Family Medicine

The student should be able to:

Conduct a culturally sensitive, empathic history. Appreciate the ways in which victims of violence may manifest symptoms and be alert to clues a patient may give that he/she has been a victim of intimate partner violence. Discuss ways to assist the patient in developing a safety plan. Discuss reporting requirements for intimate partner violence. Appreciate a survivor’s perspective in an abusive relationship and the barriers to his/her seeking help. Apply knowledge of the differential diagnosis of lower abdominal and pelvic pain in evaluating the patient. Family Medicine

Knowledge

Significance of the Location of Lower Abdominal Pain

The location of the abdominal pain is important, as it can help narrow your differential diagnosis. For example, diffuse abdominal pain may represent gastroenteritis, whereas localized right lower quadrant pain is classic for but not limited to appendicitis. Think about what is in the various quadrants of the abdomen when considering the differential diagnosis of abdominal pain.

Red Flags of Life-Threatening Condition in Patient with Lower Abdominal/Pelvic Pain

There are many signs and symptoms of a life-threatening condition in a patient with abdominal or pelvic pain. Examples include: Abrupt onset of severe pain Shock with hypotension and tachycardia Distension Peritoneal irritation signs Rigid abdomen Pulsatile abdominal mass Absent bowel sounds Fever Vomiting Diarrhea Weight loss Menstrual changes Trauma, prior surgeries, or operative scars History/presence of blood in emesis History/presence of blood in stool Severity of the pain Ecchymoses/bruising Rebound tenderness Mass or ascites Family Medicine

Obstetrical History

G Gravida or number of pregnancies

T Number of Term pregnancies

P Number of Preterm infants

A Number of spontaneous or inducedAbortions

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L Number of Living children Family Medicine

Documenting Follow-Up and Lab Reporting

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Documentation of attempts to schedule follow-up visits and inform patients of laboratory results is very important. Failure to reach a patient by phone or mail should also be documented. If a provider is unable to reach a patient about an important test result (e.g. an abnormal Pap smear), reaching out to emergency contacts and sending a certified letter should be done to document every effort to reach a patient.

Abdominal Pain History

Location Quality Severity Timing Aggravating factors and alleviating factors

Some Common Causes of Lower Abdominal Pain Presenting in Primary Care

Constipation: Patients may give a history of having small, hard pellets for stools, decreased frequency of stooling, harder stools than usual, or occasionally having loose stools, which may actually signify an impaction, where the patient has soft stool leaking around an impacted hard stool. This type of stooling pattern is more often associated with irritable bowel syndrome. Irritable bowel syndrome (IBS): Many patients will describe abdominal pains of varying location, associated with either soft, frequent, loose stools, or constipation, or an alternating stool pattern. They may also describe abdominal bloating, increased flatulence, and mucus in the stool. The symptoms of IBS are frequently worse when the patient is under stress, anxious, or depressed. Symptoms of IBS can be brought on initially by a case of gastroenteritis and can be aggravated by stress, diet, and change in activity—and the symptoms are often unpredictable. Caffeine and dairy products can make symptoms worse. The diagnosis is based on clinical history, physical exam, and absence of alarming symptoms suggesting other pathology. The Rome IV criteria is often used to aid diagnosis of adult IBS: Recurrent abdominal pain, on average ≥ 1 day per week in past 3 months with two or more of following features: Family Medicine

1. Related to defecation 2. Associated with change in stool frequency 3. Associated with change in stool form (appearance)

Endometriosis: Patients with endometriosis may begin to notice increasingly more painful and heavier menstrual cycles as early as late adolescence. A patient with endometriosis might indeed have lower abdominal discomfort, often starting after ovulation during most cycles and continuing through their menstrual cycle. There may also be low back pain or painful stooling. It is not uncommon for a patient with endometriosis to experience pain with intercourse. Ultrasounds or MRIs may be needed in order to help diagnose the problem. Laparoscopy may be needed to definitively diagnose, treat, or alleviate symptoms. Hormonal contraception often stops the pain and the process, thus preserving the patient’s ability to become pregnant later. Genetic factors are often involved. Inflammatory bowel disease (IBD): Patients with IBD usually have some combination of abdominal pain, bloody diarrhea, and frequent stooling. The onset of symptoms frequently occurs in the late 20s or early 30s. The patient may ultimately be diagnosed with either ulcerative colitis or Crohn Disease. Diagnosis is made through specific radiological findings on barium enema, small bowel follow-through, and by colonoscopy. Muscular pain or musculoskeletal pain is generally reproducible. On exam, there is usually point tenderness to palpation of the affected muscles. The pain may recur during certain activities or when the offending position is (re)assumed. Psychosomatic pain: Symptoms from this type of pain are variable and can be associated with or aggravated by other etiologies such as IBS or gastritis. The pains can occur anywhere throughout the abdomen. They usually present as an atypical pain pattern, occur in a depressed or otherwise mentally ill patient, and may point toward a psychogenic cause. This is a diagnosis of exclusion. Stress: The patient’s symptoms and pains tend to be increased when the patient is under increased stress or is involved in other negative interactions. The patient may present with a whole constellation of other stress-related symptoms, such as headache, depression, anxiety, appetite changes, and sleep disorders. Stress can also aggravate other conditions, such as irritable bowel syndrome. This diagnosis, which is related to psychosomatic disease, is one of exclusion. Urinary tract infection (UTI): Symptoms may include lower abdominal or suprapubic pain, urinary frequency, burning with urination (dysuria) that is frequently worse at the end of the urinary stream (terminal dysuria) and which can also involve hematuria. There may even be lower back pain in severe infections that involve the kidney. Among patients with female genitalia, the onset of symptoms may be related to recent sexual intercourse. UTI is a common condition and should always be considered in patients with lower abdominal pain. Vaginitis: The patient’s symptoms and concerns will vary depending on the cause of the discharge. She can present with a vaginal discharge that is watery to pasty; it may be malodorous; discomfort can vary from itching to burning, and there may or may not be pain with intercourse (dyspareunia) and pelvic pain. Being at risk for sexually transmitted infections widens the differential, and the use, or lack thereof, and the type of contraceptive used impacts that risk. An expanded history is needed in this case. Examination of the discharge under the microscope, or sending a vaginal swab and cervical cultures to the lab, is generally required Family Medicine