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S2D: The Symptom to Diagnosis Podcast - Episode 01: Abdominal Pain
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S2D: The Symptom to Diagnosis Podcast - Episode 01: Abdominal Pain
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Language: EN.
Segment:0 .
DR. CIFU: Hello, I'm Adam Cifu.
DR. STERN: And I'm Scott Stern.
DR. CIFU: Welcome to episode 1 of the Symptom to Diagnosis podcast. Scott and I are both general internists and medical school professors at the University of Chicago. We have what? Scott, about 50 years of clinical experience between us?
DR. STERN: I think so.
DR. CIFU: Yeah, kind of scary. So the goal of this podcast is to teach evidence-based strategies for diagnosing common medical symptoms. The podcast is based on our textbook "Symptom to Diagnosis: An Evidence-Based Guide." Each week, we will address the diagnostic approach to one symptom, we will discuss differential diagnosis, diagnostic frameworks and the details of the diagnostic reasoning process.
DR. CIFU: Each episode will be divided into four parts, we'll begin each episode with a case which is unknown to one of us. We will then discuss five high yield features that help to accurately diagnose the cause of the symptom at hand. We'll then return to our case, figure out what was going on with that case, before finishing up with a discussion of fingerprints, common misconceptions, pet peeves, and other random pearls of knowledge pertaining to the week's symptom.
DR. CIFU: The cases that we discuss are drawn from our clinical experiences but, because protecting patient privacy is part of our oath, we never discuss actual patients and most cases are composites. So, this week, our symptom is abdominal pain. Scott, you're the expert of the day, do you have a case to present to me?
DR. STERN: I do, Adam. I saw a woman many years ago, who my first contact with her was actually over the telephone.
DR. CIFU: [chuckling] Always a good way to start, right?
DR. STERN: This was a particularly bad way to start. So actually, her husband called me up, and he called me up to report that his wife was having severe abdominal pain. And in the background, I heard her screaming.
DR. CIFU: [chuckles]
DR. STERN: This is a very uncomfortable feeling, when you're on the phone with someone--
DR. CIFU: That has severe abdominal pain.
DR. STERN: That is severe, and then the next thing he says to me, "Oh, sh*t, she's passed out again."
DR. CIFU: Wow.
DR. STERN: So pretty terrifying. I told him to call 911, and he said he'd already done that. And she sent them away the first time. And I recommended he call them again and send her to the emergency room.
DR. CIFU: I love it, how old is she, do you know?
DR. STERN: She is 44.
DR. CIFU: Okay, so sort of middle-aged woman. And I think hearing it so far, all I would say is, if I was trying to figure out what was going on with this person, I'd say this is severe abdominal pain, and the fainting, collapsing, syncope, whatever we want to call it, is interesting. I would say, how the things that would explain that to me would be blood loss, you're not hearing about blood splattered all over the room. So that's maybe a little less likely.
DR. CIFU: Certainly with severe pain, one could have kind of vasovagal syncope, neurocardiogenic syncope, or I guess, lastly, if the person has been sick, and we haven't learned about that, they could be hypovolemic, and fainting because they're severely orthostatic, I guess.
DR. STERN: Right.
DR. CIFU: But right now, I guess otherwise, I should be at a loss, right?
DR. STERN: I think so, I was.
DR. CIFU: [chuckles] Okay, good. So what happened next?
DR. STERN: Well, what happened next was she went to the emergency room, and I was still in my office, and I got a call about an hour, two hours later from the emergency room physician saying that she looked just fine, and that they were going to send her home. And I said that doesn't sound right. This is a woman who was screaming on the telephone and lost consciousness. I recommended they keep her until I could leave the office and get over to see her.
DR. CIFU: Good, good. So I'm trying to think now, what adds to this now, is that you have someone who's really got waxing and waning symptoms, right? So when I think of that with abdominal pain, I'd certainly think about colicky pain, right? And that's usually some sort of obstruction. So certainly biliary tract disease could cause that. That would make sense given her-- 40-year-old woman fits in well with that.
DR. CIFU: Obstruction of the intestine, small bowel obstruction, large bowel obstruction would make sense there as well. Kidney stones too, but none of these work very well with the syncope we heard about before.
DR. STERN: Right.
DR. CIFU: Did you see her? Did you get some sense of the exam?
DR. STERN: I did. And I saw her and her general vital signs were stable and her abdominal exam actually by the time I saw her, was relatively unremarkable. Some mild lower quadrant tenderness, but not much else.
DR. CIFU: Okay. I guess all I'd add, so lower abdominal tenderness in a woman of this age, it's a little confusing, because certainly you could think of diverticular disease, which we mostly think about in older women, and then, you know, adnexal ovarian pathology which I usually think about in younger women, but could this be a ruptured ovarian cyst, could this be a ruptured ectopic, I guess so, possibilities.
DR. CIFU: ould this be a ruptured ectopic, I guess so, possibilities.
DR. STERN: Right, exactly.
DR. CIFU: And what happened next, what kind of diagnostic tests were done?
DR. STERN: Well next, the most important diagnostic test was actually a physical examining.
DR. CIFU: Oh shocking. [chuckles]
DR. STERN: Yeah, it's shocking. So I did a very unusual physical exam maneuver, and I took her blood pressure myself, both when she was sitting and when she was standing. And the results were very interesting. So sitting, her blood pressure was 110 over 70 with a pulse of 80, pretty unremarkable. But because she'd passed out, and you've commented several times that that's really peculiar, I stood her up to check her blood pressure again.
DR. STERN: And I started lowering the blood pressure and got to 110 and didn't hear anything, got to 100 and didn't hear anything, got to 90 and didn't hear anything and started getting nervous, got to 80 and didn't hear anything. And around the time I got to 70, the eyes rolled to the back of her head, as she proceeded to begin to lose consciousness.
DR. STERN: I pushed her promptly back onto the bed, lifted her legs, and I was happy when she regained consciousness.
DR. CIFU: Good, good, that's quite an intervention there. Wow, so that's incredibly interesting. So I mean, I think now you've sort of proven with that level of orthostasis that this lady has to be hypovolemic, right?
DR. STERN: Exactly.
DR. CIFU: That kind of rules out everything else we talked about for the reason of her fainting. And it's confusing because you haven't told me that she's been having terrible diarrhea, she hasn't been having melena, she hasn't been vomiting. So it makes me think that she has to have lost blood internally. And so if we put that together with my sort of colicky pain, I guess causes of colicky pain, none of those make sense.
DR. CIFU: You don't lose a lot of blood with biliary tract disease, you don't lose a lot of blood with intestinal obstructions. So I think that the woman's pain, which I was calling colicky must not be, it must be real, almost intra-abdominal catastrophe that for some reason is causing waxing and waning pain, which I can understand. In a woman of this age, I think we're talking about ovarian pathology, or maybe a ruptured AAA, but a 42, 44-year-old woman, that seems really unlikely.
DR. CIFU: So I guess, if I was managing her at this point, I'd say we need some abdominal imaging, we'd need to see the pelvis really well. And whether that's an ultrasound or a CT, you know, probably a toss of the coin.
DR. STERN: Right, that pretty much mimics my thinking at the time. The tremendous hypotension on standing, is really dramatic, and I asked her again, about volume loss, dehydration, or recurrent vomiting or diarrhea, she'd had none of that. I asked her again about bright red blood rectum, or melena, she's had none of that. So this really falls under the rubric of unexplained hypotension.
DR. STERN: And so it really does suggest some sort of intra-abdominal catastrophe, and like you, I started going through the list of possibilities. A 44-year-old woman, with an abdominal aortic aneurysm would be very unusual. On the other hand, she's still of childbearing age. And I asked her at that point, when was her last menstrual period? And she said, "You know it's funny you ask?
DR. STERN: because I think it was about six weeks ago, and it was irregular." And at that point, the light bulbs really started going off, suggesting that, in fact, maybe she had ruptured an ectopic pregnancy.
DR. CIFU: Great, let's stop there in the case. And let's talk a little bit more generally about abdominal pain. So what we imagined we would do in this section, is have the expert of the day, which today is Scott, tell us about some of the really high yield features that you think about when you're faced with a patient with abdominal pain. Take us through those, I'll ask some questions or maybe try to expand on some of them as you go.
DR. CIFU: So when you start, what are sort of the points that you always think about when you're faced with someone with abdominal pain?
DR. STERN: Well, the first point, which is true for both abdominal pain, and almost any symptom that a patient has, is to try to clarify and characterize a symptom as precisely as possible. You need to be able, at the end of the visit, to describe it in so much detail, that someone else felt like they were watching the patient with the symptom or that they were having this symptom themselves. And a mnemonic that I learned in medical school that I find is still very helpful is P, Q, R, S, T, to remind me of all the questions to ask.
DR. STERN: So P is provocative and palliative, and that means, what brings it on and what makes it better. I want to know about Q, which is what's the quality of the pain, what does it feel like? R is region where is the pain? And we'll come back to that in more detail in a little bit. And where does it radiate? S is the severity, how bad is that pain and what setting is it occurring in?
DR. STERN: What were you doing at the time? And finally T, what are the temporal features of the pain? When did it start? How long does it last? Does it recur? Have you had it before and so on?
DR. CIFU: That's funny, I'm also, I'm a P, Q, R, S, T addict as well, I think of that with basically every patient and the beauty of that is, that it works for anything. So it's not just pain, but someone presents to you with dyspnea. It's incredibly helpful in that case, dizziness, basically, anything that someone comes in with, you can fall back on that, and I often find that if I'm completely lost with a patient, and I don't even know what questions to ask, that sometimes going to those questions kind of bails me out in that situation.
DR. STERN: Absolutely, helps with illness script recognition. Oftentimes, there's the one specific detail that when the patient elaborates on it, all of a sudden the light bulb goes off in your head, and you say, "Oh, I know what this is." That's very helpful.
DR. CIFU: Okay, so if number 1 is symptom characterization P, Q, R, S, T, what's number 2?
DR. STERN: Number 2 is using the pivotal point of location to try to narrow the differential diagnosis. It's pretty obvious that pain in the right upper quadrant has a completely different differential diagnosis than pain in the left lower quadrant. So to the extent that it's possible for the patient, I really ask them where in the abdomen is their pain?
DR. CIFU: Yeah, that's funny, I thought you would go to there, go to that first, since people so classically structure their abdominal pain, differential diagnoses based on region, but makes total sense, where you put it. And it's interesting thinking back to this case, because you realize that there are a lot of abdominal pain cases that it's not-- I have periumbilical pain, which is radiated to the right lower quadrant, and it's obvious, it's, I don't know, my pain is general, it's both lower quadrants, and you're sort of at a loss.
DR. STERN: For sure,
DR. CIFU: So number 3?
DR. STERN: The third issue is the time course of the pain. It's pretty obvious that some diseases will present acutely, some will present chronically, and some can do either. But it's very helpful. For instance, if someone's had pain for 10 years, it's not an abdominal aortic aneurysm. And also, it can help to know whether the pain is very discreet in its episodes, or whether it waxes and wanes more gradually. An example, you'd mentioned biliary colic, and as you know, biliary colic tends to have very acute episodes.
DR. STERN: People actually come in and say, I've had an attack of something. Whereas peptic ulcer disease waxes and wanes typically.
DR. CIFU: Yeah, I always pitch to people that they should buy a copy of Cope's Early Diagnosis of the Acute Abdomen, which is this-- probably 75 years old at this point. But it's such a wonderful book because it focuses so carefully on what the history is of all the different causes of abdominal pain. And it really points that out actually, with sort of pictures and graphs of what peptic ulcer disease pain look like, what biliary colic pain looks like, it's a terrific point.
DR. CIFU: Number 4?
DR. STERN: It's even older than we are.
DR. CIFU: [chuckles] Shocking. Okay, let's go into number 4.
DR. STERN: So the fourth point really is to integrate what you've learned on location, with the time course. So you can think about right upper quadrant pain that's acute, right upper quadrant pain that's chronic, similarly for epigastric pain and so on. And once you do that, you've often narrowed the differential diagnosis down from a very large list to a very small handful of possibilities.
DR. CIFU: That's great. So it's a little cheating, using four to bring together two and three, but I'm good with that. So we've got symptom characterization, we've got location of the pain, we've got the, we'll call it maybe the history of the pain, the ability to synthesize what you've learned. And then what about number 5?
DR. STERN: Well, number 5 is to leverage key features that are occasionally present that can really narrow the differential diagnosis. They're not often there, but when they are, you really need to take advantage of them. They include things like jaundice. If a patient has jaundice and abdominal pain, we know we're talking about some problem in the liver, or their biliary tract. [coughs] On the other hand, if they have unexplained hypotension, like our patient, we really want to think about some causes of intra abdominal hemorrhage.
DR. STERN: Other things that can be telling would be a mass, of course, if we see a mass, we're going to think about where that mass is. If they have distension, we need to think about ascites or bowel obstruction. And of course, if they have peritonitis, we really want to think about some ruptured viscus.
DR. CIFU: Great, we're going to talk about fingerprints in a minute, but this is sort of getting to that, because what you're talking about is that, when you have a positive finding, you really need to follow that finding.
DR. STERN: Exactly, exactly.
DR. CIFU: Okay, so Scott, we've been through those five high yield features. So let's get back to the case. We were talking about, I think you definitively, me a little less definitively, was thinking about ectopic pregnancy in this woman. So what happened next?
DR. STERN: Well, I did this another amazing test, called a pregnancy test, which was positive. And called the OB-GYN at the time, because this is before we had rapid ultrasounds in the emergency room, and we scanned her as you had suggested, and she had 750cc's of blood in her pelvis.
DR. CIFU: Wow well, that really brings everything together. I mean, I guess the one thing that's still left is the weird intermittent nature of her pain, which just goes to show you that not every patient reads the textbook before they present.
DR. STERN: Well, I think the intermittent nature is actually 'cause she ruptured the fallopian tube.
DR. CIFU: Huh!
DR. STERN: So I think the tube was getting stretched, giving her the colic and then when it ruptured, it was no longer stretched.
DR. CIFU: Interesting, and she was better, but she was exsanguinating. [chuckles]
DR. STERN: Exactly. Her pain was better, she was dying.
DR. CIFU: Terrific, well I shouldn't say terrific. I hope she did well.
DR. STERN: She did do well. Actually, she went to the OR and had an uneventful course. But imagine had we not checked her blood pressure when we stood up? Imagine had we sent her out of the emergency room saying she was fine, what would the outcome have been? I think not so great.
DR. CIFU: She could have done terribly. Okay, so to finish things up, our last segment is going to be talking about some really key points, that we think are important to leave with. And we're going to kind of trade back and forth during this. And they're really going to be four different categories. The first is fingerprints. The second is common misconceptions. The third is pet peeves, which we'll have a little bit of problem, a little bit of fun with.
DR. CIFU: And then the last one are clinical pearls, which is a term we've been using since the original edition of Symptom to Diagnosis, which was I think, in 2002?
DR. STERN: Right.
DR. CIFU: A long, long time ago. So fingerprints, I'm going to let Scott describe what fingerprints are.
DR. STERN: Well, fingerprints are findings on the examination typically, that are so specific that they essentially point to a specific disease, and they're analogous to fingerprints at a crime scene. Fingerprints at a crime scene, like DNA at a crime scene, really point to one particular suspect. And if they're there, they're very helpful in diagnostic. If they're not there, they don't tell you much. [De. Cifu] And fingerprints are not common, we should say. But when you find them, they are important.
DR. STERN: I think the one we always toss around, is an S3 in someone presenting with symptoms suspicious for congestive heart failure. If a patient comes in with dyspnea or orthopnea and you listen to that person, and you hear an S3, says a very high likelihood ratio, it essentially makes the diagnosis. But if you see a patient with dyspnea, who doesn't have an S3, you still don't really know what's going on.
DR. STERN: Exactly.
DR. CIFU: Okay, amazingly, there're really no fingerprints for abdominal pain. But there's certainly findings on lab tests and radiology procedures which are suggestive, but we really limit fingerprints to things in the history and physical examination. The next point is common misconceptions. There are common misconception that tends to torture you, Scott?
DR. STERN: Sure, one of them is actually the unusual way that peptic ulcer disease presents, it's commonly thought that patients with peptic ulcer disease will always present with pain in the upper gastric, that gets better when patients eat and it gets worse on an empty stomach. And the reality is that food can make the pain better or worse. And some patients with peptic ulcer disease actually present with weight loss without pain, and bleeding and massive bleeding, never having had pain.
DR. CIFU: Hmm interesting, I think mine that I jotted down for this actually comes from a recent experience for me. And it's the point that a lack of fever or lack of leukocytosis really does not rule out appendicitis in a patient. I saw a patient recently in our urgent care settings, very interesting, he was a surgeon from another country, who came in and said-- not working as a physician here, came in and said-- I said, "What brings you in?" and he said, "I have appendicitis." I examined this guy, not really striking physical examination, no fever, I sent a CBC his white count I think was eight and a half.
DR. CIFU: But you're faced with a surgeon who thinks he has appendicitis, that person needs to be worked up, he did in fact, have appendicitis. And it really pointed out to me that fever and leukocytosis have very negative likelihood ratios, quite close to 1 and therefore does not exclude a diagnosis. It's probably useful to think about that, actually, I think, right after you talked about fingerprints, because we should really say there's really very few things that are the converse of the fingerprint.
DR. CIFU: A finding that if it's absent rules out a diagnosis, you should really not think that when you're working up any problem,
DR. STERN: I would say that's maybe the most common error I see among students and residents, is the perception that because they've studied classical findings, that patients are going to present with classic findings. And then when they don't have the classic findings, they don't have the disease. And as I often joke with them, patients aren't reading that book, they just are not.
DR. CIFU: Yeah, pulmonary embolism is probably the classic one for that, right. As soon as you say, "Oh, this person doesn't have pulmonary embolism, because they don't have tachycardia, or they don't have pleuritic chest pain," you've made a mistake.
DR. STERN: Absolutely.
DR. CIFU: Okay, so our third section is pet peeves. I'll start with this because I'm just overflowing with pet peeves. This pet peeve could probably go beyond abdominal pain to basically anything. And for me, it's beginning to think about diagnostics before creating a differential diagnosis. I may have been guilty of this actually in the first part of this podcast. But so often I hear, this is a 45-year-old woman who comes in with abdominal pain, plan CT.
DR. CIFU: And the question is, what are you looking for? Why are you doing the CT? Is that the appropriate test? Do you even need a test in this case?
DR. STERN: I agree with that, and it often short-circuits thinking. You can imagine a patient who has acute mesenteric ischemia where the CT would be negative and now folks are assuming it's nothing.
DR. CIFU: Right, you're so right. What about you, do you have a pet peeve?
DR. STERN: Well, one of them is evident from this case, I think the failure to do orthostatics is a huge problem, because occasionally it shows you life-threatening hemorrhage. And I often talk to residents about getting orthostatics. And I'm often told that they've been ordered, well ordering them doesn't do them. Take the blood pressure of the patient sitting down, stand them up, check it again, and find out what you have. And if you're too busy to do that, get another job.
DR. CIFU: Terrific. I'll go on with another one. And this may seem really unimportant, but it's a pet peeve, so it can be unimportant. The abdomen should be examined from the right, which is the correct side of the bed. The human species, I guess, is predominantly right-handed. If you're examining patients from the left side of the bed, you're examining them essentially, in a backhanded way.
DR. CIFU: You also get the best feel for the liver from the right side of the bed, which is often what's the most important thing in the abdominal exam, to examine. And maybe least important, but actually quite important, is that people who have learned the abdominal exam, have learned to do it from the right side of the bed. And so if you as a student or an intern, examine someone from the left side of the bed, you look like an amateur, and the person who's watching you, assumes that you really don't know what you're doing.
DR. CIFU: You got one more for us, Scott?
DR. STERN: I do, I think another pet peeve I have, is the failure to take an adequate NSAID history in a patient who has GI bleeding. As you know ulcers are a common cause of GI bleeding for which NSAIDs are a leading cause. And I'm often told, that patients haven't been taking any NSAIDs because perhaps they asked a patient, "Are you taking taking any NSAIDs?" Which is a terrible way to ask that question. You have to ask about aspirin, you have to ask about every single thing for pain both over the counter and prescription to get an adequate history.
DR. STERN: [Dr. Cifu) Good, good point. Okay. We're going to finish up with a few real clinical pearls. Scott, why don't you begin with this one? Well, the one that I'd like to emphasize is the limited accuracy of a CBC for acute bleeding. When someone bleeds, nothing dilutes the hemoglobin that's left in their system until they get IV fluids or PO fluids. So if you're bleeding to death, and you've not received IV fluids, and you've received oral fluids, your hemoglobin and your hematocrit are exactly the same as before you started hemorrhaging.
DR. STERN: So it's an error to think, well, the CBC is normal or the hemoglobin is normal, the patient can't be bleeding significantly.
DR. CIFU: That's a great point. I think my clinical pearl may actually echo something that you said early on. It's that when you're faced with a patient with abdominal pain, you need to really attend to the time course of the pain. We often when we're seeing patients quickly and we just say, so you have abdominal pain, and maybe we characterize the symptom with the P, Q, R, S, T.
DR. CIFU: You really have to ask the patient, so tell me about this pain. How long have you had this pain? Have you ever had pain like this before? Because often that sort of history, of someone telling you, "Well, yes, I've actually had this pain to varying degrees for the last 10 years, or no, I've never felt anything like this until Tuesday afternoon," completely alters your differential diagnosis.
DR. STERN: I totally agree.
DR. CIFU: You want to bring us home with one more?
DR. STERN: Well, yes, I would. So another one to think about is, we often see patients with pancreatitis who don't have a history of heavy drinking, and I think in those cases, we have to remind everyone to really look for gallstones. As you know, a leading cause of pancreatitis is gallstone associated pancreatitis, and the failure to recognize that, can lead patients have recurrent attacks that can not only lead to recurrent pancreatitis, but choledocholithiasis, ascending cholangitis and really hideous complications.
DR. STERN: We need to do justice by evaluating those patients appropriately and not just saying, well, it's pancreatitis.
DR. CIFU: I think that actually may be more of an issue now than it was a decade ago. Because as people get out of the hospital quicker, as we feed patients with pancreatitis earlier, and the whole process moves more quickly, often that evaluation isn't done, because let's face it, the majority of patients who come in with pancreatitis, don't have gallstone pancreatitis, end up not really needing any specific treatment or evaluation.
DR. CIFU: But that is so crucial, because as you say, and as you know, if you don't diagnose gallstones in someone with gallstone pancreatitis, that patient is almost guaranteed to be back with another complication.
DR. STERN: Absolutely.
DR. CIFU: Okay, I hope this was useful to everybody. We will be back in a couple of weeks with another episode. I think our next one will be headache. So we hope you found this episode of the Symptom to Diagnosis podcast useful and a bit enjoyable. As a reminder, our textbook, "Symptom to Diagnosis: An Evidence-Based Guide" takes a much deeper dive into how to think about and reason through the diagnosis of medical presentations. The book is available in print through all the usual places and also available and fully searchable via the Access Medicine website available worldwide from McGraw Hill, and also available on your iPhone or other handheld device.
DR. STERN: Thank you very much.
DR. CIFU: Thank you. The music for the S2D Podcast is courtesy of Dr. Maylyn Martinez.