Differentials

History
Exam
1st investigation
Other investigations

poor diet and fluid intake; history of cerebral palsy, learning difficulties, or spinal cord problems; psychological factors (e.g., depression, abuse, ADHD, autism, oppositional disorder), weaning, toilet training, start of schooling or other causes of stress may be present; vague abdominal pain, painful defecation (infants may extend their legs and squeeze anal and buttock muscles to prevent stooling; toddlers often rise up on their toes, shift back and forth, and stiffen their legs and buttocks), fecal incontinence; medication with known constipating agents (e.g., iron supplements); obesity, low birth weight

exam findings may be minimal (mild abdominal tenderness, stool in rectum); abdominal distension in severe cases or in small children; fecal mass palpable on abdominal or rectal exam; absence of peritonitis (guarding or rebound tenderness); sacral dimples or pits and/or tags/tufts indicative of spinal cord abnormality (i.e., spina bifida); anal fissure, hemorrhoids (rare in children; may be mistaken for skin tags from Crohn disease); imperforate anus or anal stenosis

  • none:

    clinical diagnosis

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  • abdominal x-ray:

    stool visible throughout colon

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  • CT scan abdomen:

    stool throughout colon; absence of other etiologies of abdominal pain

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History
Exam
1st investigation
Other investigations

history of sharp or stabbing periumbilical pain that migrates to the right lower quadrant (RLQ); anorexia, fever, vomiting, and/or diarrhea may be present; occurs in all age groups but is rare in infants

patient lies still, tries not to move (especially in severe cases with significant peritoneal irritation); positive McBurney sign (RLQ pain and tenderness to palpation at a point two-thirds along a line from the umbilicus to the anterior superior iliac spine); positive Rovsing sign (pain in the RLQ in response to left-sided palpation, suggesting peritoneal irritation); positive psoas sign (pain in the RLQ when child placed on left side and right hip gently hyperextended, suggesting irritation to the psoas fascia and muscle); positive obturator sign (RLQ pain on internal rotation of the flexed right thigh); rectal tenderness and/or palpable abscess in RLQ

  • CBC:

    normal or elevated WBC

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  • urinalysis:

    normal

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  • urine pregnancy test:

    negative

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  • abdominal ultrasound:

    dilated appendix, free fluid; appendicolith may be present

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  • CT scan abdomen and pelvis:

    dilated appendix, free fluid, mesenteric stranding, or appendicolith; abscess or phlegmon consistent with perforated appendicitis

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  • MRI scan abdomen and pelvis:

    dilated appendix; hyperintensity of the luminal contents of the appendix, periappendiceal tissue and thickened wall

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History
Exam
1st investigation
Other investigations

vague abdominal pain with nausea and vomiting; diarrhea with or without mucus in stool; recent travel or contact with sick individual(s) or ingestion of suspected food and drink; >10 days suggests parasitic or noninfectious cause; fever, chills, myalgia, rhinorrhea, upper respiratory symptoms

diffuse abdominal pain without evidence of peritonitis (no guarding or rebound tenderness); abdominal distension; hyperactive bowel sounds; mucus in stool (bacterial or parasitic); signs of volume depletion (tachycardia, hypotension, dry mucous membranes, poor capillary refill, sunken fontanelle in infants); low-grade fever, lethargy and/or irritability, reduced response to noxious stimuli, abnormal temperature (elevated or low)

  • none:

    clinical diagnosis

  • serum electrolytes:

    normal or low sodium and potassium

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  • BUN and creatinine:

    normal; may have evidence of renal failure in patients with hemolytic uremic syndrome

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  • stool microscopy and culture:

    fecal leukocytes; ova or parasites; culture positive for infectious agent in bacterial gastroenteritis

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  • urine dipstick:

    may detect presence of albumin or blood in hemolytic uremic syndrome

  • CBC:

    variable

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  • blood culture:

    may be positive for infectious agent in presence of sepsis

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  • endoscopy with biopsy:

    variable

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History
Exam
1st investigation
Other investigations

neonates and infants: fever, vomiting, lethargy, irritability, and poor feeding; older children: dysuria, urinary frequency and urgency, back pain if pyelonephritis

variable; fever >102.2°F (>39°C); suprapubic and/or costovertebral angle tenderness; irritability; foul-smelling urine; gross hematuria

  • urine dipstick:

    positive leukocyte esterase and/or positive nitrite

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  • urine microscopy:

    >4 WBC per high-power field or any bacteria

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  • urine culture:

    suprapubic aspirate: >1000 colony-forming units (CFU)/mL; catheter: >10,000 CFU/mL; clean-catch midstream: >100,000 CFU/mL

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  • renal ultrasound:

    abnormalities may be present such as dilatation of the renal pelvis or ureters, or distension of thick-walled bladder; renal abscess: area of radiolucency to the renal parenchyma with local hypoperfusion on color Doppler; perinephric abscess: hypoechoic fluid

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  • voiding cystourethrogram (VCUG):

    if vesicoureteral reflux is present: contrast seen ascending out of the bladder into the upper urinary tract

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History
Exam
1st investigation
Other investigations

history of trauma; abdominal pain may be out of proportion to exam findings; may have multiple complaints; history may suggest child abuse or nonaccidental trauma (e.g., inconsistent or changing history)

abdominal tenderness; skin marks reflecting mechanism of injury (e.g., seatbelt mark); referred left shoulder pain (due to splenic injury); blood at the urethral meatus, or hematuria (indicate urinary tract or kidney injury); signs of nonaccidental trauma may be present (e.g., cigarette burns, subdural hemorrhages in an infant/young toddler)

  • CBC:

    may be normal or show decreased hematocrit and hemoglobin

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  • abdominal CT scan with intravenous contrast:

    variable

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  • chest x-ray:

    may be normal or show compatible thoracic injury (e.g., pulmonary contusion, pneumothorax); free air under diaphragm (suggests perforation)

  • abdominal ultrasound:

    variable; may show free fluid in abdominal cavity

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  • full skeletal x-rays:

    variable

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History
Exam
1st investigation
Other investigations

recurrent, episodic right upper quadrant (RUQ) pain, may radiate to the back and is classically colicky in nature; often occurs after eating, particularly fatty foods; nausea, vomiting, and anorexia may be present; persistent pain and fever may signify acute cholecystitis; referred pain to right shoulder can occur; presence of risk factors (e.g., sickle cell disease, cystic fibrosis)

right subcostal region tenderness; positive Murphy sign (during palpation, deep inspiration causes pain to suddenly become worse and produces inspiratory arrest); palpable distended, tender gallbladder; fever suggests acute cholecystitis; jaundice rare

  • RUQ ultrasound:

    gallstones; thickened gallbladder wall (>4 mm); pericholecystic fluid; may also see ultrasonographic Murphy sign

  • liver tests:

    may see elevated alk phos, bilirubin, and aminotransferase

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  • CBC:

    normal WBC (suggests cholelithiasis) or leukocytosis (suggests acute cholecystitis)

  • C-reactive protein:

    normal (suggests cholelithiasis) or elevated (suggests acute cholecystitis)

  • abdominal x-ray:

    opacities in RUQ consistent with gallstones

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  • hepatobiliary iminodiacetic acid (HIDA) scan:

    nonfilling gallbladder

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History
Exam
1st investigation
Other investigations

history of recurrent crampy abdominal pain associated with menstruation

lower abdominal tenderness; normal pelvic exam

  • none:

    diagnosis is clinical

  • abdominal/pelvic ultrasound:

    normal; however, useful to rule out other diagnoses

History
Exam
1st investigation
Other investigations

cough; purulent sputum production; upper respiratory tract symptoms (rhinorrhea, sore throat, nasal congestion), shortness of breath, fever, and chills; splinting secondary to pain; vomiting, diarrhea, anorexia

tachypnea, cyanosis, decreased breath sounds, crackles/rales on auscultation, dullness on percussion; abdominal tenderness and distension without guarding or rebound

  • CBC:

    variable

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  • chest x-ray:

    infiltration, consolidation, effusion

  • sputum culture:

    growth of infecting organism

  • chest ultrasound:

    localized fluid collection

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  • CT scan chest with intravenous contrast:

    consolidation of lung parenchyma; extraparenchymal fluid with loculations suggests empyema

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History
Exam
1st investigation
Other investigations

history may be acute, chronic, or cyclic (frequently girls ages 8-12 years), complaint of vague, persistent, central abdominal pain common, may be associated nausea and vomiting, particularly in chronic cases; family history of functional disorders common (e.g., irritable bowel syndrome, anxiety, psychiatric disorders, and migraine); Rome IV criteria use symptoms for diagnosis[37]

periumbilical tenderness, abdomen is soft, undistended, no guarding or rebound tenderness; exam of other systems normal

  • none:

    diagnosis is clinical after exclusion of possible organic causes

  • CBC:

    normal

  • erythrocyte sedimentation rate:

    normal

  • urinalysis:

    normal

  • stool microscopy:

    normal

Uncommon

History
Exam
1st investigation
Other investigations

usually infant between 3 and 12 months of age presenting with colicky abdominal pain, flexing of the legs, fever, lethargy, and vomiting; Henoch-Schonlein purpura (HSP) may be initiating factor in an older child (usually <11 years of age); vague abdominal complaints; severe, cramp-like abdominal pain; child may be inconsolable

may see gross or occult blood that may be mixed with mucus and have "redcurrant jelly" appearance, abdominal tenderness, and palpable abdominal mass; signs of HSP may be present in older child (rash of palpable purpura, blood in the stools)

  • barium enema:

    filling defect or cupping in the head of contrast as it advances to the site of the intussusception

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  • CT scan abdomen and pelvis:

    target lesion: intraluminal soft-tissue density mass with an eccentrically placed fatty area; reniform mass: high attenuation peripherally and lower attenuation centrally; sausage-shaped mass: alternating areas of low and high attenuation representing closely spaced bowel wall, mesenteric fat and/or intestinal fluid and gas

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  • abdominal ultrasound:

    tubular mass in longitudinal view; target lesion in transverse view

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  • CBC:

    may show elevated WBC (suggests intestinal ischemia)

History
Exam
1st investigation
Other investigations

typically aged <2 years; may present with abdominal pain (may be intermittent or mimic acute appendicitis), and/or painless passage of bright red blood per rectum (hematochezia); often asymptomatic

dark red, maroon, or "red currant jelly" stools; abdominal tenderness with guarding and rebound (may suggest diverticulitis); palpable abdominal mass (may suggest intussusception)

  • abdominal ultrasound:

    tubular mass in longitudinal views and a doughnut or target appearance in transverse views suggests intussusception

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  • technetium-99m pertechnetate scan:

    positive

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  • CT scan abdomen and pelvis:

    may show intussusception, Meckel diverticulitis, and/or dilated bowel consistent with bowel obstruction

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History
Exam
1st investigation
Other investigations

diffuse abdominal pain; history of recent or current upper respiratory tract infection

fever, abdominal tenderness not localized to right lower quadrant, rhinorrhea, hyperemic pharynx or oropharynx (pharyngitis), and/or associated extramesenteric lymphadenopathy (usually cervical)

  • abdominal ultrasound:

    enlarged mesenteric lymph nodes

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  • CT scan abdomen and pelvis:

    enlarged mesenteric lymph nodes

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History
Exam
1st investigation
Other investigations

males affected more commonly, mainly presents in early infancy (prior to 6 months); failure to pass meconium in first 36 hours of life strongly suggestive; may be history of Down syndrome

abdominal distension, fullness in left lower quadrant; palpable fecal mass on abdomen exam; absence of peritonitis (no guarding or rebound tenderness); small rectum and absence of stool on rectal exam; dysmorphic features of Down syndrome may be present

  • abdominal x-ray:

    stool visible throughout colon, decreased air in rectum; air-fluid levels may be present

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  • contrast barium enema:

    proximal dilation with narrowing of the distal colon

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  • rectal biopsy:

    absence of ganglion cells and the presence of an excess of nonmyelinated nerves; presence of increased acetylcholinesterase

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  • anorectal manometry:

    absent reflex

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History
Exam
1st investigation
Other investigations

positive family history, bloody diarrhea, cramping abdominal pain, anorexia, weight loss, fever, rash

evidence of weight loss, pallor, abdominal tenderness, abdominal mass, iritis (inflamed irritated eyes), arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

  • CBC:

    leukocytosis, anemia, thrombocytosis

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  • colonoscopy with biopsy:

    continuous uniform rectal involvement, loss of vascular marking, diffuse erythema, mucosal granularity and friability, mucosal edema ulcers, fistulas (rarely seen), normal terminal ileum (or mild backwash ileitis in pancolitis)

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  • erythrocyte sedimentation rate:

    elevated

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  • CRP:

    elevated

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  • plain abdominal x-rays:

    dilated loops with air-fluid level secondary to ileus; free air is consistent with perforation; in toxic megacolon, the transverse colon is dilated to 6 cm or more in diameter

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  • CT scan abdomen:

    thickened inflamed bowel mucosa, thumbprinting, intestinal dilation or evidence of stricture; inflamed mesentery; intra-abdominal abscesses

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  • serologic markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA):

    positive pANCA

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History
Exam
1st investigation
Other investigations

crampy abdominal pain, intermittent diarrhea, bloody diarrhea if colitis a feature (blood less common in Crohn disease than in ulcerative colitis, weight loss, fatigue, family history of inflammatory bowel disease

aphthous ulcers, evidence of weight loss, pallor, abdominal tenderness, abdominal mass, perianal fistula, perirectal abscess, anal fissure, perianal skin tags; extraintestinal manifestations including iritis, arthritis, sacroiliitis, erythema nodosum, pyoderma gangrenosum

  • CBC:

    leukocytosis, anemia, thrombocytosis

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  • CRP:

    elevated

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  • erythrocyte sedimentation rate:

    elevated

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  • colonoscopy with biopsy:

    may demonstrate inflammation, friability, ulcer formation, and edema

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  • plain abdominal x-rays:

    small bowel or colonic dilatation; calcification; intra-abdominal abscesses

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  • upper gastrointestinal series with small bowel follow-through:

    edema and ulceration of the mucosa with luminal narrowing and strictures

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  • CT scan abdomen and pelvis:

    skip lesions, bowel wall thickening, surrounding inflammation, abscess, fistulas

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  • serologic markers: perinuclear antineutrophil cytoplasmic antibody (pANCA) and anti-Saccharomyces cerevisiae antibody (ASCA):

    positive ASCA

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History
Exam
1st investigation
Other investigations

intolerant of feeding, with nausea and/or bilious vomiting; abdominal pain may or may not be a feature; history of previous abdominal surgery; history of cystic fibrosis may be present

limited abdominal distension (with proximal obstructions in the duodenum or early jejunum); abdominal tenderness may or may not be present; rebound tenderness and guarding may occur if perforation, ischemia, and peritonitis; hyperactive bowel sounds (early finding), hypoactive or absent bowel sounds (late finding); incarcerated femoral, obturator, umbilical or ventral hernia may be present

  • abdominal x-ray:

    dilated small bowel loops, air-fluid levels throughout abdomen

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  • abdominal ultrasound:

    may demonstrate focal area causing obstruction

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  • upper gastrointestinal contrast study:

    dilated small intestine; may demonstrate a transition zone of obstruction

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  • lower gastrointestinal contrast study:

    dilated small intestine; may demonstrate a transition zone of obstruction

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  • CT scan abdomen:

    dilated small intestine; may demonstrate a transition zone of obstruction, mass, tumor, abscess

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History
Exam
1st investigation
Other investigations

infant age group; history of bilious vomiting; pain usually manifests as notable transition to an inconsolable state

often diffuse abdominal distension and tenderness; faint or no bowel sounds, rigid abdomen, guarding, rebound tenderness, fever, or hematochezia

  • upper gastrointestinal contrast study:

    bird beak sign of stricture at the site of the volvulus

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  • abdominal x-ray:

    partial or complete obstruction; dilated bowel loops; air-fluid levels; abdominal free air with perforation

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  • CBC:

    elevated WBC (suggests intestinal ischemia)

  • CT scan abdomen:

    bowel obstruction with whirl pattern of mesentery

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History
Exam
1st investigation
Other investigations

history of risk factors: mental illness, inflammatory bowel disease, diabetes, poor diet, previous colorectal resection, laxative abuse, megacolon, or previous abdominal surgery; change in bowel habit with partial or complete obstruction, or change in caliber of stool; colicky abdominal pain becoming more constant and worse with movement, coughing or deep breathing as bowel approaches perforation; intolerant of feeding, with nausea or vomiting

tympanic, distended abdomen; hyperactive bowel sounds that become absent in advanced stages; abdominal rebound, guarding, and/or rigidity if perforation or close to perforation; empty rectum; incarcerated femoral, obturator, umbilical, or ventral hernia may be present

  • abdominal x-ray:

    gaseous distension of large bowel; volvulus suggested by kidney-bean-shape bowel loop

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  • abdominal ultrasound:

    may demonstrate focal area causing obstruction (e.g., intussusception)

  • lower gastrointestinal (GI) contrast study:

    may indicate site of obstruction

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  • CT scan abdomen and pelvis:

    gaseous distension of large bowel; may demonstrate a transition zone of obstruction

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  • flexible/rigid sigmoidoscopy:

    flood of stool and mucus upon passing and decompressing apex of volvulus

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History
Exam
1st investigation
Other investigations

premature neonate weighing less than 1500 g; feeding intolerance, apnea, lethargy, bloody stools

abdominal distension, tenderness, abdominal wall erythema, hematochezia, bradycardia

  • CBC:

    leukocytosis or leukopenia, anemia, thrombocytopenia

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  • blood culture:

    negative

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  • serum electrolyte panel:

    hyponatremia

  • abdominal x-ray:

    dilated loops of bowel, pneumatosis intestinalis, portal venous gas, free air, fixed loop of bowel, lack of normal intestinal gas pattern

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  • abdominal ultrasound:

    fluid collections, ascites

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History
Exam
1st investigation
Other investigations

family history of peptic ulcer disease; weight loss, vomiting, anorexia, and intermittent epigastric pain, usually related to eating meals; pain often nocturnal and usually relieved by antacids; melena and/or hematemesis if blood vessel perforated

unremarkable or epigastric tenderness; melena may be present on rectal exam or occult bleeding on stool hemoccult test

  • CBC:

    normal or leukocytosis; anemia present if sustained blood loss

  • erect chest x-ray:

    usually normal

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  • upper gastrointestinal series with water-soluble contrast:

    mucosal defect(s) consistent with ulcer or free intraperitoneal contrast consistent with perforation

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  • upper gastrointestinal endoscopy:

    mucosal inflammation, ulceration, and hemorrhage

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  • Helicobacter pylori breath test or stool antigen test:

    positive result if Helicobacter pylori present

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History
Exam
1st investigation
Other investigations

recurrent abdominal pain, cramping, or distension; bloating and diarrhea; dermatitis herpetiformis, an intensely pruritic papulovesicular rash that affects the extensor limb surfaces, almost universally occurs in association with celiac disease; may be a history of immunoglobulin A deficiency, type 1 diabetes, autoimmune thyroid disease, Down syndrome, Sjogren syndrome, inflammatory bowel disease, or primary biliary cholangitis; may be a family history of celiac disease

generalized abdominal pain or bloating; underweight or failing to thrive; aphthous stomatitis; dermatitis herpetiformis

  • CBC:

    may show iron deficiency anemia

  • immunoglobulin A-tissue transglutaminase (IgA-tTG):

    titer above normal range for laboratory

  • endoscopy and small bowel biopsy:

    presence of intraepithelial lymphocytes, villous atrophy, and crypt hyperplasia

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  • endomysial antibody (EMA):

    elevated titer

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  • human leukocyte antigen (HLA) typing:

    positive HLA-DQ2 or HLA-DQ8

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History
Exam
1st investigation
Other investigations

birth or residence in endemic area, prenatal exposure, family history of chronic viral hepatitis, multiple sexual partners, sexual intercourse with infected individuals (hepatitis B and/or C), travel to developing countries, pregnant (hepatitis E); early disease: malaise, muscle and joint aches, fever, nausea, vomiting, diarrhea, headache, anorexia, dark urine, pale stool, abdominal pain; late disease: weight loss, easy bruising and bleeding tendencies

jaundice; early disease: tender hepatosplenomegaly, lymphadenopathy; late disease: generalized wasting, cachexia, gynecomastia, ascites, altered sensorium, asterixis, or decreased deep tendon reflexes, caput medusa, ascites, hepatosplenomegaly, congestion secondary to right heart failure

  • serum LFTs:

    high direct bilirubin, AST, ALT, alk phos and gamma-GT

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  • serum IgM anti-HAV:

    positive if acute hepatitis A infection

  • serum hepatitis B surface antigen (HBsAg):

    positive if hepatitis B infection

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  • serum hepatitis B core antigen (HBcAg):

    positive if hepatitis B infection

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  • serum hepatitis B e antigen (HBeAg):

    positive if hepatitis B infection

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  • serum HCV RNA:

    positive if hepatitis C infection

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  • serum total (IgM and IgG) anti-HDV antibodies:

    positive if hepatitis D infection

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  • serum anti-HEV IgM antibodies:

    positive if acute hepatitis E infection

  • CBC:

    low or normal platelet count

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  • coagulation profile (prothrombin time [PT], INR):

    May be elevated or normal

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History
Exam
1st investigation
Other investigations

history of previous negative workup for cholelithiasis common; recurrent right upper quadrant (RUQ) pain; nausea and vomiting; symptoms may or may not be associated with eating

may be equivocal; RUQ tenderness

  • LFTs:

    normal aspartate aminotransferase, alanine aminotransferase, alk phos, and bilirubin

  • RUQ ultrasound:

    normal

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  • hepatobiliary iminodiacetic acid (HIDA) scan:

    decreased (<35%) gallbladder ejection fraction

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History
Exam
1st investigation
Other investigations

nausea, vomiting, epigastric pain radiating to back; acute-onset abdominal pain

epigastric or upper abdominal tenderness; tachycardia and hypotension in severe cases; discoloration around the umbilicus (positive Cullen sign) or flanks (positive Grey-Turner sign) in cases of hemorrhagic pancreatitis; small children may demonstrate increased irritability and abdominal distension only

  • amylase:

    at least 3 times upper limit of normal range

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  • lipase:

    at least 3 times upper limit of normal range; can be elevated if amylase normal

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  • bilirubin:

    normal or elevated

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  • abdominal ultrasound:

    may appear normal early in disease course; enlargement of the pancreas; peripancreatic edema; dilated pancreatic duct; may show underlying biliary disease

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  • CT scan abdomen with intravenous contrast:

    peripancreatic inflammation (fat stranding); may show gallstones

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History
Exam
1st investigation
Other investigations

varied; may be history of trauma; cysts either asymptomatic or dull, left-sided abdominal pain; infarction typically causes fever as well as pain, but occasionally asymptomatic; left-sided shoulder and/or chest pain; presence of risk factors for splenic infarction (sickle cell disease, high altitude)

may be vague left upper quadrant tenderness

  • Doppler ultrasound:

    infarction or cyst on spleen

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  • CT scan abdomen with intravenous contrast:

    infarction or cyst on spleen

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History
Exam
1st investigation
Other investigations

family history of nephrolithiasis and/or gout; intermittent, severe, colicky flank and/or abdominal pain; nausea and vomiting; gross or microscopic hematuria; urinary frequency/urgency; atypical presentation common in younger children

ipsilateral costovertebral angle and flank tenderness; tachycardia and hypotension in pain-controlled patient may suggest concurrent urosepsis

  • ultrasound of the urinary tract:

    calcification seen within urinary tract; possible dilated proximal ureter and hydronephrosis

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  • urinalysis:

    may be normal or dipstick-positive for leukocytes, nitrites, blood; microscopic analysis positive for WBCs, RBCs, or bacteria

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  • abdominal x-ray:

    radio-opaque stones

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  • noncontrast CT scan abdomen and pelvis:

    calcification seen in renal collecting system or ureter; possible dilated proximal ureter and hydronephrosis

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History
Exam
1st investigation
Other investigations

acute-onset testicular pain; nausea, and vomiting; history of recurrent episodes suggests repeated episodes of testicular torsion followed by spontaneous detorsion; history of trauma may be present

tender, edematous testicle; affected testicle may appear higher than unaffected testicle with horizontal lie; associated scrotal erythema and edema; absent cremasteric reflex; usually no pain relief with elevation of the scrotum

  • duplex Doppler ultrasound of scrotum:

    presence of fluid and the whirlpool sign (the swirling appearance of the spermatic cord from torsion as the ultrasound probe scans downward perpendicular to the spermatic cord); absent or decreased blood flow in the affected testicle; decreased flow velocity in the intratesticular arteries, increased resistive indices in the intratesticular arteries

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    History
    Exam
    1st investigation
    Other investigations

    acute onset of one-sided lower abdominal or pelvic pain; nausea and vomiting common; history of frequent, similar episodes; fever rare

    tender pelvic mass (adnexal); in patients old enough to undergo pelvic exam, cervical motion tenderness may be elicited; typically no vaginal discharge, but may be some mild to moderate vaginal bleeding

    • pelvic ultrasound:

      solid appearance of the ovary, unilateral ovarian enlargement, ovarian peripheral cystic structures, marked stromal edema, fluid in the pouch of Douglas

    • color Doppler:

      reduced or absent intraovarian blood flow

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    • CT scan abdomen and pelvis:

      enlarged, edematous ovary with or without vascular enhancement; free fluid in pelvis

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    History
    Exam
    1st investigation
    Other investigations

    rupture usually spontaneous, can follow history of trauma or sexual intercourse; mild chronic lower abdominal discomfort may suddenly intensify

    adnexal tenderness; adnexal size unremarkable due to collapsed cyst; peritonism may be present in lower abdomen and pelvis

    • pelvic ultrasound:

      complex mass appearance; fluid in the pouch of Douglas

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      History
      Exam
      1st investigation
      Other investigations

      sexually active; multiple partners; history may be suggestive of sexual abuse (particularly if young child); pain worse with sexual intercourse; dull, aching lower abdominal pain with or without dysuria; vaginal discharge, low-grade fever

      temperature >101°F (38.3°C); cervical motion tenderness, adnexal or uterine tenderness, vaginal or cervical mucopurulent discharge

      • wet mount of vaginal secretions:

        polymorphonuclear leukocytes (PMNs) seen

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      • nucleic acid amplification test or culture of vaginal secretions for Neisseria gonorrhoeae and Chlamydia trachomatis:

        positive result indicates presence of organisms

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      • pelvic ultrasound:

        normal or may demonstrate endometritis, hydrosalpinx, pyosalpinx, tubo-ovarian abscess

        More
      • HIV serology:

        positive or negative

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      • hepatitis studies:

        positive or negative

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      • rapid plasma reagin (RPR):

        positive or negative

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      • CBC:

        leukocytosis

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      • CRP or erythrocyte sedimentation rate:

        elevated

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      • laparoscopy:

        normal or may demonstrate endometritis, hydrosalpinx, pyosalpinx, tubo-ovarian abscess

        More
      History
      Exam
      1st investigation
      Other investigations

      history of previous ectopic pregnancy or miscarriage, fallopian tube or pelvic surgery, pelvic inflammatory disease; lower abdominal pain, amenorrhea, and vaginal bleeding

      minimal abdominal tenderness and/or vaginal bleeding; pelvic exam may reveal a mass, eliciting cervical motion tenderness if hemoperitoneum is present; tubal rupture can cause hemodynamic instability

      • urine pregnancy test:

        positive

        More
      • quantitative serum beta-hCG:

        positive

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      • pelvic ultrasound:

        demonstrates free fluid in the pelvis and/or a periovarian mass

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      • transvaginal ultrasound:

        presence or absence of intrauterine pregnancy

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      • blood type and screen:

        variable

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      History
      Exam
      1st investigation
      Other investigations

      recent pneumonia, fever, cough, chest pain; malaise, anorexia, weight loss, or fatigue may occur; presence of risk factors (immunocompromise, comorbidities predisposing to the development of pneumonia, pre-existing lung disease, iatrogenic interventions in the pleural space, male sex)

      febrile, toxic patient, dullness on percussion, absence of breath sounds over affected area; abdominal tenderness and distension without guarding or rebound

      • CBC:

        elevated WBC count

      • chest x-ray:

        blunting of costophrenic angle or effusion on affected side, possible consolidation, pleurally based "D" shape in empyema

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      • thoracentesis:

        frank pus in empyema, serous or cloudy in complicated parapneumonic effusions

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      • blood culture:

        positive for specific pathogens

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      • chest ultrasound:

        localized fluid collection

        More
      • CT scan chest with intravenous contrast:

        consolidation of lung parenchyma; extraparenchymal fluid with loculations suggests empyema

        More

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