1.5 Abd Complaint Evaluation Flashcards

1
Q

Name key components of history-taking for a chief complaint of abdominal pain

A
  • Complete OLDCARTS
    • Insidious vs acute onset
    • Progressive, constant, waxing/waning
    • Character
      • Visceral: dull, aching, colicky, poorly localized
      • Peritoneal: sharp, stabbing, localized
      • Referred: chest, shoulder, upper back, lower back, flank, genitalia
  • Social hx
    • Sexual history
    • Substance abuse
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2
Q

What are core components of physical exam for CC of abd pain?

A
  • Vitals
  • Gen appearance
  • Abd/GU
  • Cardiopulmonary
  • Peripheral vascular
  • Integumentary
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3
Q

Your patient presents with CC of abd pain, and you understand the following to be “red flags”

A
  • Toxic appearance
  • Abnormal vitals
    • Fever, tachy, hotn, htn, hypoxia
  • Severe, intractable pain
  • Associated chest, back, flank pain
  • Fever
  • Intractable vomiting
  • Elderly
  • Recent trauma
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4
Q

What risk factors may worry you in particular in a patient with CC of abdominal pain?

A
  • Age > 50
  • Women of childbearing age
  • Heavy EtOH use
  • Remote/recent abdominal surgery
  • Recent hospitalization/critical illness
  • Hx of smoking
  • Significant PVD
  • Coagulopathy
  • Poor historian
  • Immunocompromise
  • Pregnancy
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5
Q

What in particular will you be on the lookout for if your patient with CC of abdominal pain is an older adult?

A
  • Atypical presentation
  • Sx may be mild/non-specific
  • Delay in seeking care
  • Poor historian
  • Multiple comorbidities
  • More likely to have poor outcome
  • Decreased Immune response
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6
Q

Your patient presents with CC of abdominal pain, and you immediately think about these 10 never-miss diagnoses:

A
  1. Ischemic bowel
  2. Perforated viscus
  3. Appendicitis/diverticulitis
  4. Ectopic pregnancy
  5. Torsion (testicular or ovarian)
  6. AAA rupture
  7. Solid-organ injury
  8. MI
  9. Ascending cholangitis/acute cholecystitis
  10. PE
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7
Q

Describe your general approach to diagnostic workup for CC of abdominal pain.

Then, specific tests for these scenarios:

  • Epigastric pain and/or vomiting in elders
  • Women under 50 years
  • Pleuritic upper abd pain
  • Bedside imaging?
  • Concern for sepsis?
A
  • Prioritize differentials, which will guide tests and mgmt
    • Acuity
    • Most likely
  • Consider clinical value of test, imaging study
  • Limit radiation when possible
  • Don’t delay early surgical consult if indicated
  • Specific:
    • Epigastric pain and/or vomiting in elders
      • EKG, troponin
      • CXR (r/o perf ulcer vs. pna)
      • CT w IV contrast
        • Large clot in mesenteric circulation
        • Hepatic vein thrombosis
        • Renal artery thrombosis
      • RUQ US
        • Gallbladder, kidneys, liver
        • Will miss perforated ulcer
      • CTA
        • Not everyone needs, but r/o mesenteric ischemia, dissection, ruptured AAA
    • Women under 50 years
      • HCG (even with IUD)
    • Pleuritic upper abd pain (pna vs. PE vs. diaphragmatic inflammation)
      • CXR
      • D-Dimer
    • Bedside imaging?
      • POCUS - gallbladder, kidneys, solid organ damage
    • Concern for sepsis?
      • Lactic acid - severity of illness
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8
Q

Describe your initial management of the patient with CC: abd pain

A
  • Fluid resuscitatation
  • Abx
    • Enteric coverage
  • Analgesics
  • Antiemetics
  • PPI
    • If GI bleed (bolus vs infusion)
  • NGT
    • Life threatening hematememsis
    • SBO
  • Specialty consult
    • Surgery
    • GI
    • Vascular
    • IR
    • Urology
    • Gyn
  • Obs vs. d/c?
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9
Q

What are your standard ‘belly labs’ youll want to get for your abd pain patient?

A
  • CBC
  • BMP
  • LFTs
  • Lipase
  • UA
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10
Q

Describe the diagnostic value of the following tests:

  • UA
  • D-Dimer
  • POCUS
  • CBC
  • Abd US
  • CT abd/pelv
  • Abd XR
A
  • UA
    • Ketones = dehydration
    • Blood = kidney stone, AAA
    • Protein = renal injury
    • Limitations:
      • Pyuria - don’t anchor to UTI
  • D-Dimer
    • High SE, low SP
  • POCUS
    • Dx value limited by training of operator
  • CBC
    • Acute anemia
    • Leukocytosis/penia
      • Can be non-specific/reactive/inflammatory
      • Immunocompromised = wont mount white count
  • Abd US
    • Appendicitis in young, thin adults
  • CT abd/pelv
    • Can be falsely reassuring, even w IV contrast
    • Acute abdomen + normal CT = dont be satisfied
  • Abd XR
    • Low SE/Sp
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