Abdomen/Pelvis

  • Abdominal Pain
  • Back Pain
  • Diarrhea
  • Hematuria
  • Vaginal Bleeding (Non-Pregnant)

Abdominal Pain

  • Differentials 
    • Gastrointestinal
      • Pancreatitis
      • Hepatitis
      • Gastritis
      • Peptic Ulcer Disease
      • Cholecystitis
      • Chiledocholithiasis
      • Cholangitis
      • Diverticulitis
      • Crohn’s disease
      • Ulcerative colitis
      • Bowel obstruction
      • Hernia
      • Constipation
    • Vascular
      • Mesenteric ischemia
      • Ischemic colitis
    • Renal/Urinary
      • Pyelonephritis
      • Urinary tract infection
    • Urologic
      • Testicular torsion
      • Epididymitis
    • Gynecologic
      • Pelvic inflammatory disease
      • Ovarian torsion
      • Ovarian cyst rupture
      • Endometriosis
      • Uterine fibroid
    • Referred pain
      • ACS
      • Pulmonary embolism
      • Pneumonia
  • History
    • Which region does the pain hurt most?
      • Differentials vary based on location
    • Fever/chills?
      • Suggests infectious process
    • Urinary symptoms?
      • Suggests pyelonephritis, cystitis, nephrolithiasis
    • Melena/hematochezia?
      • Consider GI bleed
    • Alcohol use?
      • Consider hepatitis or pancreatitis
    • Exacerbated or relieved with foods?
      • Consider gastric or duodenal ulcers
    • Hx of unprotected sex or recent STI?
      • Consider PID
  • Physical Exam
    • Murphy’s sign
      • Suggests biliary process
    • Rigid abdomen
      • Suggests peritonitis
    • Rebound Tenderness/Rovsing’s/Obturator/Psoas Signs
      • Suggests appendicitis
    • CVA tenderness?
      • Suggests pyelonephritis or nephrolithiasis
  • Work-Up
    • Labs
      • CBC, CMP, Lipase
      • Lactate (if suspect mesenteric ischemia, sepsis, strangulated hernia)
    • Imaging
      • Abdominal X-ray
      • RUQ ultrasound 
      • CT abdomen/pelvis
Video Credit: Strong Medicine

*Deep Dive: Abdominal Pain Mimics: Pearls and Pitfalls (emDocs)



Back Pain

  • Differentials 
    • “CRAFTI”
      • Compression 
        • Cauda equina
        • Conus medullaris
        • Epidural hematoma
      • Renal stone 
      • Aortic aneurysm/dissection
      • Fracture
      • Tumor
      • Infection/Inflammatory
        • Pyelonephritis
        • Perinephric abscess
        • Epidural abscess
        • Osteomyelitis
        • Discitis
        • Transverse myelitis
    • Other common causes
      • Mechanical low back pain
      • Sciatica/Radiculopathy
  • History
    • Recent injury?
      • Consider fracture, strain
    • Recent unintentional weight loss?
      • Consider malignancy
    • IV drug use?
      • Consider epidural abscess
    • Syncopal episode?
      • Consider aortic dissection, aneurysm
    • Urinary incontinence? Saddle anesthesia?
      • Consider cauda equina
    • Fever/chills?
      • Consider infectious process
  • Physical Exam
    • Spinal tenderness? Step-off deformity?
      • Consider fracture
    • CVA tenderness?
      • Consider nephrolithiasis or pyelonephritis
    • Sphincter dysfunction
      • Consider cauda equina
  • Work-Up
    • Labs
      • CBC, BMP, ESR, CRP
      • Urinalysis
      • Beta-hCG
      • Post-Void Residual
    • Imaging
      • X-ray (spinal)
      • CT Spine (non-contrast)
Video Credit: The Center for Medical Education

*Deep Dive: Back Pain (EMRA)



Diarrhea

  • Differentials 
    • Bacterial
      • C. difficile
      • Campylobacter
      • Shigella
      • Salmonella
      • E. coli
    • Viral
      • HIV
      • Enteroviruses
    • Parasitic
      • Entamoeba histolytica
      • Giardia lamblia
    • Other
      • Inflammatory bowel disease
      • Ulcerative colitis
      • Diverticulitis
      • Medications
      • Alcoholism
  • History
    • Frequency and volume of stools?
      • Watery, large volume stools likely viral
    • Recent antibiotics?
      • Consider C. difficile
    • Exposure to poultry, livestock, turtles? 
      • Consider salmonella
    • Travel to developing countries?
      • Consider bacterial/parasitic infections
    • Consumption of raw, undercooked meats?
      • Consider bacterial organisms
  • Physical Exam
    • Dry mucous membranes?
      • Suspect dehydration
    • Abdominal tenderness
      • Suspect inflammatory process (pancreatitis, cholecystitis, appendicitis) 
    • Bloody stools?
      • Suggest bacterial/parasitic
  • Work-Up
    • Labs
      • CBC, BMP, hepatic panel
      • C. diff PCR
      • Hepatic panel
      • Stool culture
      • Stool ova/parasites
    • Imaging
      • CT Abdomen pelvis (if concern for acute abdomen)
Video Credit: JJ Medicine

*Deep Dive: Diarrhea (emDocs)



Hematuria

  • Differentials 
    • Urinary tract infection
    • Nephrolithiasis
    • Bladder/Kidney cancer
    • Nephropathy
    • Foreign Body
    • BPH
  • History
    • Ingestion of new foods or medications?
      • Consider pseudohematuria
    • Clots?
      • Consider nonglomerular etiology (bladder)
    • Beginning, middle, or end of stream?
      • Helps identify source of bleeding
    • Recent procedures or trauma?
      • Consider urethral injuries
  • Physical Exam
    • CVA tenderness
      • Suggests pyelonephritis or nephrolithiasis
    • Suprapubic tenderness
      • Suggests cystitis
    • External lesions/lacerations
      • Evidence of urethral injury
  • Work-Up
    • Labs
      • CBC, BMP, Coags, CK
      • Urinalysis 
      • Urine culture
    • Imaging
      • CT (may be useful for identifying pyelonephritis vs nephrolithiasis)
Video Credit: Strong Medicine

*Deep Dive: Evaluation and Management of Hematuria in the Emergency Department (emDocs)



Vaginal Bleeding (Non-Pregnant)

  • Differentials 
    • Menstruation w/ coagulopathy
    • Uterine fibroids
    • Polyps
    • Breakthrough bleeding w/ OCPs
    • Atrophic vaginitis
    • Foreign Body
    • Endometrial/Cervical cancer
  • History
    • Amount of blood (in pads or tampons)
      • Helps quantify severity of bleeding
    • Recently started contraceptives?
      • Consider breakthrough bleeding
    • Family history of malignancy?
      • Consider endometrial or cervical cancer
    • Abdominal/Pelvic pain?
      • Consider ectopic pregnancy
  • Physical Exam
    • Signs of trauma
      • Consider vaginal or uterine injury
    • Abdominal/Pelvic tenderness?
      • Consider ectopic pregnancy or ovarian cyst
  • Work-Up
    • Labs
      • CBC, CMP, Type and Cross
      • Beta-hCG
      • DIC panel (fibrinogen, coags, reticulocyte count, d dimer)
    • Imaging
      • Transvaginal ultrasound
Video Credit: Lecturio

*Deep Dive: Vaginal Bleeding in the Non-Pregnant Patient (emDocs)


Brandon Simpson, PA-C
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