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Flashcards in medical abdomen Deck (142):
1

Three choices in Abdominal Pain

surgeon, admit, home

2

what is the workup for medical abdomen

Hx, PE, labs, diagnostics = no surgeon

3

when can you send an abdomen case home?

i. Home if: pain improved (not “gone”), can take PO’s, can walk, stable home, stable vitals, they look better

4

what to do with “Non-specific abdominal pain”

12-24hr f/u: cause may reveal itself

Strict return precautions, document understanding

5

RUQ abd pain think

PNA
HEPATIC TUMOR
HEPATIC ABSCESS
HEPATITIS
RETROCAECAL APPENDICITIS
BILIARY COLIC
CHOLANGITIS
PYLONEPHRITIS
RENAL COLIC
RENAL INFARCTION

6

Epigastric pain think


duodenal ulcer
oesophagitis
gastritis
gastric ulcer
pancreatitis

7

LUQ pain think

PNA
splenic infarction
pancreatitis
pylonephritis
renal colic
renal infection

8

central painthink

aortic aneurysm
Meckle's diverticulitis
infarction
enteritis
obstruction
intussusception

9

LLQ causes

renal colic
UTI
diverticulitis
sigmoid volvulus
diverticulitis
colitis
ovarian cycst
salpingitis
ectopic pregnancy

10

suprapubic pain causes

pelvic appendicitis
diverticulitis
uterine fibroid
ovarian cyst
salpingitis cystitis

11

RLQ

renal colic
UTI
Meckle's diverticulitis
chorn's disease
acute appy
perforated
caecal carcinoma
ovarian cyst
salpingitis
ectopic prenancy

12

Meckle's diverticulum

true diverticulum of small bowel

Congenital, present 2% at birth

Incomplete obliteration/vestigial remnant of the Vitelline duct

13

how do they present and what is the big symptom

3. Asymptomatic until a complication – obstruction, inflammation, perforation

Kids w/ hematochezia – think Meckel’s

14

esophagus think

GERD
PUD
Motility
barret's
hiatal hernia
immune cancer

15

Bowel think

GIB
diverticulosis
UC
Crohn's
hernias
gastroentritis

16

solid organ infection/unflammation

pancrease, liver, spleen, kidney, prostate

17

stones

GB
Kidney

18

something not working

urinary retention
ascites
gastroparesis
pseudoobstruction

19

metabolic

DKA (almost always seen with abd pain)

20

vasculitis

sickle cell

21

toxicology

etoh
cocaine
other

22

tricky pain

PNA
Pleural effusion
AMI/ACS

23

RIGHT SHOULDER referred pain from

biliary tree,
GB,
diaphragm irritation

24

epigastric referred pain from

Cardiac
esophagus

25

ipsilateral groin referred pain from

renal colic
hernia

26

ipsilateral flank
lower abdomen
or thigh

Testicles, female reproductive

27

back pain can be referred from the

Aorta, pancreas

28

sacrum can be referred from

rectum
prostate
female gYN

29

physical exam for an abdominal complain should include

skin
heart
lungs
CVAT
Gyn/GU
rectal

WATCH THEM WALK

30

why do you want to watch an abdominal pain walk

because if they can walk properly they are not retroperitoneal

31

how to inspect the abdomen on a physical exam

one finger ask patient to point to it
look at it is it distended or shiny or is the pt holding onto it
listen to bowel sounds
percuss organs for tympany, ascites, bladder

palpate soft hard or flat or distended

do all special moves

32

how should we think about guarding

involuntary is

involuntary

muscles are rigid
hard

think peritoneal

33

how can you fatigue muscles on exam in a pt with peritoneal pain

Won’t be able to fatigue their muscles on exam if it’s peritoneal

34

what is voluntary guearding

abd is soft but pt is resisting touch

35

treat pain

need to treat pain

can't hide surgical abd

IV fluids
1L bolus
THN 200 cc/hr x 1L crystalloid

36

why do we give fluids to a abd complain

get dehydrated with gut stuff and will benefit form IVF

37

hot oto treat pain

ketorolac
IV acetaminophen

38

know 3 opiates to use for pain

morphine 4-8 mg IV/IM
diluadid .5-1mg IV/IM
fentanyl 50-100mcg mcg iV/IM

Remember hypotension!

39

three antiemetics
IV
IM
SL

Zofran 4-8mg
compazine 5-10mg
reglan 10 mg
anzemet 12.5 mg
phenergran 12.5-25 mg

40

how to approach vomiting-hx

OLDCARTS

abd pain
cough
chest pain
dysuria
stool
melena
GY
PREGNANT
VERTIGO
HA
sick contacts
diet?
vomiting or pain first

41

important PMH with vomiting

hx same? Also – trauma, psych, cancer, etc

42

red flags for vomiting

Abnormal VS like HoTN
blood
old/young/pregnant
cancer
HA
neuro findings
psych

43

IV choices for vomiters
what are you worried about

IV NS or LR: dehydration, ketosis, alkalosis

44

vomiting without abdominal pain think

ICP
CNS issues
toxicology
exposure

45

what is diarrhea

Diarrhea – 8-10 stools in a 24 hr period

46

diarrhea questions

think outbreaks
OPQRST, assoc sx’s, PMH, meds, foods, sick contacts, travel, laxatives, recent abx (think C.Diff), gut surgery, sex habits, day care, food handlers

47

inflammatory diarrhea is classified by

blood in stool
fever
abd pain

48

non-inflmmatory diarrhea looks like

blood rare, n/v prominent, mild abdominal pain (crampy)

49

red flags with diarrhea

VS
fever
old
young
pregnant
altered
PMH
hyperthyroid
HIV
Endocrine
renal failure
GI issues
cancer

50

what do you worried about in a elderly pt with diarrhea

fecal impaction, mesenteric ischemia

51

constipation is a dx of

Diagnosis of exclusion for abdominal pain in the ED

52

hx of BM you want to ask with constipation

frequency, character, pain, blood, fever, obstipation, tenesmus, sudden onset, weight loss

53

what do you want to do for fecal impaction

DRE

54

what would you want to do for fissures

Anoscopy for fissures --> to visualize hemorrhoids, mass

55

labs for the constipated pt

: anemia (chronic dz), thyroid, electrolytes, LFT’s, lactic acid if sick - no radiology unless considering secondary diagnosis or older

56

when can't you dx a pt with constipation

Abnormal VS, ill appearance or peritonitis should NOT be blamed on constipation

57

what are the belly labs

CBC w/ diff, CMP, lipase, UA, Upreg

58

when would you get a lactic acid

Lactic acid? Significant pain, Hx/PE, fever, hypotension, older

59

when would you order a EKG

EKG? >40, epigastric pain, tachycardia, chest pain, cardiac risk

60

when would you treat with antibiotics

antibiotics? Early if fever, high lactic acid

61

KUB, flat/upright ordered if

ordered much less d/t CT but would order in BO or foreign body

62

Gold standard for obstructed bowel

CT

63

When would you get a CXR

ii. Chest x-ray - everyone if admitted

64

Bedside ULS IF

Billiary
ascites
free fluid
female pelvis
hydronephrosis
appy
aorta
trauma

65

special tests you would want to order if signs of septic or CVA tenderness

2. Blood cultures (get if they are septic), urine culture (cath) – get if pyelonephritis

66

special tox tests

1. ETOH, Urine tox

67

when would you order a PT or a INR

anticoagulated, liver Dz, going to surgery

68

order a LDH for

LDH for severe pancreatitis

69

surgery prep labs

5. Type and Screen or Type and Cross
a. Blood products, surgery prep

70

NG tube would be ordered if

gastric decompression (SBO),
sample contents (GI bleed),
bowel rest (protracted vomiting)

1. Specific indications, less common these days in ED

71

when would you order antibiotics

infection, obstruction, perforation, inflammation

72

what do you want to cover with belly antibiotics (what pathogens)

Cover anaerobes, enterococci, gram neg’s

73

PUD/Gastritis/GERD presentation

Epigastric pain, burning/aching, +/-n/v, radiates to chest, triggers, night pain, “sour brash”, belching. Recurrent

Not acute abdomen (if so – think perf)

74

GI cocktail

Mylanta 30cc, 2% Viscous Lidocaine 15cc

Donnatol 10cc (that makes it green) is falling out of favor

75

Dx test that might be needed for a presentation that looks like GERD

+/-IV fluids; pain control, antiemetics, H2’s, PPI’s (usually PO)

76

Red Flags following GERD suspicion

abrupt change in sx’s, VS, bleeding/melena, elderly

9. D/C if stable w/ follow-up

77

burning/sharp/ache
epigastric and chest,

may radiate
weight loss, recurrent, occurs at rest

Esophagitis

Look in their mouth – look for thrush for HIV

chronic GERDà Barrett’s Esophagitis – pre-cancerous

78

workup for esophagitis

Labs, EKG, CXR; GI cocktail

79

D/C esophagitis if

F/U with

D/C home if stable, outpatient f/u
Dysphagia +/- barium; both endoscopy

80

Hiatal hernia

Often asx’atic: relation to GERD


Delays esophageal acid clearanceà esophagitis, increase risk Barrett’s

81

Hiatal hernia tx

CXR, endoscopy. Tx like GERD

82

upper GIB sxs

hematemesis, melena (melena is foul)

83

lowerr GIB sxs

hematochezia, BRBPR
bright red blood per rectum

84

key to a GIB workup

How much/how long? Painful or painless? Retching/vomiting prior? Vomit/stool appearance, recent surgery/procedure, other bleeding, PMH, meds, habits, Hx same

85

labs for UGIB or BRBPR

CBC
Chem
PT/INR

EKG if tachy

UPPER GIB +/-NG tube trial w/ irrigation

86

tx of minor UGIB

oral PPI’s, surgery referral LGIB or rectal issues

87

workup of big UGIB or melena

Add 2 IV’s
Type/Screen
lactic acid
CXR
O2
monitor
NG tube

88

workup of big UGIB

IV PPI’s with drip, urgent endoscopy
octreotide for varicies;
GI, surgery consult

89

when to d/c GIB

may d/c minor bleed/stable/low risk pt’s w/ return precautions, f/u endoscopy/colonoscopy

90

common ddx with abdominal pain in alcoholics

etoh gastritis, pancreatitis, GI bleed

91

workup of alcoholic with abd pain

: undress, be thorough: head to toe

Labs:

CBC,
Chem,
lipase,
PT/INR,
UA,
Upreg,
CXR,
EKG

92

tx for alcoholic with abd pain

IV hydration, “banana bag” (multivitamins w/ Mg++ and thiamine), pain control ok, antiemetics

93

red flags for an alcoholic with abd pain

a. Fever, VS not resolving
b. Persistent ALOC – think head trauma
i. If Etoh has worn off then think about something going on in the brain
c. Bleeding, pettechiae, acidosis
d. Signs of EtOH withdrawl (tongue wag, fever, tremor)
e. Low CO2, AG: alcoholic metabolic acidosis (part of MUDPILES

94

what do you see in gastroenteritis

Vomiting = gastritis;

diarrhea = enteritis: need both

95

how can you rule out other things in gastroenteritis

Hx key. Exam not impressive: dehydrated, miserable

Not peritoneal or “sick”: presumptive dx, self-limiting

96

RF in gastroenteritis

a. VS that don’t normalize after IV fluids
b. Old/young/pregnant/immunocompromised
c. Serial abdominal exams with persistent pain
d. Blood in stool, fever, rash, ALOC

97

tx of gastroenteritis

Tx: IV NS or LR, antiemetic. No imaging unless 2nd diagnosis; d/c home if stable w/ antiemetics, return precautions

98

prodrome of hepatitis

malaise, fatigue, anorexia, n/v; then abdominal pain, jaundice, dark urine, “light colored” stool

Mild sx’s to fulminant liver failure

99

hepatitis RF

Hx key for risk: travel, exposures, sex hx, sick contacts, EtOH/drugs

100

labs for hepatitis or jaundice

Labs

Upreg

Hep serologies,

ULS biliary tract

CT if suspect cancer/mets

101

Painless jaundice is the HALLMARK for

a. Painless jaundice is the HALLMARK for pancreatic CA

102

RF in a juandice workup

jaundice plus – EtOH w/d, altered, ascites, asterixis, bleeding

103

when can you d/c a jaundice pt

Can d/c select, stable pt’s. If admit - GI or Surgery consult (depends on Dx)

104

what do you see with a hep A panel

First fecal HAV

then

increase igM early anti HAV

Then IgG ANTI hav

increase in ALT
HAV in seruM

105

heb B panel

see increase in ALT
HBeAG
and then anti HBe
HBV DNA early
HBsAG

anti HBs throughout life

106

cause of pancreatitis

= Gallstone 40%, hx ETOH 40%, previous pancreatitis, post trauma

107

presentation of pancreatitis

1. Epigastric pain, +/- radiates to back, vomiting, anorexia

108

labs for pancreatitis

: lipase up x3 for dx; LDH, glucose, AST, WBC’s all increased
4. First test = ULS for gallstones, and then CXR, EKG, CT

109

how do you make a pancreatitis dx

a. CT scan is how you make the diagnosis
i. Fat stranding, fluid, inflammation

110

RF in pnacreatitis

peritoneal, fever, hypotension = very sick!!

111

admission f/u for pancreatitis

– NPO, watch ETOH w/d

112

ranson criteria -on admission

i. Age >55
ii. Glucose >200
iii. WBC >16k
iv. SGOT (AST) >250
v. LDH >350

113

what does the ranson score tell you about pancreatitis

>/= 3: pancreatitis Dx likely, <3: unlikely

114

48 hours after onsent the ranson criteria score tells you

11 criteria

3-4 = 15%, 5-6 = 40%, 7-8 = 100%

115

Malaise, fever, vomiting, abdominal, back or flank pain, CVAT, usually dysuria or irritated voiding, hematuria

pyelonephritis

116

best test for pyelo in females

in/out cath best in females, send culture,

117

other than a UA what should you order in suspected pyelo

ULS kidneys (hydronephrosis), RUQ if pain on R. CT only if uncertain dx

UPREG

118

red flags for pylo

Hypotension, signs of sepsis
Pregnant + pyelo
Stone + pyelo
Intractable vomiting
Preexisting renal dz

119

treatment of pylonephritis

ADMIT
IVFluoroquinolones, Amikacin, +/- Ceftriaxone


outpatient – 10-14 day course fluoroquinolone, return precautions

120

presentation of

Middle age/older, often Hx same, gradual onset, constant, diarrhea, +/-n/v, lower abd pain; LLQ pain common

121

red flags of diverticulosis

i.VS abnormal, fever/chills, guarding, old/young/pregnant

122

diverticular disease tx


IV fluids, antibiotics, CT abd/pelvis w/ con

Outpt abx (Augmentin or Cipro/Flagyl) if not sick; clear liquid diet, close f/u, colonoscopy referral

123

Sudden, sharp, excruciating, unilateral pain; radiates around abdomen or to groin, diaphoresis, n/v common, can’t lie still, hematuria (15% do not)

renal colic

124

lab work up for renal colic

i. Labs, UA, bedside US for hydronephrosis
ii. CT w/o contrast if first episode (not KUB) to confirm

125

RF for renal colic

i. VS remain abnormal after pain controlled
ii. Stone + fever or infected urine
iii. Hydronephrosis + fever or infected urine
iv. Stone >6mm on CT (won’t pass on own)
v. One kidney or transplant pt
vi. Risks for AAA, ectopic, appy, torsion, PID/TOA, etc…

126

renal colic tx

Can d/c home if: resolves, not infected, not sick, peeing
ii. Oral pain meds, @ blocker, urology f/u
iii. IV fluids, pain control (Ketorolac great), antiemetics

127

RF for ascites

SBP: subacute bacterial peritonitis
Fever or painful: must consider SBP
Hypotension, altered, GI bleed, EtOH withdrawl

128

Ascites

liver failure, cirrhosis, malignancy

129

when would you do a Paracentesis for ascites

diagnostic and/or therapeutic

ULS first; take off 3-5 liters not unusual
Recurrent ascites/stable; tap for comfort, home

130

ascites

First time ascites? Admit for w/u.
Fever/SBP? Sick. IV abx, monitor, admit

131

Common causes of urinary retention

prostate, meds, hematuria (clot) from bladder CA

132

Urinary Retention tx

Tamsulosin (Flomax), Doxazosin (Cardura), etc

133

labs for DKA

: d-stick first; Chem for CO2, Anion Gap, Na, K+; lipase; search for infection (UA, CBC, CXR, ULS RUQ), EKG; serum/urine ketones, mag, phosphorous, upreg

134

DKA

Begin IV NS 2L bolus, add K+, protocol, monitor, admit

135

gastroparesis rf

DM autonomic neuropathy, Parkinson’s, MS, post surgical

Emptying of stomach is delayed

136

gastroparesis sxs

Emptying of stomach is delayed

137

causes cycling vomiting syndrome

chronic marijuana use, migraines, stress, anxiety, infection

138

Labs for SS

CBC, reticulocytes, UA, CXR
Search for infection from H.Flu, E.coli, M. Pneumoniae, Salmonella, S. Aureus
They are functionally asplenic

139

Sickle Cell Crisis tx for

: IV hydration, pain control, +/-opiates

140

RF for ssc

VS, fever, sepsis, SOB, jaundice, neuro sx’s

141

Older pt’s, LLQ abd pain - CT
Document risk factors

AAA

142

RF for constipation

old/young, sudden onset, anemia, weight loss, neuro deficit, change in stool caliber