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Rationale

Abdominal pain is a common problem that can be caused by a wide variety of acute and chronic disease processes, many of which can be life threatening. Mastery of the approach to patients with abdominal pain is important to general internists because they often are the first physicians to see such patients.

Prerequisites

Basic courses in anatomy, physiology, and pharmacology, and introductory required pre-clinical course in physical diagnosis

Specific Learning Objectives

  1. Knowledge: Students should be able to describe and define:
    1. principal types of pathophysiologic mechanisms of abdominal pain (i.e., obstruction, peritoneal irritation, vascular insufficiency, abnormal motility, mucosal irritation, metabolic aberrations, nerve injury, referred pain, psychopathology)
    2. describe the relative likelihood of common causes of abdominal pain according to the quadrant in which the pain is located
    3. list symptoms and signs indicative of an acute abdomen
    4. describe the key diagnostic criteria for common causes of abdominal pain, based on a history, physical exam and laboratory testing
    5. identify the indications and the limitations of the following principal diagnostic studies necessary to differentiate among common causes of abdominal pain, including:
      1. fecal leukocytes
      2. stool culture
      3. stool guaiac
      4. stool fat
      5. hepatitis serology
      6. liver enzymes
      7. amylase and lipase
      8. paracentesis
      9. upper endoscopy
      10. sigmoidoscopy
      11. colonoscopy
      12. barium studies
      13. abdominal ultrasound
      14. CT scan
      15. radionuclide scan of hepatobiliary system
    6. identify indications for dietary intervention, drug therapy and therapeutic procedures in patients with common causes of abdominal pain, and describe the physiological basis and/or scientific evidence supporting each type of intervention
    7. identify indications for empiric therapy in patients with abdominal pain
    8. describe steps in a critical pathway for patients with an acute abdomen
  2. Skills: Students should demonstrate specific skills including:
    1. history-taking skills: Students should be able to obtain, document, and present an age-appropriate medical history, that differentiates among etiologies of disease, including:
      1. elicit features of a patient’s abdominal pain, including location, radiation, duration, associated symptoms, weight change, exacerbating and remitting factors, surgery, medications, and family history.
    2. physical exam skills: Students should be able to perform a physical exam to establish the diagnosis and severity of disease including:
      1. demonstrate correct order and technique for examining the abdomen.
      2. perform an adequate rectal and pelvic exam (under supervision).
      3. identify relevant scars, abnormal bowel sounds and signs of peritoneal inflammation.
    3. differential diagnosis: students should be able to generate a list of the most important and likely causes of a patient’s abdominal pain, recognizing specific history and physical exam findings that distinguish between:
      1. peptic ulcer disease
      2. dyspepsia
      3. gastroparesis
      4. pancreatitis
      5. irritable bowel syndrome
      6. diverticulitis
      7. pseudomembranous colitis
      8. acute and chronic hepatitis
      9. inflammatory bowel disease
    4. laboratory interpretation: Students should be able to recommend when to order diagnostic and laboratory tests and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis, including consideration of test cost and performance characteristics as well as patient preferences.
      1. laboratory and diagnostic tests should include studies necessary to determine the cause of a patient’s abdominal pain
    5. communication skills: Students should be able to:
      1. explain the results of the evaluation to the patient, taking into consideration the patient’s knowledge about his/her condition
    6. basic and advanced procedure skills: Students should be able to:
      1. insert a nasogastric tube after explaining the procedure to the patient
    7. management skills: Students should be able to develop an appropriate evaluation and treatment plan for patients, including:
      1. selecting an appropriate medical regimen for patients with peptic ulcer disease, dyspepsia, gastroparesis, pancreatitis, irritable bowel syndrome, diverticulitis, and pseudomembranous colitis
      2. determining when to prescribe medical therapy for patients with chronic hepatitis
      3. determining when to involve a surgeon in the management of patients with peptic ulcer disease, inflammatory bowel disease, cholecystitis, and pancreatitis
      4. recognizing the value of psychotherapy in the management of chronic abdominal pain
      5. accessing and utilize appropriate information systems and resources to help delineate issues related to abdominal pain
  3. Attitudes and Professional Behaviors: Students should be able to:
    1. recognize the importance of involving a surgeon as soon as possible when a patient is identified as having an acute abdomen
    2. recognize the importance of patient preferences when selecting among treatment options