initiated by pain receptors located in the parietal peritoneum surrouning or adjacent to the abdominal organs

• usually described as sharp, discrete and localized
• responsible for pain on palpation, guarding and rebound

• Feeling for spasm of retus abdominis muscle
• the reflex contraction of the abdominal wall musculature in response to palpation of underlying peritonela irritation
• can be voluntary or involuntary
• voluntary guarding is less significant in predicting surgical disease 

• classically the hallmark of peritoneal irritation--> usually a somatic cause
• may not be present in 25% of the cases
• elicited by slow and dep gental palpation of the tender area
• followed by an abrupt, but discreet withdrawl of the examiner's hand 

PT will flex thigh against the resistance of the exainmer's hand. 

A painful response inidcates that there is inflammation involving the psoas muscle due to a retrocecal appendix

the PT thigh is flexed to the right angle and gently rotates, first interally then externally. the pain is elictedthen there is an inflammatory lesion that is involving the obturator muscle

suggests that the inflammed appendix is deep in the right hemipelvis

• as the patient takes a slow dep breath, the examiner elicts an abrupt cessation in insperion by deep palpation of the RUQ.
• the is usually sugesstive of acute cholecystitis, hepatitis or a disease in the RUQ

• Second most common cause of abdominal pain in the ED
• caused by the obstruction of the appendiceal lumen by various causes such as: lymphoid hyperplasi in childern, IBE fecal stasis and Fecaliths (most common) 

• WBC: may have leuocytosis --> more often not going to have this
• possible appendicitis--> CT with oral or rectal contrast
• the best way to do it in kids is a US--> test question 

• risk factors: H. pylori, NSAIDs, smooking
• Clinical features: burning epigastric pain, sharp, dull, achy, or "empty" or hungry" felling

• PT will complain of sudden severe abdominal pain
• upper abdominal tenderness with regidity of the abdomen goign to have peritoneal signs
• tx--> NGT for drainage of gastric acid, IVF, abx and immediate surgical consultation
• free air under the diaphragm is a surgical emergency

• Outpouching of the colonic wall that is usually caused by western diet
• features --> steady, deep discomfort in LLQ, changes in bowel habits, urinary symtoms
• CT--> pericolic fat stranding, diverticula, thickened bowel wall
• Tx--> fluid, correct electroyte abnormalties, NPO, abs: flagyl 500 mg + cipro

• due to intermittent obstruction of the biliary tree due to gallstones a teh level of the cystic duct
• pain may occur in discrete episodes, usually after eating a meal 
• pain anywhere but usually in RUQ and radiate to the scapula
• 4F's --> fat, female, 40, fertile --> TEST QUESTION

• RUQ or epigastric pain, radiating to the back or shoulders iniatially dull and achy later sharp and localized N/V/ anorexia, fever and chills
• PE--> murphy's sign, PT appears ill, peritoneal signs suggest perforation
• DX--> CBC LFT

• age is a significant risk factor often older
• severe abdominal pain or sudden onset that often radiates toward the back
• unequal lower extremity pulses may be palpated
• if rupture occurs--> Cullen sign or gray turns's sign 
• TX--> IV acess x2, emergent surgical consultation

• consider DX in all elderly PT with atrial fib, recent MI, atherosclerosis, CHF, degoxin therpay, herpcoagulability, prior DVT
• Sudden onset of severe, difuse abdominal pain in the mid or lower abdomen, pain is poorly localized 
• pain is out of proportion to the exam is is not releived by narcotics 
• embolic sorce: sudden onset, thrombic: gradual
• DX--> CT angiogram

• Sudden unilateral lower abdominal or pelvic pain
• pain may radiate into the back, groin or flank 
• history of ovarian abnormalities such as masses or cysts
• US is test of choice

the unpleasent sensation that precedes vomiting

autonomic response: hypersalivation, repetive swallowing, tachycardia, may be related to afferent vagal stimulation

• most viral agents produce a secretory diarrhea
• viral cytotoxins will lead to an increase in cellular permeability, resulting in the secretion of water and electrolytes into the intestineal lumen
• PT usually lack significant symptoms
• generally not associated with fever and abdominal pain
• TX--> self limiting and requires supportive care 

• bacterial agents may produce either an inflammatory of secretory diahrea
• impacts small bowel: watery diarrhea
• water, electrolytes, blood, proteins, and mucus are released into the intestinal lumen

• vomiting blood (hematemesis or coffee ground emesis) or passage of black, tarry stools (melena) 
• classically, hematemesis and coffe ground emesis suggest an UGI source

• less often occurs then UGI bleeds
• UGI bleeds are the most common cause of LGI bleeds

• typically benign headache and no underlying pathology including migraine, tension cluster and sinus HA
• HA itself is the disease, no organic lesion

pain is behind browbone and cheak bone

Plain is in and around the eye

short and severe in intensity come on suddenly

typically in males

unilateral sharpa or stabbing pain (ice pick)

sx--> ipsilateral lacrimation, rhinorrhea, and eyelid edemia

Tx--> oxygen, triptains, analgesia 

pain is liek a band squeezing the head 

mild to moderate pain intensity

bilateral pain with tightness like a band 

may last 30 minutes to days

no other associated symtoms--> phono or photophobia

TX --> NSAIDs

pain, Nausa and visual chagnes are typicall of classic form

HA with an aura

unilateral and pulsating

N/V photo and phonophobia

Tx--> NSAIDs, caffeine, triptains, ergotamines, and combo of reglan/decadron/ benadryl IV

• 10% of HA a symptom of antoher underlying disease
• treat the disease

• Ages <5 or >50
• increasing frequency or intensity
• worse with strainging --> bending over
• HA prevents sleep --> think tumor
• Neurological changes--> extraocular movements
• jaw claudication
• stiff neck, fever, malase
• "worst headache of my life--> SAH

• Sudden onset of "worst headache of your life" that doesnt go away no waxing or waning
• >50 yr old with new onset of HA

• most common cause of HA in kids
• classically, occurs fight thing in the AM or causes PT to awaken
• Supratentoral usually seen in adults
• infrententoral usualy see in kids in the cerebellar region
• could cause compression of CN III with ipsilateral mydriasis (asymmetry of the pupils) 

• Age >50
• HA, jaw claudication, temproal artery tenderness, blurred vision
• ESR>50
• TX--> high dose steroids in acute setting usually follow up with temporal artery biopsy for definitive DX

• Thombosis in the dural venous sinuses
• HA, diplopia, neurolgical deficits--> typically in younger PT that use OCP and have a factor deficiency
• Dx confirmed with CT venography or MRI
• Treament is anticoagulation --> heparin or long term warfarin

• also know as benign intracranial hypertension
• obese young wome
• HA, N/V, double vision
• papilledemia on exam
• Dx and tx with LP with CSP opening pressure >25 cm H2O
• Treat with Diamox or lasix

• ptosis, droopy lid, small pupil and absence of facial sweating. the presence of horner's syndrome in conjunction with a HA may respresent a Carotid dissection

Ask PT to rapidly shake head formside to side, this study is 100% sensitive and 54% specific for meningitis

the test is the most usful adjunctive maneuver for evaluating headache in the presence of fever

• Fever and altered mental status
• Evaluate and treat for shock or hypotension
• stabalize alert PT with normalvital signs by administering oxygne, and sucuring IV access

• GCS 14-15 --> 80% of all TBI
• low risk--> GCS of 15 w/ no LOC
• medium risk--> GCS 15 and LOC, amneisa, vomiting, or diffuse HA--> 1-3% risk of hematoma CT should be done
• High risk--> GCS 14-15 w/ neurological deficits up to 10% risk of hematoma requiring evacuation 

• GCS 9-13--> 10% of all TBI
• <20% mortality
• 50% morbidity
• 40% positive CT

• GCS <9
• 10% of all TBI
• 40% mortality
• < 10 make moderate recovery 

• Hypertonic saline --> improves CPP and brain tissue, decrease ICP by 35%
• Mannitol--> osmotic agent, affects, ICP, CBF
• Hyperventilation--> not recomened as prophylactic intervention, reduces ICP by vasoconstriction, used as last resort 

• most common CT finding in moderate to severe TBI
• if isolated head injury, may present with HA, photophobia, and meningismus
• Nimodipine (CCB) reduces death and disabilitity by 55%

• head injury w/ or w/o LOC, followed by an awake lucid interval then decline in mental status, alterations in LOC, collapse and death
• blunt trauma to temperoparietal region
• 80% w/ associated skull fracture
• rapidly expanding and very fatal
• commonly secondary to middle meningeal artery

• slower progression
• sudden acceleration-deceleration injury with tearing of bridging veins
• commonly in elderly, alcoholics, and PT on anti-coagulation
• classified as acute <2 wks, subacute or chronic >2 wk
• these PT require reversal of their anticoagulation
• lens shaped on CT 

• high tvelocity MCV or shaken baby syndrome
• disruption of asons in white matter and brainsteam
• injury occurs immediatley and is irreversible
• usualy have persistent vegative state
• CT usually normal
• very poor prognosis