• Recognize the value of:
  • Mnemonics, such as FARCOLDER and VINDICATE, as checklists that ensure one asks all the pertinent questions and considers all possible diagnoses.
  • Creating summary statements with semantic qualifiers and the effect this has on narrowing down the differential diagnosis.
  • Writing down a diagnostic considerations/key features list and using it to focus the evaluation and to prompt pattern recognition.
  • The importance of applying a systematic approach to disorders such as abdominal pain, where there are a multitude of potential causes that could be overlooked. Note that specific constructs (e.g., VINDICATE applied to anatomy) may help organize the analytic approach.
  • The need to employ worst case scenario medicine – considering the most severe diagnoses first.
  • That the diagnostic process often involves several working diagnoses at any given time
• Know that using the hypothetico-deductive model can help weigh clinical factors in favor and against each working diagnosis.
• Know the characteristics of the two forms (pattern recognition and analytic) of clinical thought.

1) Identify the “Serious Six”; the six causes of abdominal pain that pose an immediate risk to life (four vascular and two peritonitis):

• Acute mesenteric ischemia
• AAA
• Aortic dissection (rare)
• Inferior MI
• Acute intra-abdominal infection with peritonitis
• Viscus rupture with peritonitis

2) Biliary colic, acute cholecystitis, and acute cholangitis are different manifestations of the same underlying disease (cholelithiasis)

• Biliary colic is typically self-limited and is not associated with evidence of systemic inflammation.
• Acute cholecystitis is longer in duration and with more severe pain than biliary colic and is often associated with systemic inflammation
• Acute cholangitis is most typically associated with jaundice/elevated bilirubin and evidence of systemic inflammation (fever, chills, sepsis).

Other manifestations of cholelithiasis include gallstone pancreatitis, gallstone ileus, and Mirizzi syndrome (the latter two are rare).

2) The combination of findings in a patient with abdominal pain rather than the presence or absence of a particular symptom leads physicians to the likely diagnosis.  For acute cholecystitis for example, the likelihood ratios for each of the individual findings are relatively low but that of the overall clinical impression is substantial.

3) Identifying and recognizing signs on exam that indicate peritonitis (i.e., “peritoneal signs”) is a crucial element of the evaluation of a patient with abdominal pain.  The evaluation of a patient with abdominal pain should always include assessment of peritoneal signs.

[Key features for each diagnosis are bolded]

A 53 year old male presents with mid-epigastric pain.  It has been present for about four hours, is dull but severe (8/10) and bores through to his back.  He is nauseated and has had several episodes of bilious emesis.  He has not had prior episodes of pain.  Past history is remarkable for gout and hypertension, for which he takes no medications.  He drinks at least 12 beers/day.  Exam shows moderate epigastric tenderness without rebound or guarding.  There is no hepatosplenomegaly.  Labs reveal a WBC of 16,000, AST of 98, ALT of 65, tbili of 0.9 and lipase of 984. [acute pancreatitis]

A 77 year old female presents with severe abdominal pain.  She has a history of coronary artery disease, atrial fibrillation and hypertension but was well until two hours about when she had sudden onset of severe (9-10/10) pain that is centered in the peri-umbilical region but which is present throughout her abdomen.  The pain does not radiate and nothing makes it better or worse.  She has had a single episode of non-bloody emesis and is nauseated.  On exam, her vitals show pulse of 134 & irregular, BP 177/88, temperature 37.9.  Abdomen is mildly tender throughout without rebound, guarding, masses or distension. Labs are remarkable for a WBC of 19,000 and a lactate of 6. [acute mesenteric ischemia]

A 55 year old female presents with abdominal pain.  She is otherwise healthy but noted onset of peri-umbilical pain the previous morning.  She subsequently became nauseated and had several episodes of emesis but remained at work.  This morning the pain moved to the right lower quadrant and her nausea worsened.  She has not been able to eat anything over the past day, but denies any other symptoms.  On exam her vitals are normal but she has tenderness to moderate palpation in the right lower quadrant along with voluntary guarding.  There is no rebound tenderness.  Labs are remarkable for a WBC of 13,000. [appendicitis]

An 82 year old female presents with abdominal pain.  She has a history of dyslipidemia and hypertension but is otherwise healthy.  Over the past two days she has noted progressive discomfort in the left lower quadrant.  There has been no nausea, vomiting, diarrhea or change in stool but she has noted low-grade fevers and anorexia.  She has not had prior episodes of pain.  On exam, her temperature is 38.5 but other vitals are normal.  There is tenderness to direct palpation in the left lower quadrant with voluntary guarding but no rebound tenderness.  Rectal exam reveals no tenderness and brown guaiac negative stool.  WBC is 18,000 but liver associated enzymes and lactate are normal. [acute diverticulitis]

A 78 year old male presents with acute onset of epigastric abdominal pain.  He reports no prior episodes of similar pain.  The pain is severe (8/10) and radiates through to his back.  He felt lightheaded when it first came on and he still feels slightly lightheaded.  He denies N/V, change in bowel habits or other symptoms.  He with a history of hypertension, coronary artery disease and localized prostate cancer.  He smokes a pack of cigarettes per day.  Exam reveals a blood pressure of 82/46, pulse of 134, and oxygen saturation of 95% on room air.  Abdomen is soft with mild epigastric tenderness.  There is no guarding or rebound.  Labs show a white blood cell count of 12, normal liver associated enzymes and a normal lipase. [leaking AAA]