Answer the following questions and discuss. A 22 year old male presents with right lower quadrant pain with nausea, vomiting and guarding of abdomen. What would you assess physically on the patient and what diagnostic studies would you do? Also, what on a CBC indicates a Bacterial Infection? What are the differential diagnoses for abdominal pain? Be Specific!
When assessing for appendicitis, first start by having the patient point to the exact location of where the pain started and where the pain is presently located at during the exam. The pain associated with appendicitis can be vague at first. However, the pain can intensify over the next 4 to 5 hours, and it can subdue and reoccur in a different location over this time frame (McCance and Huether, 2006). Appendicitis pain classically begins peri-umbilical and then shifts to the right lower quadrant. Further assess for voluntary abdominal guarding that may lead to involuntary muscle rigidity by the patient. A rectal exam and pelvic exam may additionally be performed to distinguish between the typical and atypical presentation from an inflamed appendix in the pelvic cavity. Other sources of abdominal pain can be additionally ruled out with these exams. Rebound tenderness should be assessed as it is associated with inflammation in the peritoneal cavity and is associated with appendicitis (Bickley and Szilagyi, ).
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The physical exam continues with assessing for Rovsing's sign that is considered positive if right lower quadrant pain is experienced with deep palpation of the left lower quadrant. This is identified by rebound tenderness when the hand is withdrawn. Psoas sign should also be assessed for. This is accomplished by placing your hand above the patient's right knee and having the patient raise the right lower extremity against the resistance of your hand. Increased abdominal pain with the maneuver indicates irritation of the psoas muscle from an inflamed appendix. The obturator sign is indicated with right hypogastric pain when the patient's right thigh is flexed at the hip with the knee bent. This additionally indicates an inflamed appendix. Finally, assess for cutaneous hyperesthesia by picking up a fold of skin along a series of points down the abdominal wall. Localized pain with this maneuver may be due to inflammation associated with appendicitis (Bickley and Szilagyi, ).
Diagnostic studies to assess for appendicitis may include Roentgenograms, C.T. scans and an ultrasound of the abdomen. These diagnostic studies can assist diagnostic accuracy when combined with lab work and presentation of the patient (McCance and Huether, 2006). Lab work can include a complete blood count along with a C-reactive protein. The white blood cell count with appendicitis is usually elevated between 10,000 and 16,000 cells/mm3 with increased neutrophils. Additionall, the C-reactive protein is elevated (McCance and Huether, 2006). The complete blood count provides information on the number of red cells, white cells and platelets. The differential provides the quantity of the individual types of white blood cells in relation to lymphocytes, granulocytes and monocytes, and these cells can indicate bacterial infection (McCance and Huether, 2006).
White blood cells - when elevated can indicate bacterial infections. White blood cell types are measured as a percentage and an absolute number per litre.
Neutrophil granulocytesÂ - when elevated can indicate bacterial infection, but they are also raised in viral infections.
LymphocytesÂ - Higher with some viral infections, chronic lymphocytic leukemia (CLL) and decreased by HIV infection.
MonocytesÂ - May be raised in bacterial infection.
Eosinophil granulocytesÂ - Increased in parasitic infections, asthma, or allergic reaction.
Basophil granulocytes- Increased in leukemia or lymphoma and other bone conditions.
Due to the close proximity of abdominal organs and the referred visceral pain associated with renal colic, it can present similar to appendicitis. Since the brain has no felt image for internal organs, referred pain is felt where the organ was located in fetal development (Jarvis, 2004). Renal colic can present like appendicitis in the right lower abdominal quadrant. Calculi that are expelled from the kidney and become lodged in the urinary tract initiate a cascade of responses resulting in pain. The lodging of calculi stretches nerve endings in the ureter mucosa, and urinary tract obstruction causes increased diuresis from vasodilatation of renal arterioles that also increases pelvic pressure (Holdgate & Pollock, 2004). With increased diuresis and pelvic pressure, smooth muscle wall contraction occurs. The increased diuresis and smooth muscle contraction is the body's attempt to move the calculi down the ureter. An increase in intra-ureteral pressure additionally causes the synthesis and release of prostaglandins (Carpena et al., 2003; Shokeir, 2002), and the release of these chemical messengers results in an inflammatory response at the site of obstruction. With the inability of muscle contractions to move calculi down the ureter, muscle spasms, prolonged isotonic contraction and lactic acid production occurs. This process irritates slow-type A and fast-type C fibers which generate afferent impulses that travel to the spinal cord resulting in a painful sensation (Carpena et al., 2003).
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Urinary tract infections (UTIs), from bacterial colonization, cause an inflammation of the urinary epithelium. Urinary Tract Infections causing an inflammation of the bladder is termed cystitis, and pyelonenephritis is an inflammation of the upper urinary tract. Acute pyelonenephritis involves an inflammation of the ureter, pelvis and parenchyma. Dysuria, frequent urination and suprapubic or lower back pain is the classic presentation of UTIs. The signs and symptoms of UTIs present differently based on age and urinary tract function, and UTI's share some common signs and symptoms that are seen in appendicitis (Grey, et al., 2006). Diagnosis is typically made on symptom presentation and by the presence of microorganisms in the urine. UTI's typically present with foul smelling urine that is present with bacteria, blood cells, leukocyte esterase and nitrites. If a diagnosis of UTI is made, urine cultures are utilized to identify the pathogenic bacteria (Porth, 2005).
\ Ectopic pregnancies are true emergencies and should be considered in any woman of childbearing age presenting with pelvic pain. An ectopic pregnancy results from fertilization of an ovum that implants in the fallopian tube or any other location than the uterine cavity. Symptoms include lower abdominal discomfort localized to the affected side and severe pain can occur with if rupture. A urine pregnancy test will detect lower-than normal hCG production in ectopic pregnancies, and a positive urine pregnancy test indicates the need for a pelvic ultrasound and possibly laparoscopy to make a definitive diagnosis (Porth, 2005).
Pelvic inflammatory disease (PID) is an additional gynecological consideration in women presenting with abdominal pain. PID is an inflammatory process of the upper reproductive tract that may be isolated to one organ, or it can encompass many organs of the tract. The inflammatory process can result from a polymicrobial infection that ascends from an infected cervix to the uterus and adnexae. The entire peritoneal cavity may become inflamed in the most severe cases. PID presents with lower abdominal pain that has an onset just after the menstrual cycle. The pain can present as sudden and severe or dull and steady with a gradual onset. Commonly, a fever along with an elevated white blood cell count and an increased erythrocyte sedimentation rate is present. C-reactive protein may be elevated. CRP is non-specific but indicates an inflammatory process. Pelvic examination along with lab tests for Gonorrhea and Chlamydia are often performed to support a clinical diagnosis (Morgan & McCance, 2006; Porth, 2005).
An abrupt excruciating pain located in the back that is described as tearing or ripping may indicate a descending aortic dissection or abdominal aneurysm. Aortic dissection is an acute life threatening condition, and persons that present with signs and symptoms indicating a probable diagnosis require medical stabilization prior to the diagnosis being confirmed (Porth, 2005). Aortic aneurysms present with a variety of symptoms. Eighty percent of aortic aneurysms are palpable as a pulsating mass, and auscultation reveals a bruit from blood turbulence (Jarvis, 2004). They are often asymptomatic and only become painful when they rupture. After rupture, arterial blood flow is disrupted and may manifest with an unobtainable blood pressure and peripheral pulses. Syncope, hemiplegia, dysphagia and dyspnea may present from blood flow disruption and pressure on surrounding organs. Confirmation of an abdominal aortic aneurysm is made by ultrasonography, computed tomography, magnetic resonant imagining or angiography (Brashers, 2006; Porth, 2005).
Bowel obstructions from mechanical causes can present with a sudden and dramatic localized colicky pain, and this presentation is typically associated with an acute obstruction. Patients experiencing bowel obstructions may be nauseated and vomiting. They may be extremely restless, diaphoretic and anxious (Porth, 2005). Obstruction of the large bowel has moderate colicky pain in the lower abdomen and irritable bowel syndrome (IBS) can present with a non-radiating sharp pain over a wide abdominal area (Jarvis, 2004). Small bowel obstructions present with colicky intermittent pain that corresponds to peristaltic waves meeting an obstruction. Like apendicitais, an autonomic nervous system response causing diaphoresis and nausea is present in the large and small bowel obstructed patient. Clinical manifestations such as vomiting, constipation, abdominal distension, hypovolemia and metabolic acidosis may be observed after complete obstruction. Ultrasound, plain film radiography and CT scans are utilized in the diagnosis process (Huether, 2006).
Mesenteric Ischemia or adenitis can result in abdominal pain that is isolated or diffuse, and abdominal pain is the most common symptom of mesenteric adenitis. A blockage or a decrease in the blood supply to the bowel, from a thrombus or embolus, is the main cause of mesenteric adenitis. A cramping abrupt onset located in the peri-umbilical area or diffusely located in the abdomen is associated with mesenteric adenitis. The pain can specifically be located to either the center of the abdominal cavity, or the lower right side of the abdomen. this right side area is referred to as the right iliac fossa. It is possible to have the pain spread to other parts of the abdomen, but practitioners normally look to these two areas as a way to identify mesenteric adenitis. The abdominal pain is not normally severe, but is often described as very uncomfortable (Bickley and Szilagyi, 2009).
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