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Surgery and Emergency Med > Acute Abdomen > Flashcards

Acute Abdomen Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

9 life threatening abdominal pain

A

AAA

Abdominal aortic dissection

GI perf

Incarcerated hernia

Acute bowel obstruction

Mesenteric ischemia

Ectopic preg

Placental abruption

Splenic rupture

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2
Q

top 10 dx in pts with abdomen pain in ER

A

appendicitis

biliary tract disease

SBO

gyn disease

pancreatitis

renal colic

perforated ulcer

cancer

diverticular disease

non-spec abd pain

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3
Q

red flags in hx of acute abdominal pain

A

age over 65

alcoholism

immunocompromised

CVD

prior surgery

comorbidities

recent GI instrumentation

early preg

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4
Q

pain characteristics of acute abdominal pain

A

acute onset

sig pain at onset

pain followed by emesis

constant pain less than 2 days

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5
Q

physical exam of acute abdominal pain

A

rigid abdomen

signs of shock

involuntary guarding

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6
Q

referred pain:

gall bladder to ____

A

right subscapular area

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7
Q

referred pain

perforated duodenal ulcer to

A

shoulders

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8
Q

referred pain

ureteral obstruction to

A

testicles

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9
Q

referred pain

MI to where

A

epigastric area, jaw, neck, upper extremity

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10
Q

referred pain

GYN to where

A

lower back

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11
Q

def acute

A

less than 72 hours

progressive worsening

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12
Q

chronic def

A

unchanged for months - years

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13
Q

visceral or parietal pain

dull, achy, colicky

poorly localized

distention, ischemia
, inflammation or spasm of a hollow organ

A

visceral

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14
Q

visceral or parietal pain

sharp

well localized

peritoneal irritation, ischemia, infalmmation/stretching of parietal peritoneum

A

parietal

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15
Q

5 things that cause abrupt excrutiating pain

A

biliary colic

ureteral colic

myocardial infarction

perforated ulcer

ruptured aneurysm

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16
Q

6 things that cause gradual, steady pain

A

acute cholecystitis

acute cholangitis

acute hepatitis

appendicitis

acute salpingitis

diverticulitis

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17
Q

3 things that cause rapid onset of severe, constant pain

A

acute pancreatitis

mesenteric thrombosis, strangulated bowel

ectopic preg

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18
Q

3 things that cause intermittent, colicky pain, crescendo with free intervals

A

early pancreatitis (rare)

small bowel obstruction

inflammatory bowel disease

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19
Q

acute abdominal pain pertinent history (think OLDCAARTS)

A

sudden or gradual?

aggravating and alleviating factors?

quality - colicky, waxing/waning, dull/sharp

site - diffuse or particular quadrant

timing - hours or weeks

radiation - shoulder, flank, chest, perineum

assoc symptoms: fever, nausea vomiting diarrhea or constipation, dysuria, bloody stool, vaginal discharge, SOB

PMH: any cardiac risk factors

surgical hx: prior abdominal surgery ***

med hx: bleeding risk, pain meds, pepto?

social hx: menstrual, contraceptives, STI risk, alcohol use

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20
Q

physical exam with acute abdomen pain

A

appearance and level of comfort

movement or lack of movement in pt

skin color

vital signs

temp: fever or hypothermia?

resp rate - may be increased due to pain or compensatory due to metabolic acidosis

BP - hypotension due to sepsis, GI bleed

auscultation of heart/lungs: afib, pnuemonia

auscultation of bowel sounds: hypoactive or hyperactive

bruits: AAA

palpation!!!

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21
Q

restless pt who cannot sit still - whatcha thinking?

A

renal colic

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22
Q

lying perfectly still or supine - whatcha thinking?

A

peritonitis

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23
Q

if hypoactive or absent bowel sounds whatcha thinking

A

peritonitis, SBO

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24
Q

if hyperactive bowel sounds, whatcha thinking?

A

blood/inflammation of GI tract

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25
Q

if you hear bruits, you’re thinking

A

AAA

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26
Q

palpation with acute abdomen pain

what should you do for bones

A

chest wall, spine, pelvis

CVAT (costovertebral angle tenderness)

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27
Q

palpation with acute abdomen pain

abdominal exam

A

complete!

check for hernias

assess for hepatospenomegaly

specialized exams: rebound, Murphys

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28
Q

palpation with acute abdomen pain - men and women who have lower quadrant or hypogastric pain

A

testicular exam/pelvic ecam in all

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29
Q

acute abdomen physical exam

palpation of butt

A

rectal exam

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30
Q

initial dx of acute abdominal pain

A

CBC with diff

BMP/CMP

AST, ALT, Alk phoh total bilirubin

lipase/amylase

lactic acid

UA

urine preg in females

stool guaiac

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31
Q

imaging with acute abdomen (what three)

A

plain films

CT

ultrasound

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32
Q

when do you use plain films with acute abdomen pain

A

dilated bowel loops

air-fluid levels

free air

constipation

foreign body

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33
Q

when do you use CT WITHOUT CONTRAST with acute abdomen pain

A

renal stone, obstruction

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34
Q

when do you use CT WITH IV CONTRAST

A

ischemic bowel, diverticulitis, peritonitis, AAA

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35
Q

when do you use CT with ORAL contrast

A

really skinny adults and kiddos

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36
Q

when do you use US

A

gall bladder, free fluid, renal, ovarian, testicle

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37
Q

General tx of acute abdominal pain

A

IV fluids

anti-vomiting

analgesia

anti-pyretic

NPO

antibx when indicated

consults

monitor for signs of sepsis and shock, repeat exam and vitals frequently - look for fever, tachy, hypotension, AMS

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38
Q

5 dx that require urgent surgical referral

A

obstruction

perforation

peritonitis

ischemic bowel

dissection

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39
Q

increased tenderness and rigidity

pain is severe and out of proportion to exam

what do you do?

A

URGENT SURGERY

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40
Q

who may have vague, nonspecific, atypical presentation of acute abdominal pain

A

elderly

DM/immunocomp

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41
Q

causes of perforation of GI tract

A

spontaneous due to inflammatory changes (gallbladder, appendix)

bowel obstruction

trauma

instrumentation

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42
Q

clinical manifestations depend on what with perforation

A

organ affected and contents released:

air
stool
succus entericus - ENZYMES and MUCUS

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43
Q

who is perforations more common in

A

over 50 y/o

less than 10 y/o

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44
Q

perforation: diffuse or localized

A

diffuse pain AFTER localized tenderness

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45
Q

progression of perforation to peritonitis

A

pain may be relieved and then peritoniitis comes about!

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46
Q

5 things that describe peritonitis

A

occurs after perforation

high fever

may lead to sepsis/death

localized - contained to surrounding viscera or omentum

generalized = gross spillage into peritoneal cavity

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47
Q

how to tx abscess?

A

drainage

antibx

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48
Q

how do pts with peritonitis present

A

SICK

lie still to minimize discomfort

bloating/feeling of fullness

rebound tenderness, tenderness to percussion

pain with light palpation/bumps

HYPOACTIVE bowel sounds

N/V

Anorexia

low urine output

fever

cannot pass stool/gas

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49
Q

spontaneous bacterial peritonitis clinical presentation

A

SBP: ascites, liver cirrhosis, fever, AMS, abdominal pain +/- hypotension

IF super ascites - ridig abdomen may not be present

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50
Q

what do you do if you suspect spontaneous bacterial peritonitis

A

paracentesis

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51
Q

what do you NOT do with spontaneous bacterial peritonis

A

NO EXPLORATORY LAPAROTOMY

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52
Q

tx of spontaneous bacterial peritonitis

A

cefotaxime (antibx)

usually e.coli or klebsiella

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53
Q

clinical presentation of secondary bacterial peritonitis

A

possible perforation - peptic ulcer disease, appendicitis

ascites, fever, AMS, abdominal pain +/- hypotension

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54
Q

tx for secondary bacterial peritonitis

A

paracentesis WITH EXPLORATORY LAPAROTOMY (different spontaneous bacterial peritonitis)

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55
Q

tx of secondary bacterial peritonitis

A

cefotaxime

e. coli or klebsiella

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56
Q

what dx?

assoc with gallbladder inflammation that is usually related to gallstone disease

severe, constant pain in RUQ over 6 hours

radiates to epigastric and right shoulder

N/V, increase pain with fatty foo intake

guarding and RUQ pain withpalpation

+ Murphys sign

ill appearing, want to lie still
tachycardia

A

acute cholecystitis

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57
Q

+ Murphys

A

Acute cholecystitis

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58
Q

most common surgical emergency in elderly

A

acute cholecystitis

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59
Q

what will you see on labs with acute cholecystitis

A

leukocytosis with bands

elevated CRP

normal alkaline phosphate and transaminase

normal bilirubin

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60
Q

what would you do for imaging for acute cholecystitis and what will you see

A

RUQ US

gallbladder wall thickening

sonographic “Murphys sign”

gallstones or sludge

pericholecystic fluid

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61
Q

mgmt of acute cholecystitis

A

IV fluids

analgesia

NPO

antibx (ceftriaxone, cefuroxime)

non-opperative or opperative (another flashcard)

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62
Q

non-operative mgmt of acute cholecystitis

A

watch and wait - if lack of noticeable improvement within 1-2 days – need to do surgery

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63
Q

operative mgmt of acute cholecystitis with UNSTABLE pts

A

percutaneous drainage with radiologic guidance

do surgery when stable

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64
Q

presence of gallstones WITHIN the common bile duct

what dx?

A

acute choledocholithiasis

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65
Q

most common cause of acute choledocholithiasis

A

secondary - passage of stones from gallbladder to common bile duct

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66
Q

less common cause of acute choledocholithiasis

A

primary - formation of stones within common bile duct

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67
Q

clinical presentation of acute choledocholithiasis

A

biliary type pain (colicky)

RUQ pain that can radiate to epigastric region

N/V

Pain can be intermittent if transient blockage

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68
Q

labs elevated in acute choledocholithaisis

A

elevated bilirubin

elevated alk phos

elevated transaminases

elevated GTT

(diff than acute cholecystitis)

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69
Q

is gallbladder palpable in acute choledocholithiasis?

what sign

A

can - Courvoisier’s sign!

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70
Q

Courvoisier’s sign (palpable gallbladder) with what dx

A

acute choledocholithiasis

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71
Q

imaging for acute acholdocholithiaiss

A

US - looking for presence of stones in gallbladder/common bile duct

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72
Q

tx of acute choledocholithiasis for high risk pts?

A

consult surgery, GI

ERCP - remove stone followed by elective cholecystectomy

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73
Q

tx of acute choledocholithiaiss for low risk pts

A

cholecystectomy only

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74
Q

complications of acute choledocholithiasis

A

acute pancreatitis

acute cholangitis

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75
Q

what is acute cholangitis

A

ascending bacterial infection

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76
Q

is acute cholangitis an emergency

A

YES

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77
Q

causes of acute cholangitis

A

it is due to obstruction of biliary ducts

causes: biliary calculi, malig, benign stenosis

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78
Q

microbio of acute cholangitis

A

enterococci (most common)

e. coli

klebsiella

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79
Q

acute cholangitis presentation (not as serious even though still serious)

A

Charcot’s triad

fever/chills
RUQ/abdominal pain
jaundice

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80
Q

acute cholangitis presentation (SEVERE SEVERE)

A

charcot’s triad (fever/chills, RUQ/abdoinal pain, jaundice)

+

AMS
Hypotension

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81
Q

labs with acute cholangisits

A

leukocytosis (neutrophilia)

elevated alk phos, GGT, bilirubin, transaminases

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82
Q

if you suspect acute cholangitis and labs come back and show elevated amylase - what does this mean

A

pancreatic involvement!

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83
Q

imaging of acute cholangitis

A

US - common bile duct dilation or stones

EUS

ERCP

MRCO

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84
Q

in pregnant people with suspected acute cholangitis - what do you do

A

US first and then fetal shielding during ERCP if needed

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85
Q

acute cholangitis management

A

admit

NPO (in case surgery)

IV fluids

analgesia

consult GI/ID

monitor for sepsis (blood cultures x 2)

empiric antibx tx

biliary drainage

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86
Q

surgery for acute cholangitis

A

biliary drainage - ERCP (dx and tx)

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87
Q

antibx tx for acute cholangitis

A

empiric - ceftriaxone AND metro)

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88
Q

what dx?

abrupt onset RUQ abdominal pain

N/V

anorexia

fever/malaise

dark urine, pale stools

jaundice/scleral icterus

hepatomegaly

splenomegaly

A

hep A

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89
Q

labs with Hep A

A

elevated ALT > AST

elevated alk phos

elevated bilirubin

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90
Q

tx of hep A

A

symptomatic

fecal oral spread is common so counsel on hygiene

pt contagious for 28 days before and up to one week following onset of jaundice

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91
Q

acute inflammatory process of pancreas

A

pancreatitis

92
Q

mild

moderate

severe

pancreatitis

A

mild: no organ failure or systemic complications
mod: transient organ failure (resolves within 48 hours)
severe: persistant organ failure can be more than one organ

93
Q

gallstone pancreatitis clinical presentation

A

well localized pain with rapid onset

94
Q

how does pancreatitis due to other causes (other than gallstone) present and what leads to pancreatitis (4)

A

less well localized with slower progression

alcohol, drugs (amiodarone, antivirals, diuretics, NSAIDS, antibx), severe hyperlipidemia, idiopathic

95
Q

pancreatitis presentation

A

persistent, severe, boring acute epigastric or RUQ pain

radiates to back

pain may be relieved by leading forward

+/- dyspnea due to diaphragmatic inflammation

N/V

Bloating

96
Q

pancreatitis physical exam

A

fever

tachypnea

hypotension

epigastric or diffuse tenderness

hypoactive bowel sounds

abdominal distention

scleral icterus/jaundice if due to choledocholithiasis

97
Q

2 “signs” of pancreatitis and describe

A

Cullens sign - periumbilical region with superficial edema and bruising in the subcutaneous fatty tissue around umbilicus

Grey turner sign: along the flank - ecchymotic discoloration due to retroperitoneal bleeding from pancreatic necrosis

98
Q

dx of pancreatitis (labs and imaging)

A

lipase elvated (3 times normal)

amylase elvated (3 times normal)

increased CRp

maybe leukocytosis

imaging:
US: enlarged pancreas, gallstones possible

CT with IV contrast: not as sensitive in early disease + diffuse enlargement, necrosis, stones

MRI: sensitive in early disease

99
Q

which imaging is sensitive to pancreatitis in early disease

A

MRI -

100
Q

pt must meet TWO of the following to meet pancreatitis dx?

A

acute onset of constant, severe epigastric pain radiating to back

elevation in serum lipase or amylase to 3 times greater the normal limit

characteristic findings of acute pancreatitis on imaging

IF pts meet first two criteria, no imaging needed to establish dx BUT helpful to rule out necrosis

101
Q

pancreatitis mgmt

A

admit, ICU monitoring

NPO

IV fluids

NG tube

Foley catheter

Serial labs - amylase + electrolytes

Analgesia (opaites)

Consult GI for gallstone pancreatitis - ERCP

102
Q

what dx?

assoc with GERD

risk factors:

NSAIDS use, H. pylori infection, smoking, excessive vomiting (people with gastroparesis, gastroenteritis, anorexia nervosa, bulimia nervosa)

A

PUD

can be atypical presentation in elderly

103
Q

epigastric pain

pain radiates to midthoracic region

early satiety

dyspepsia

heartburn

pain with eating

shortness of breath, cough, (esp with lying flat)

N/V

Hematemsis

anorexia

melena

hematochezia with perf

A

PUD

104
Q

PUD dx (labs)

A

CBC for Hgb/Hct

BMP for electrolytes

Hemoccult

105
Q

PUD dx (imaging and consult)

A

kidney/ureter/bladder - check for free air

GI consult: endoscopy with biopsy

106
Q

PUD tx

A

NSAIDS, H.pylori should be tx

if perforated - surgery!

107
Q

what dx?

LUQ pain

+/- splenomegaly

fever

+/- left side pleural effusion

typ. results from endocarditis or seeding from another site

A

splenic abscess

108
Q

typ results from endocarditis or seeding from another site

A

splenic abscess

109
Q

dx of splenic abscess

A

CT scan with IV contrast

110
Q

tx of splenic abscess

A

admit

NPO

IV fluids

antibx

consult with srugeon for splenectomy +/- ID consult

111
Q

what dx?

splenic arterty or sub-branch occluded by embolus, clot or by infection

A

splenic infarct

112
Q

risk factors for splenic infarct

A

hypercoagulable state (malig)

embolic disease (afib, infective endocarditis)

sickle cell disease

trauma

complication of mono

113
Q

clinical presentation of splenic infarct

A

acute LUQ pain

+/- splenomegaly

fever

N/V

Elevated LDH

leukocytosis

114
Q

dx of splenic infarct

A

CT scan with IV contrast

115
Q

tx of splenic infarct

A

varies due to cause

uncomplicated - analgesia, monitor

complicated (abscessm sepsis, hemorrhage) - surgical eval for splenectomy

consult GI/surgery

116
Q

atraumatic splenic rupture hx

A

neoplasms (leukemia, lymphoma)

infection (mono, CMV, HIV)

inflammatory disease (acute/chronic pancreatitis)

drugs (anticaog)

mechanical (preg)

idiopathic

117
Q

classic presentation of splenic rupture

A

pain, fullness in LUQ

referred pain in left shoulder

pleuritic pain

early satiety

118
Q

dx of splenic rupture - gold standard

A

US

119
Q

other way to dx splenic rupture - not gold standard

A

CT with IV contrast

120
Q

tx of splenic rupture

A

NPO

IVFluids

type and cross for transfusion??

immediate surgery - splenectomy

121
Q

risk factors for what?

prior abdominal/pelvic surgery (adhesions)

abdominal wall/groin hernia

intestinal inflammation

neoplasm

prior irradiation

foreign body ingestion

intussusception/volvulus**

A

small bowel obstruction

122
Q

the lead point of the bowel is pulled forward by normal peristalsis, telescoping or prolapsing the affected segment of the bowel into another segment of bowel

waht is this

A

intussusception

123
Q

air filled loop of the sigmoid colon twists about its mesentery - what is this

A

volvulus

124
Q

volvulus and intussusception - common or rare in adults

A

rare

125
Q

N/V

Cramping abdominal pain, periumbilical

pain may become more focal if ischemia/necrosis

obstipation (inability to pass flatus or stool)

may be dehydrated

+/- fever if abscess/ischemia/necrosis

labs are variable dep on cause/timing

clinical presentation of what

A

small bowel obstruction

126
Q

small bowel obstruction imaging

A

abdominal x ray

CT

127
Q

what do you see on abdominal xray with small bowel obstruction

A

dilated loops of bowel with air-fluid levels

proximal bowel dilation with distal bowel collapse

128
Q

what do you see on CT with small bowel obstuction

A

severity

masses, inflammatory changes

necrosis, perforation, ischemia

129
Q

tx of small bowel obstruction

A

admit

NPO

IV fluids

anti-emetics

NG tube

consult surgery - GI

130
Q

when is surgery warranted with small bowel obstruction

A

when it is not resolved with NG tube and bowel rest

131
Q

surgical tx of small bowel obstruction and WHEN

A

immediate surgery - antibx for signs of complicated bowel obstruction

132
Q

decreased or no perfusion to section of colon

occlusive process (arterial or venous)

embolic, thrombotic, athersclerosis

waht dx

A

acute mesenteric ischemia

133
Q

risk factors for acute mesenteric ischemia

A

cardiac arrhythmias

advanced age

low cardiac output states

valvular heart disease

MI

malig

134
Q

clinical presentation of acute mesenteric ischemia with arterial thrombosis/emboli

A

rapid onset, severe periumbilical pain out of proportion to physical exam

N/V common

possible forceful bowel evacuation

post-prandial pain (15-30 min)

+/- hematochezia

high mortality

135
Q

acute mesenteric ischemia with venous thrombosis

A

more indolent course

lower assoc mortality

136
Q

which is more assoc with mortality: arterial thromvosis/emboli and acute mesenteric ischemia OR venous thrombosis and acute mesenteric ischemia

A

arterial thrombosis/emboli and acute mesenteric ischemia

137
Q

labs with acute mesenteric ischemia

A

hemoconcentration

increased lactate

increased LDH

MAYBE elevated serum amylase

d-dimer

138
Q

dx of acute mesenteric ischemia

A

early signs/symptoms are non-specific

plain abdominal films: free air and signs of dead bowel

139
Q

while trying to dx acute mesenteric ischemia and you see free air and/or signs of dead, bowel, what do you do?

what do you do if you do NOT see free air or signs of dead bowel

A

if you do - do laparotomy - embolectomy or colon resectioning

if you do NOT - abdominal CT angiography with IV contrast

140
Q

acute mesenteric ischemia mgmt

A

admit

IV fluids

NPO

foley

empiric antibx (ceftriaxone + metro)

systemic anticoag

consult GI/surgery/cardio/vascular

141
Q

most common abdominal emergency

A

appendicitis

142
Q

blockage of appendix with stool, appendicolith, tumor with secondary infection can lead to what

A

appendicitis

143
Q

is appendicitis easily missed?

A

yes - in pts under 12 y/o, up to 57% of cases are missed

if under 2 y/o, approx 100% of cases are missed

144
Q

normal location for appendicitis pain

A

starts at periumbilical and moves to RLQ in approx 35% of patients

145
Q

retroceccal appendix

what will you see

A

back/flank/testicular pain + psoas sign

146
Q

+ psoas sign seen in what

A

retroceccal appendix

147
Q

pelvic appendix - what will you see

A

suprapubic/rectal pain/dysuria/diarrhea more common

obturator sign

148
Q

+ obturator sign seen in what

A

pelvic appendix

149
Q

what is the psoas sign

A

hip extension

150
Q

what is the obturator sign

A

rotation of right flexed hip

151
Q

appendicitis - pt will complain of

A

N/V

anorexia

fever (later finding)

rebound tenderness/positive rovsing sign

MAYBE rigidity, voluntary guarding, pain on rectal exam - this all depends on duration of symptoms/location of appendix

152
Q

labs of appendicitis

A

leukocytosis (bands) - extreme elevation? consider perforation

153
Q

does a normal WBC rule out appendicitis

A

NOPE

154
Q

what can UA show with appendicitis

A

pyruria, bacteria, hematuria if appendix is near bladder or ureter

155
Q

where can pain present with appendicitis in third trimester of pregnancy

A

RUQ

due to displacement

156
Q

is imaging needed for appendicitis

A

nope - not if clinical dx can be made

157
Q

how to dx appendicitis if dx is UNCLEAR

what do you do in pregnant pts?

A

CT with contrast - shows inflammation, abscesses, fat stranding, fluid collection

MRI with contrast for pregnancy

158
Q

appendicitis tx

A

admit

IV fluids

NPO

analgesia

antibx (Cefoxitin or cefazolin + metro)

surgery consult

159
Q

inflammation generally considered to be due to microperforation of a diverticulum

A

diverticulitis

160
Q

diverticulitis - prevalence ____ with age

A

increases

161
Q

diverticultis pts usually have a hx of what

A

diverticulosis

162
Q

diverticulitis pain description

A

deep, constant, steady

163
Q

what can result from acute attack of diverticulitis

A

obstruction/paralytic ileus due to edema and compression of colon (inflammation)

164
Q

clinical presentation of diverticulitis

A

N/V

change in bowel habits

urinary urgency, freq, dysuria

low grade fever

rebound/guarding

localized tenderness

left sided pain (tender mass) on rectal exam

165
Q

diverticulitis - positive or negative stool guaiac

A

positive

166
Q

diverticulitis - hyperactive/high pitched bowel sounds lead you to believe what

A

obstruction

167
Q

diverticulitis - hypoactive/absent bowerl sounds lead you to believe what

A

peritonitis

168
Q

UA will show what with diverticulitis

A

pyruria (PUS)

169
Q

imaging for diverticulitis (preferred)

A

CT with contrast to see localized bowel thickening, colonic diverticula, abscesses, fistulas, dilated loops of bowel (bowel obstruction)

170
Q

tx of uncomplicated diverticulitis

A

home with oral antibx (cipro + metro)

close follow up within 2 days with GI

171
Q

tx of complicated diverticulitis - perforation, abscess, fistual, or obstruction

A

admit

iv fluids

NPO

IV antibx (type varies)

consult GI/surgery

172
Q

most common complicatino of IBD

A

toxic megacolon

173
Q

toxic megacolon can be complication of what diseases

A

IBD

volvulus

diverticulitis

obstructive colon cancer

secondary to C. diff

CMV in HIV pts

174
Q

what dx?

severe, bloody diarrhea

toxic appearing pt

AMS

tachycardia

fever

postural hypotension

abdominal distension and tenderness

A

toxic megacolon

175
Q

imaging for toxic megacolon

A

XRAY (abdomen)

transverse and right colon most dilated (up to 15 cm)

may or may not have air fluid levels

176
Q

dx criteria for toxic megacolon

A

enlarged, dilated colon on xray

fever over 38C

HR over 120 bpm

neutrophilic leukocytosis over 10,500

Anemia (PLUS)

Dehydration

AMS

Electrolyte disturbance

Hypotension

177
Q

tx for toxic megacolon

A

admit

IV fluids

NPO

NG tube placement

no anti-motility agents, opiods

broad spectrum IV antibx (amp, gentamycin, metro)

IV steroids (prednisolone or methylprenisolone)

surgery/GI consult

178
Q

complications of toxic megacolon

A

perf

massive hemorrhage

progression of dilation

179
Q

assoc with rectal bleeding, bright red, can be copious

anal pruritis, prolapse

acute perianal pain; “lump” due to thrombosis

what dx?

A

hemorrhoid

180
Q

complications of hemorrhoid

A

prolapse

strangulated

gangrenous changes

181
Q

phys exam for hemorrhoids

A

visual inspection

DRE

anoscopy

other endoscopic procedures

182
Q

internal and external hemorrhoid mgmt

A

internal or external can be excised by surgeon

183
Q

thrombosed hemorrhoid tx

A

incise overlying skin and evacuate small clot to provide immediate relief

184
Q

symptomatic tx of hemorrhoids

A

increased fluid and fiber

185
Q

severe in pain in anal area

fever uncommon unless cellulitis

areas of flatulence/indurated skin perianal area

no findings on digital rectal exam

what dx?

A

perianal abscess

186
Q

tx of simple perianal abscess

A

can be drained in ER

anesthetize area, open wound, evacuate pus, irrigate well

no packing

sitz baths at home

187
Q

when do you use antibx with perianal abscess

A

cellulitis, signs of systemic infection, DM, valvular heart disease, immunosuppression

188
Q

for extensive non-superficial perianal abscesses, what do you do

A

Admit

CT or MRI to determine extension

drained

GI +/- surgeon

189
Q

frequently long delay before medical attention

shape and size of object influences mgmt

anorectal or abdominal pain, blood per rectum, mucus discharge

what is this dx

A

rectal foreign body

190
Q

physical exam of rectal foreign body

A

findings are variable

plain radiograph - flat and upright

CT scan if rectal foreign body is radio-opaque (WHITE)

191
Q

tx of rectal foreign body

A

remove it - relax with IV sedation

OR

surgical removal - abdominal palpation allows for caudal pressure and stabilization; laparoscopy; colotomy with primary closure

following removal further evaluate with rigid proctoscopy or flexible sigmoidoscopy

192
Q

5 causes of pelvic pain

A

ectopic preg

PID

ovarian torsion

ovarian cancer

postpartum endometritis

193
Q

female pelvic pain workup

A

CBC with diff

BMP

Urinalysis

HCG (get quant if +)

Nucleic acid amp test (NAAT) for chlamydia and gonorrhea

Gram stain, cultures

Pelvic exam, check for cervical motion tenderness, erythema/edema

palpate ovaries for size, pain, masses

194
Q

dx tests for female pelvic pain workup

A

US transvaginal:

suspected ovarian neoplasms, masses, torsion, ectopic preg

CT for further eval if needed following US

MRI in pregnant women

195
Q

vaginal bleeding with pain, typically 6-8 weeks after last menses

can present with life-threatening hemorrhage if ruptured

what dx

A

ectopic preg

196
Q

what do you monitor with ectopic preg

A

Hgb/Hct

197
Q

dx of ectopic preg

A

transvaginal + HCG ultrasound

198
Q

ectopic preg tx for stable pt

A

methotrexate

199
Q

ectopic pregnancy methotrexate NOT used when

A

if high hCG concentration

fetal heart activity noted

large ectopic size

renal/liver disease

breastfeeding

200
Q

ectopic pregnancy tx IF suspected tubal rupture/hemodynamically unstable

A

oophorectomy

201
Q

who do you consult with ectopic pregnancy tx

A

GYN

202
Q

85% of PID are related to STI - consider testing for what

A

HIV and syphillis

203
Q

Will you have fever/chills with PID

A

yes

204
Q

new vaginal discharge (mucupurulent/intermenstrual bleeding)

pelvic tenderness on palpation

cervical friability

presence of abundant WBCs on saline microscopy of vaginal fluid

what dx

A

PID

205
Q

what dx tests for PID

A

ESR + CRP

Transvaginal US to evaluate for suspected abscess/pelvic free fluid

NAATs for C. trachomatis and N. gonorrhea

gram stain + cultures

206
Q

when do you hospitalize your PID pt

A

severe clinical illness

unable to tolerate POs

complicated PID with abscess

preg or post-partum

207
Q

PID mgmt (general)

A

IV fluids

pain control

anti-emetic

antibx

GYN consult

208
Q

if you decide inpt tx for PID, how do you tx and what do you do?

A

cefoxitin + doxy

blood cultures x 2 if admitting

IV fluids

pain control

anti-emetic

consult GYN

209
Q

outpt tx of PID

A

ceftriaxone + doxy

IV fluids

pain control

anti-emetic

consult GYN

210
Q

what dx?

partial or complete rotation of ovary, often results in ischemia

most common GYN emergency

increased risk in preg

acute onset of pain, N/V and adnexal mass on exam

pain can radiate to back/flank/groin

+/- fever (marker of necrosis)

+/- abnormal genital tract bleeding

A

ovarian torsion

211
Q

imaging of ovarian torsion

A

ultrasound with duplex for blood flow (transvaginal + transabdominal)

direct visualization during surgical eval

212
Q

tx of pre-menopausal with viable ovary, no malignancy

A

laparoscopic detorsion

213
Q

tx of post-menopausal with nonviable ovary or suspected malignancy

A

salpingo-oophorectomy

214
Q

adnexal mass, abdominal distention

bloating, early satiety

weight loss

urinary uregency, frequency

acute presentation can be malignant effusion or SBO

what dx?

A

ovarian cancer

215
Q

dx tests of ovarian cancer

A

US: transvaginal + transabdominal

Labs: tumor markers (CA 125)

216
Q

tx tests of ovarian cancer

A

consult surgery

oncology/GYN

217
Q

common cause of postpartum febrile mortality caused by infection of endometrium after delivery

what dx

A

postpartum endometritis

218
Q

how will postpartum endometritis

A

fever/chills + uterine tenderness

foul smelling discharge (lochia)

uterus may be soft

+/- excessive uterine bleeding

219
Q

tx of postpartum endometritis

A

admit

IV antibiotics (clindamycin IV + gentamycin IV)

consult GYN

220
Q

what do you ALWAYS do in ALL pts with lower abdominal pain

A

a pelvic/rectal exam

221
Q

significant abdominal pain should/should not be attributed to gastroenteritis

A

should not

222
Q

in older pts with risk factors and abdominal pain exclude _____

A

AAA

223
Q

is pain awakening the pt from sleep is/is not significant

A

is significant

224
Q

does a lack of free air on chest xray rule out perforation

A

NO

225
Q

anytime you have concern with surgical GI bleed - what do you order

A

type/cross

226
Q

pts on chronic steroids or chronic opiate therapy can have what

A

masking of pain

227
Q

older pts typically perceive pain more/less than younger pts

A

LESS

same with DM**

Surgery and Emergency Med (6 decks)

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