Abdomen/Pelvis

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

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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

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

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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)

*Deep Dive: Back Pain (EMRA)

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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)

*Deep Dive: Diarrhea (emDocs)

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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)

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

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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

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

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