon to consult will depend on suspected etiology and local specialist accessibility, and may warrant consultation with general surgery, gynaecology, urology, cardiac surgery, vascular surgery, or otolaryngology. Of course, consultation with a nonsurgical medical specialist may also be warranted given the working diagnosis, such as a gastroenterologist, nephrologist, or infectious disease specialist, among others. The timing of when to involve such specialists must be driven by the urgency of the situation in combination with the working differential, be it to provide diagnostic clarity when there is confusion or to administer therapy that is not in the general practitioner's scope of practice. *In a patient presenting with acute abdominal pain, it is particularly important to examine the patient's abdomen to decide if it is "peritonitic" (otherwise known as a surgical abdomen). Peritonitis is the inflammation of the peritoneum, the sac that encases much of our abdominal organs, and is an ominous finding that suggests surgical intervention is needed. Features most suggestive of peritonitis on physical exam that warrant urgent surgical consultation, in the order in which they would be assessed as per the Inspect-Auscultate-Percuss-Palpate (IAPP) approach to the abdominal exam as is standard medical school teaching, include:
**A tangent on how the management of disease in children differs from adults: A consideration that a physician must have when working up a pediatric concern is how the potential for harm and benefit of various interventions is different from that of an adult or geriatric patient. For example, the potential for harm from repeated CT scans could increase a person's risk of cancer down the road, and having hopefully much more time to live and bear secondary mutations possibly related to effects of radiation, the risk to benefit ratio of performing CT scans in pediatric patients is not the same as in older patients. Although the harm of a single CT scan is not so significant if it means possibly saving a life, it is something to consider if your pre-test probability of ominous disease is low. The converse is also true for the elderly or other patients that have risk factors for true and serious pathology: where the weight balances on the risk vs benefit scale shifts. The same general rationale regarding management decisions applies to considering interventions in pediatric patients as compared to other demographics, and the wise physician will remember to consider that the benefit to harm ratio of anything we choose to do or abstain from doing will differ depending on the individual before us. Key Feature 1a: Given a patient with abdominal pain, paying particular attention to its location and chronicity: Distinguish between acute and chronic pain.
Skill: Clinical Reasoning Phase: History While on my family practice ward rotation I received a consult from the gastroenterology service to assess a patient in the emergency department (ED) to determine whether or not they would be suitable for admission to our service. I was told the patient had a chronic history of abdominal pain that began about 10 years ago, and that there were no acute concerns from gastroenterology's perspective apart from the fact that the patient was in significant pain and so their service felt uncomfortable for her to be sent home. I came to the ED to assess the patient, and on taking her history I learned that there was indeed a history of previous episodes of abdominal pain that stemmed back at least 10 years. I also discovered that the abdominal pain over this time was intermittent, typically spread apart by years at a time. These episodes of abdominal pain were distinct - this was a case of acute abdominal pain, and in this patient it started 3 days ago. Deciding whether a concern of abdominal pain is acute or chronic is important in order to inform the working differential diagnosis, but there is no clear time cutoff that absolutely distinguishes these presentations. The UpToDate article, "Evaluation of the adult with abdominal pain" (2017) states: "There is no strict time period that will classify the differential diagnosis unfailingly. A clinical judgment must be made that considers whether this is an accelerating process, one that has reached a plateau, or one that is longstanding but intermittent. Patients with chronic abdominal pain may present with an acute exacerbation of a chronic problem or a new and unrelated problem. Pain of less than a few days’ duration that has worsened progressively until the time of presentation is clearly "acute." Pain that has remained unchanged for months or years can be safely classified as chronic. Pain that does not clearly fit either category might be called subacute and requires consideration of a broader differential than acute and chronic pain." It could reasonably be argued that presenting on the third day after the onset of abdominal pain may better fit the "subacute" classification. In any case, if a presentation is thought to be "subacute," this would necessitate a broader working differential, including those of a more acute nature, and I think it would be prudent for these to first be in the forefront of the clinician's mind. My conclusion: When assessing a patient with abdominal pain, it is important to distinguish whether the presentation is acute or chronic in order to narrow the working differential diagnosis. When in doubt (i.e., the presentation flirts with being subacute), first consider the possibility that the pain is a manifestation of an acute disease process and investigate accordingly. |
Categories
All
|