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