AAICM Cases Flashcards
1
Q
Physical Exam Finding of High Positive Predictive Value for Acute Appendicitis
A
RLQ Pain
2
Q
High Positive Predictive Value for Bowel Obstruction
A
New Onset Constipation
3
Q
Non-abdominal causes of abdominal pain
A
MI
Pleurisy
4
Q
Abdominal Pain sx suggestive of surgical/emergent conditions?
A
Fever Protracted Vomiting Syncope/Presyncope Evidence of GI bleed Obstipation
5
Q
Causes of Diffuse Abdominal Pain
A
Pancreatitis Bowel Obstruction Early Appendicitis Ischemic Bowel Constipation Peritonitis
6
Q
4 Syndromes of Abdominal Pain
A
Peritonitis
Bowel Obstruction
Abdominal Vascular Catastrophe
Nonspecific Abdominal Pain/Medical Conditions
7
Q
Causes of Peritonitis
A
Localized: acute appendicitis, cholecystitis, diverticulitis, pancreatitis
Generalized: perforated viscus
8
Q
Causes of Bowel Obstruction
A
Strangulated Hernia
Volvulus
9
Q
Abdominal Vascular Catastrophe
A
Acute Mesenteric Infarction
Ischemic Colitis
Abdominal Aortic Aneurysm
10
Q
Nonspecific Abd Pain/Medical Conditions
A
Drug Induced Constipation Acute Gastroenteritis Acute MI Lower Lobe Pneumonia
11
Q
Causes of Abdominal Catastrophes to never miss
A
Ischemic Bowel Cholangitis Bowel Perforation Splenic Rupture Ruptured AAA Ectopic Pregnancy Appendicitis
12
Q
Criteria to admit a patient with abd pain to hospital
A
Severe pain of unclear cause Peritoneal Signs Unstable Vitals Suspected abd catastrophers Pyelonephritis/PID with vomiting requiring IV abx
13
Q
Key feature of Acute Mesenteric Ischemic on Physical Exam
A
Absence of abnormal physical findings in presence of severe acute abd pain
14
Q
Risk Factors for Acute Mesenteric Ischemia
A
Cardiovascular Comorbid Conditions Arrhythmias Structural Heart DIsease Hypotension Atherosclerosis Hypercoagulability
15
Q
CT Abd findings suggestive of ischemic colitis
A
Thickened colon with pericolonic stranding
16
Q
General Approach to Management of Patientw ith Abd Pain
A
Assess Hemodynamic Stability (if unstable consider sepsis, perforated viscus, ischemic bowel -> need imaging and hospitalization)
Fluid Resuscitation
Inform senior and order appropriate imagings
Surgery Consult If Appropriate
*Cautiously use narcotics to avoid masking pain and prevent further assessment
17
Q
Treatment of Ischemic Colitis
A
Reverse the precipitating cause
Fluid Resuscitation to maintain perfusion pressure
Avoid Vasoconstrictors
If ischemia is mild and no peritoneal signs or sepsis, can manage medically with oral abx and clear liquid diet
Surgery if evidence of bowel ischemia
18
Q
Causes of Abdominal Pain in Hospitalized Patients
A
Unrelated Conditions first arising in hospital
Direct Consequence of problem related to patient’s illness
19
Q
Cause of Abd Pain in hospitalized patients arisisng as a direct consequence of problem related to patient’s illness (Post Op Patient in this case)
A
Mesenteric Ischemia Ischemic Colitis Acalculous cholecystitis Pancreatitis Ileus Acute Colonic Pseudo-obstruction Post Surgical/Procedure COmplications C-Diff Colitis
20
Q
Management of Abd Pain in Hospitalized Patient
A
Labs: CBC, UA, CMP, Amylase, Lipase
Imaging: Abdominal X Ray (flat and upright or R lateral decubitus)
Establish Hemodynamic stability
21
Q
Indications for Ultrasonography in Abd Pain
A
Cholecystitis suspected
22
Q
Indications for CT Scan for Abd pain
A
Appendicitis, Ischemic Bowel, AAA, Intra-abdominal abscess, retroperitoneal hemorrhage, pancreatitis
Complication of invasive procedure (abd pain within 24-48hrs)
Severe abd pain of unclear etiology
23
Q
Management of Patient with Abd Pain
A
Aggressive Volume Resuscitation as needed
Decompression with NG Tube (Severe vomiting, ileus, acute colonic pseudo-obstruction or bowel obstruction)
Broadspectrum Abx if infection suspected
Consult Surgery based on suspicion, acuity, and hemodynamic stability
24
Q
Management of Patient with Abd Pain likely due to Colonic Pseudo Obstruction?
A
Decompression with rectal Tube
Frequent repositioning
Colonic Decompression
Decrease Narcotics Dose
25
What kind of diet should patients be tolerating by discharge?
At least a clear liquid diet prior to discharge
26
Considerations of pathologies in Abdominal Pain in Women
```
Tubo-Ovarian Abscess
Ectopic Pregnancy
Ovarian Cysts
UTI
Nephrolithiasis
```
27
What should all childbearing age females presenting with abd pain get?
Pregnancy Test
Pelvic Exam
Pelvic U/S
Urinalysis
28
Differential of LLQ Abd Pain
```
Acute Diverticulities
Ischemic Colitis
Infective Colitis
IBD
UTI
Nephrolithiasis
```
29
What imaging should you get if you're suspecting acute diverticulitis
CT with Oral and IV Contrast
30
40 yr old F with hx of OSA, depression presenting with RUQ pain after eating at a cookout. Described as colicky initially and then constant with nausea and vomiting. Denies fevers, chills, cough, SOB, urinary changes,, smoking, etoh use.
Exam: mild distress due to pain. fever. tenderness to palpation in RUQ and +Murphy sign. negative CVAT
DDx:
Acute Cholecystitis
Pancreatitis
Acute Hepatitis
Work Up:
Serum Lipase, LFTs, US Gall Bladder
31
What are indications a patient should have ultrasound of gall bladder?
Colic
Fever
+Murphy Sign
32
What imaging should you get if worried about acute retroperitoneal bleeding?
CT Abdomen
33
Differential for renal Failure
Acute Renal Failure
Chronic Renal Failure
Acute on Chronic Renal Failure
34
Causes of Prerenal Failure
Decreased PO Intake
Vomiting
Infection: causes peripheral vasodilation but kidney is constricted due to increased catecholeamines and ATII
NSAIDs: decreases PGs -> unopposed vasoconstriction of afferent artery -> decreased renal plasma flow
ACE-I: decreases ATII -> decreased resistance in efferent artery -> decreases glomerular hydrostatic pressure
Hypotension
35
Causes of Intrarenal Failure
Pyelonephritis
| ATN
36
Causes of Post-Renal Failure
Obstruction
37
What imaging studies for renal failure?
Renal Ultrasound
38
Winter's Formula
expected pCO2 = 1.5 (HCO3) +8 +/- 2
39
Hypertensive Emergency
Severe HTN (>180/>120 mm Hg) with end organ dysfunction
40
Hypertensive Urgency
Severe HTN without end organ damage
41
Medications for HTN Emergency in Setting of CHF
```
IV Loop Diuretic (Furosemide)
IV Vasodilator (Nitroglycerin, ACEi etc)
```
42
What medicaiton should you avoid in treating HTN Emergency in someone with impaired renal function?
Nitroprusside- can lead to cyanide toxicity
43
Which anti-HTN drugs should be avoided in HTN Emergency patients with HF?
Hydralazine- increases HR
| Labetolol/Beta Blocker: decreases contractility
44
Target Goal in Treating HTN Emergency
Rapidly decrease BP over 1-6 hours to diastolic BP of 100-110mmHg
45
Target Goal in Treating HTN Urgency
Slowly decrease BP over 24-48 hours to diastolic BP of 100-110mmHg
46
Causes of Hypovolemic Hyponatremia
Nonrenal: Diarrhea, Vomiting
Renal: Addison's , Diuretic
47
Urine Na in nonrenal causes of hypovolemic hyponatremia
Diarrhea, Vomiting
| UNa: <20mEq/L
48
Urine Na in renal causes of hypovolemic hyponatremia
Addison's, Diuretic
>20mEq/L
49
Causes of Euvolemic Hyponatremia
SIADH: PNA, Small Cell Ca, Brain (stroke, subdural hemorrhage, tumor)
Hypothyroidism
Compulsive Water Drinking
50
What is the Una in Euvolemic Hyponatremia?
>20mEq/L
51
Causes of Hypervolemic Hyponatremia
CHF, Liver Disease
52
Una in Hypervolemic Hyponatremia
<20mEq/L
53
Why is Una decreased in nonrenal causes of hypovolemic hyponatremia?
Diarrhea, vomiting
Increased levels of catecholeamines 2/2 dec BP -> Activate RAA System -> inc ATII and Aldosterone -> inc proximal reabsorption of Na
Even though the urine is concentrated, there is little Na in the urine so the concentration is low
54
Why does Uosm increase in hypovolemic hyponatremia?
Decreased volume -> stimulate ADH -> reabsorb water from urine
55
How does Addison's disease cause euvolemic hyponatremia?
Decreased glucocorticoids and mineralocorticoids -> renal losses of sodium -> Una>20mEq/L
56
Treatment of Hyponatremia caused by Heart Failure
Likely hypervolemic
| Treatment: Sodium Restriction, Water restriction, diureses
57
Electrolyte Free Water Equation
Urine Volume (V)= (Una + Uk)V/Pna + CH2O
58
Treatment of Hyponatremia due to SIADH
Euvolemic Hyponatremia
| Tx: Water Restriction
59
Differential Diagnosis of Seizure
Exacerbation of Previous Seizure Disorder
Toxic/Metabolites: Hypoglycemia, hyponatremia
Medications: Wellbutrin, Quinolones
Drug Abuse/Withdrawal: etoh, benzo withdrawals
CNS Lesions: Metastatic lesions, SAH, CVA, infection
60
What should you look for in a patient who is seizing?
```
Hemodynamic Instability?
Really a seizure?
Localized vs Generalized
Tonic(spasms) vs Clonic (flaccid) vs Tonic-Clonic
Neuro Exam with CNS Lesion?
CNS Infection Sign?
Recent CNS Trauma?
```
61
Signs of pseudoseizure?
Asymmetric Movements, Complex Vocalizations, Rigidity
62
What should you do when assessing patients?
```
Obtain frequent vitals
Cardiac Monitor
Check Puls Ox
Start O2
Confirm Patency of at least 2 peripheral IV access
```
63
What are the dangers of prolonged seizures/status epilepticus?
Seizures increase susceptibility for further seizures -> inc risk of status epilepticus
64
Actively Seizing Patient. What do you do?
Oxygen
Administer IV Benzo (Ativan) 0.02-0.03mg/kg IV
Wait 1 min for response. Give additional Ativan PRN
(Max Dose: 0.1mg/kg)
65
What parts of the history is important in assessing someone wiht a seizure?
```
Hx of previous seizures
Alcohol/Substance Abuse
Insulin/Meds
Previous Neuro-imaging
Metastatic Work Ups
```
66
What kind of seizures are related to alcohol withdrawal compared to intracranial lesions?
Etoh: Generalized
| Intracranial Lesion": Focal Onset
67
What should be the initial test in a patient who had a seizure?
CT Scan
But MRI is preferred due to greater sensitivity and higher yield
If first seizure, get a EEG
68
When is LP indicated in seizure?
If suspected of infection or diffuse neoplastic process
69
What medications should be ordered in patient with seizures 2/2 to alcohol/benzo withdrawal?
Multivitamin
Thiamine
Folate
*Anticonvulsant not usually indicated if etoh thought to be cause of seizure
70
What happens if patient who just seized seizes again?
Get Help
Start Benzos -> If Fail -> Barbiturates (may cause resp failure and necessitate ICU monitoring)
If these fail, will need general anesthesia or propofol
71
What does feculent vomiting indicate?
Distal Intestinal Obstruction
Gastrocolic Fistula
Peritonitis
72
What does Bilious Vomiting indicate?
Prolonged Vomiting
| Obstruction distal to ampulla of vater
73
What does vomiting of undigested food 4-6 hrs after ingestion ndicate?
Pyloric Obstruction
Gastroparesis
Achalasia
Zenker's Diverticulum
74
What does relief of abd pain with vomiting indicate?
Peptic Ulcer
75
What does early satiety with vomiting indicate?
Gastroparesis
76
What does projectile vomiting indicate?
suggests increased intracranial pressure
77
What does early morning vomiting indicate?
alcoholism
| uremia
78
What does chronic small volume vomiting with maintained weight indicate?
Psychogenic vomiting
79
What does missed menses with vomiting indicate?
Morning Sickness 2/2 Pregnancy
80
What does abnormal CAGE questions with N/V indicate?
Alcoholic Gastritis
| Pancreatitis
81
What does vertigo with vomiting indicate?
CNS involvement in CN VIII
82
What does orthostatic decrease of pulse and BP indicate in patient wiht N/V
Intravascular volume depletion
| Tx: IV fluids to prevent organ failure
83
What does absent jugular venous pulse in patient with N/V indicate?
intravascular volume depletion
| Tx: IVF
84
What does dry mucous membranes with N/V indicate?
Dehydration
| Tx: IVF
85
What does abnormal abd exam with N/V indicate?
Disorders of GI tract and related organs
86
What does Papilledema, Nystagmus, or FND indicate with N/V?
Disorder of CNS
87
What tests are useful in DDx of N/V?
```
Pregnancy Test
BMP
Renal Function Tests
LFTs
Lipase
Abd X Ray
Stool for Occult Blood
EKG
Brain Imaging
```
88
Complications of N/V?
```
Dehydration
Metabolic Alkalosis
Hypokalemia
Malnutrition
Vitamin/Mineral Deficiencies
Dental Caries
Aspiration Pneumonitis
Boerhaave's Syndrome
Mallory Weiss Syndrome
```
89
Medication Classes for N/V
```
Serotonin Antagonists
Dopamina Antagonists
Corticosteroids
Benzodiazepines
H1 Antagonists
Antimuscarinics
```
90
Serotonin Antagonists used for N/V
```
Ondansetron
Dolasetron
Granisetron
Tropisetron
Palonosetron
```
91
Dopamine Antagonists used for N/V
Promethazine
Prochlorperazine
Metoclopramide
**If N/V persists after first dose, then switch to different class
92
Corticosteroids used for N/V
Dexamethasone
****If N/V persists after first dose, then switch to different class
93
What should you watch out for when using dopamin antagonists for N/V
Dystonia and EPS SE
94
What should you watch out for when using Dexamethasone for N/V?
Hyperglycemia
95
H1 Antagonists for N/V
Meclizine
Diphenhydramine
Hydroxyzine
96
Antimuscarinics for N/V
Scopolamine
97
75y F with hx of HTN and osteoporosis presenting with acute onset of vertigo with severe nausea and vomiting. Dx with acute labrynthitis. Which anti-emetic will you use?
Meclizine
Diphenhydramine
Good for patients with migraine, motion sickness, vertigo
98
Patient with Hodgkin's Lymphoma receiving chemotherapy now wiht severe nausea. Which anti-emetic will you use?
Serotonin Antagonists: Ondansetron
Others: Dexamethasone, Promethazine
If not responding to any of the above, then consider Benzo as adjunnct therapy for chemo sx
99
Post-Op patient with Nausea and Vomiting currently on morphine PCA. Which anti-emetic will you use?
Decrease or D/C morphine
Add non-opioid adjuvant analgesic
Ondansetron
100
65 y/o F with hx of DM evaluated for nausea of 1 month worsening in intensity. Dx with gastroparesis. Which anti-emetic will you use?
Metoclopramide
| Watch out for dystonia and EPS
101
Cyclic vomiting syndrome. Which anti-emetic will you use?
Supportive Care
| Consider TCA in adults
102
Labs/Imaging to order for possible dementia in 80 year old Male
```
CBC with Diff
CMP
TSH
B12
Folate
RPR
CT Scan without Contrast: r/o subdural hematoma, tumors, etc
```
103
Treatment of Hypernatremia due to volume depletion?
Initially with NS
| Then switch to 1/2NS once euvolemic
104
Confusion in elderly patient in hospital
Provide environment that does not exacerbate
Allow to sleep at night but awake in day
Restraints only as last resort if patient likely to be hurt
Low dose haldol 0.5mg only when other meds haven't worked
105
Plasma Glucose in DKA
>250mg/dl
106
Arterial pH in DKA
<7.3
107
Serum Bicarb in DKA
,< 15mEq/L
108
Features of DKA
>250mg/dl glucose
<7.3 arterial pH
<15mEq/L bicarb
+Ketones
109
Features of HHS
>600mg/dl glucose
Dehydration with serum osm >320 mOsm/kg
Absence of ketoacidosis
AMS
110
Features of Hypoglycemia
Blood Glucose <50 mg/DL
Adrenergic Symptoms
Neuroglycopenic Symptoms
111
Adrenergic Symptoms of Hypoglycemia
Sweating, Pallor, Tachycardia, Palpitations, Hunger
112
Neuroglycopenic Sx of Hypoglycemia
HA, LOC, confusion, somnolence, transient sensory/motor defects, convulsions, coma
113
Metabolic Complications of Diabetes
DKA
HHS
Hypoglycemia
114
What would you assess in a patient with diabetes presenting with symptoms?
Vitals
| Blood Glucose LEvel
115
What labs would you order if suspected DKA?
ABG
Serum Bicarbonate
Serum/Urine Ketones
116
Immediate Treatment Measures for DKA
IVF
| Insulin
117
Do you give Bicarbonate for DKA?
Acidosis should resolve with just IVF and insulin
| Consider if pH <6.9 and initial IVF and insulin do not reverse acidosis
118
What information regarding diabetes should patients need before discharge?
Self Monitoring of Blood Glucose
Prevention, Detection, Treatment of Hypoglycemia
Education on Diet and Exercise
119
Hypoglycemic Patient. What do you start right away?
Establish IV access
| Give D50 glucose 50cc per IV
120
After initial steps of managing acute hypoglycemia in a patient what would you do for maintenance?
Maintenance D10 IVF
| *Single IV push of D50 will not be sufficient
121
Which oral Diabetes medications do not produce hypoglycemia?
Thiazolidinediones
| Metformin
