Pain On Upper Stomach

 Pain On Upper Stomach


Pain On Upper Stomach


Today you're going to learn how to best approach the patient with upper abdominal pain as always on easy med you're going to be provided with a simple trick or strategy to remember the material and today you're gonna be provided with an easy mnemonic that's gonna help you remember the different emergent causes - upper abdominal pain let's start this off by taking a look at how many things can cause abdominal pain to complicate matters some of these causes are emergent while others are less urgent and can be managed outpatient it's your job to be able to distinguish does the patient have an emergent cause or less urgent cause to their symptoms.


• For example a patient with upper abdominal pain could be presenting with a heart attack or they could be presenting with a simple ulcer that could be managed outpatient this video is gonna help provide you with the necessary tools to best approach the patient with upper abdominal pain so you don't miss anything bad so the first thing to do with any patient that initially presents to you is a primary survey this will include assessing the patient's airway breathing and circulation and if any of those need to be optimized you're going to want to address that sooner than later take a look at the patient as a whole do they look sick or not sick you might also want to obtain an EKG especially if you're worried about a cardiac cause leading to their upper abdominal pain.


• As all of this is going on you're also going to want to obtain the patient's vital signs this will include blood pressure heart rate temperature respiratory rate and oxygen saturation you might also want to get a point-of-care glucose things like DK can cause upper abdominal pain as well lastly the patient will need to be hooked up to cardiac monitor pulse oximetry and an IV should be established if the patient is stable and time allows you can do a chart review and this will include things like looking at the patient's age their gender what are their vital signs.


• What medications do they take review their past medical surgical family and social history see if they have any previous visits for similar complaints and if they do what were they diagnosed with and what was done at that time you can also review any previous imaging especially those that pertain to the abdomen this could include things like CT abdomen and pelvis x-ray the abdomen or any ultrasounds of the abdomen don't forget to also review previous EKGs this chart review is going to allow you to better understand the patient and it might tail your conversation into what questions you're gonna ask them when you're getting a history I will warn you though don't let the chart review form premature bias as this could lead to error and you might miss something bad and unfortunately as we saw before that.


• List of potential causes - upper abdominal pain is long so I've got an easy mnemonic to help you remember the main emergent causes tell abdominal pain and this mnemonic fittingly is upper stomach the U is going to help you remember urinary causes and this includes things like kidney stone and infection such as urinary tract infection and pyelonephritis pee is going to help you remember pancreatic causes this will include pancreatitis or any type of pancreatic mass the second P is going to help you remember pulmonary causes remember things in the thorax can cause upper abdominal pain.


• As well so this will include things like pneumonia or pulmonary embolism east dance for ectopic and this is going to help you remember to get that pregnancy test if appropriate our stands for really early appendicitis most of the time appendicitis will present with right lower quadrant abdominal pain but in the early presentation it could be generalized abdominal pain or even upper abdominal pain as stands for stomach and the main emergent cost upper abdominal pain that's related to the stomach is gastric perforation T stands for twisting and this will help you remember things like volvulus as well as ischemic bowel o stands for obstruction and this could include bowel obstruction or foreign body.


• Ingestion that's leading to obstruction M stands for MI this will help you remember that there are cardiac causes that can lead to upper abdominal pain as well this could include things like acute coronary syndrome but M also stands for myocarditis this wall if you remember the realm of myocarditis and pericarditis that could lead to upper abdominal pain as well so the point is don't forget about the heart there are cardiac causes that can lead to abdominal pain.


• As well hay is going to help you remember a Horta and this will include things like triple-a and aortic dissection C stands for cholecystitis and cholangitis this will have to remember biliary and gall bladder causes - upper abdominal pain and lastly H stands for hepatitis and this will help you remember hepatic causes - upper abdominal pain so hopefully this mnemonic will help you remember the main emergent causes - upper abdominal pain it's not to say that other causes can't become emergent or that there other emergent causes.


• But these are the main ones and with that list of potential diagnoses that can lead to upper abdominal pain being so long this will help organize it by organ or by system so that way you're less likely to miss something bad so now that you have done that primary survey on the patient possibly perform that chart review of time allowed and the patient was stable and you're starting to think about the upper stomach mnemonic as the causes to upper abdominal pain it's time to obtain that history from the patient you're gonna use that history to refine and prioritize that differential remember we said a lot of things can cause upper abdominal pain.


• So you're gonna use that history to prioritize the more likely versus the less likely and it's also going to help you figure out how you're gonna work up the patient so when you obtain that history I think it's always good to let the patient talk to you first don't ask too many questions don't interrupt them let them share their thoughts and feelings as to what's going on then afterwards if you have more questions feel free to ask them but by the end of the conversation you should have a good idea of the nature and onset of their pain where's their pain located and does it radiate what were they doing when their symptoms.


• Started how bad is their pain one to ten what does it feel like have they done anything for their symptoms does anything make it better or worse do they have any other associated symptoms so you get the point and there's other questions you can ask too but by the end of the conversation you really want to have a good understanding of the nature of their pain you'll also want to perform a review of systems and some considerations on how to do that include ease in the upper stomach mnemonic or you can go by organ system starting with intra-abdominal sources and then moving to extra abdominal sources.


• Once you've obtained that history you'll want to perform a thorough physical examination some considerations include palpating all the quadrants of the abdomen checking for things like guarding rebound tenderness or masses don't forget to check the overlying skin as well you'll want to check for signs of trauma bruising rashes maybe they have early shingles or herpes zoster that's leading to their abdominal pain you can also auscultate the abdomen and listen for bowel sounds don't forget the thorax either listen to the heart and lungs remember that there are thoracic causes.


• That can lead to upper abdominal pain you can also check for CVA tenderness and if you're worried about a GI bleed you might need to do a quack test if you feel that's necessary so now that you have obtained that history and performed the physical examination you should have a pretty good prioritize differ list that's going to help you figure out how you're gonna work up this patient some lab considerations include the following for most patients with abdominal pain standard basic labs will include CBC chemistry liver function tests and lipase.


• Which checks the pancreas if you're worried about a urinary source or need to check the urine for any reason then get a urinalysis if the patient has higher risk or you worried about surgical or ischemic causes or sepsis or any other reason to get a lactate then do so don't forget about a pregnancy test and for propria and if there's any concern for an infectious etiology then you should consider blood cultures and/or urine cultures if the patient has higher risk for a cardiac cause leading to their upper abdominal pain then make sure to obtain that EKG lastly the patient may require.


• Imaging this could include a CT abdomen and pelvis or maybe you're concerned about a pet a biliary disease and a right upper quadrant ultrasound could help you with that you could get an aortic ultrasound to assess for Triple A maybe worried about a peritoneal abdomen from a perforated ulcer and getting an upright chest and abdomen x-ray could show you free air abdominal x-rays could also be used to look for obstructive pathology or other reasons maybe you're worried about an intra thoracic cause to their upper abdominal pain and a chest x-ray could help you with that or maybe you need.


• To go more advanced and get a CT chest lastly if there's any concern for a renal cause - their abdominal pain you can consider a renal ultrasound let's wrap this up by talking about different presentations that medical exams and board exams like to use to describe upper abdominal pain it's not to say that all patients present this way but this is how they show up in question stems on tests so if a patient presents with epigastric pain that's worse after meals then they describe it as burning what do you want to consider think about things like peptic ulcer disease gastritis or GERD.


• If a patient presents with right upper quadrant abdominal pain that's worse after meals you want to consider things like biliary colic if the question stem asks you about fever right upper quadrant pain vomiting a positive Murphy sign then they're asking you about cholecystitis if the patient presents with fever right upper quadrant pain and jaundice remember that this is shark o's triad and this will help you remember that it's cool and joyous if the patient has fever right upper quadrant pain jaundice which is that triad we just talked about plus altered Mental Status and hypo tenshun well this is reynolds pentad and this too describes cholangitis if the patient complains of burning sharp epigastric pain.


• That radiates to the back maybe they had recent alcohol use or ingestion or history of cholelithiasis well those are risk factors to pancreatitis so that's what they're going to be testing you on if the patient has flank pain nausea the writhing in pain they have hematuria then this one's pretty obvious it's going to be natural a diocese or kidney stones if the patient is a smoker they're a male and you appreciate a pulsatile mass on examination then they're going to be asking you about a triple-a if the question stem describes a distended abdomen no bowel movements are philetus a history of multiple abdominal surgeries.


• Then they're going to be asking you about bowel obstructions if the patient has abdominal pain out of proportion to the examination and maybe they have a history of afib and even worse they're not anticoagulated then consider things like mesenteric ischemia if the question stem describes a sudden onset abdominal pain presentation and the examination is consistent with the peritoneal abdomen then you want to think about gastric or bowel perforation lastly if the patient has exertional epigastric pain that improves with rest then you want to think about acute coronary syndrome hopefully the upper stomach mnemonic was useful to you and hopefully this video provides you with an organized approach to the patient with undifferentiated upper abdominal pain.