Rosen & Barkin's 5-Minute Emergency Medicine Consult by Jeffrey J. Schaider, Adam Z. Barkin, Roger M. Barkin, Philip Shayne, Richard E. Wolfe, Stephen R. Hayden, Peter Rosen

is palpating under liver
Carnett sign indicates abdominal wall pain
Pain when a supine patient tenses the abdominal wall by lifting the head and shoulders.
Tender or discolored hernia site
Rectal and pelvic examination:
Tenderness with pelvic peritoneal irritation
Cervical motion tenderness
Adnexal masses
Rectal mass or tenderness
Guaiac positive stool
Genitourinary:
Flank pain
Dysuria
Costovertebral angle tenderness
Suprapubic tenderness
Tender adnexal mass on pelvis
Testicular pain:
May be referred from renal or appendiceal pathology
Referred pain:
Kehr sign (diaphragmatic irritation due to blood or other irritants) causes shoulder pain.
Extremities:
Pulse deficit or unequal femoral pulses
Skin:
Jaundice
Liver disease (caput medusa)
Hemorrhage
Grey Turner sign of flank ecchymosis
Cullen sign is ecchymotic area round the umbilicus
Herpes zoster
Cellulitis
Rash (Henoch–Schönlein purpura [HSP])
ESSENTIAL WORKUP
For a woman in reproductive age group a pregnancy test is essential
Where applicable for majority of cases, ultrasonography should be done with CT used in cases of negative or inconclusive ultrasonography.
DIAGNOSIS TESTS & NTERPRETATION
Lab
CBC
Serum electrolytes, creatinine, and glucose
ESR
LFTs
Lactic acid
Serum lipase:
More sensitive and specific than amylase
Urinalysis
Stool analysis and culture
Pregnancy testing (age reproductive women)
Imaging
EKG:
Consider if risk factors for coronary artery disease are present
Abdominal radiograph: Supine and upright
CT is superior for suspected visceral perforation and bowel obstruction.
Upright CXR:
Pneumoperitoneum
Intrathoracic disease causing referred abdominal pain
US:
Biliary abnormalities
Hydronephrosis
Intraperitoneal fluid
Aortic aneurysm
Intussusception
US (Doppler ultrasonography)
Volvulus and malrotation
Testicular and ovarian torsion
Hepatitis, cirrhosis, and portal vein thrombosis
Abdominal CT:
Spiral CT without contrast:
Renal Colic
Retroperitoneal hemorrhage
Appendicitis
CT with intravenous contrast only:
Vascular rupture suspected in a stable patient (e.g., acute abdominal aortic aneurtsn [AAA], aortic dissection)
Ischemic bowel
Pancreatitis
CT with IV and oral contrast:
Indicated when there is a suspicion of a surgical etiology involving bowel
History of inflammatory bowel disease
Thin patients (low BMI)
Diverticulitis
CT angiography:
Mesenteric ischemia
AAA
IVP:
CT has replaced the use of intravenous urography in detection of ureteral stones
Barium enema:
Intussusception
Treatment and confirmation of intussusception is with air contrast enema.
MRI:
If concerns for radiation exposure or nephrotoxicity
Contraindicated in patients with metallic implants
Pregnancy Considerations
    Ultrasonography and MRI should be preferred to prevent exposure of ionizing radiation to the fetus.
DIFFERENTIAL DIAGNOSIS
AAA
Abdominal epilepsy or abdominal migraine
Boerhaave syndrome
Adrenal crisis
Early appendicitis
Bowel obstruction
Cholecystitis
Constipation +/– fecal impaction
Diabetic ketoacidosis
Diverticulitis
Dysmenorrhea
Ectopic pregnancy
Esophagitis
Endometriosis
Fitz-Hugh–Curtis syndrome
Gastroenteritis
Hepatitis
Incarcerated hernia
Infectious gastroenteritis
Inflammatory bowel disease
Irritable bowel syndrome
Ischemic bowel
Meckel diverticulitis
Neoplasm
Ovarian torsion
Ovarian cysts (hemorrhagic)
Pancreatitis
Pelvic inflammatory disease
Peptic ulcer disease
Renal/ureteral calculi
Renal Infarction
Sickle cell crisis
Spider bite (Black widow)
Splenic infarction
Spontaneous abortion
Testicular torsion
Tubo-ovarian abscess
UTI
Volvulus
Referred pain:
Myocardial infarction
Pneumonia
Abdominal wall pain:
Abdominal wall hematoma or infection
Black widow spider bite
Herpes zoster
Pediatric Considerations
Under 2 yr:
Hirschsprung disease
Incarcerated hernia
Intussusception
Volvulus
Foreign body ingestion
2–5 yr:
Appendicitis
Incarcerated hernia
Meckel diverticulitis
Sickle cell crisis
HSP
Constipation
TREATMENT
ED