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Surgery Clerkship > Acute Abdomen OSCE > Flashcards

Acute Abdomen OSCE Flashcards

1
Q

List the 8 general categories of common causes of acute abdomen.

A
  1. GI tract disorders
  2. Liver, spleen, and biliary tract disorders
  3. Pancreatic disorders
  4. Urinary tract disorders
  5. Gynecologic disorders
  6. Vascular disorders
  7. Peritoneal disorders
  8. Retroperitoneal disorders
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2
Q

List the 15 GI tract disorders presenting as acute abdomen.

A
  1. Non-specific abdominal pain*
  2. Appendicitis*
  3. Small and large bowel obstruction*
  4. Perforated peptic ulcer*
  5. Incarcerated hernia
  6. Bowel perforation
  7. Meckel’s diverticulitis
  8. Boerhaave syndrome
  9. Diverticulitis*
  10. IBD
  11. Mallory-Weiss syndrome
  12. Gastroenteritis
  13. Acute gastritis
  14. Mesenteric adenitis
  15. Parasitic infections
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3
Q

List the 8 liver/spleen/biliary tract disorders presenting as acute abdomen.

A
  1. Acute cholecystitis*
  2. Acute cholangitis
  3. Hepatic abscess
  4. Ruptured hepatic tumor
  5. Spontaneous rupture of the spleen
  6. Splenic infarct
  7. Biliary colic
  8. Acute hepatitis
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4
Q

List the 1 pancreatic disorder presenting as acute abdomen.

A
  1. Acute pancreatitis*
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5
Q

List the 4 urinary tract tract disorders presenting as acute abdomen.

A
  1. Ureteral or renal colic*
  2. Acute pyelonephritis
  3. Acute cystitis
  4. Renal infarct
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6
Q

List the 6 gynecologic disorders presenting as acute abdomen.

A
  1. Rupture ectopic pregnancy
  2. Twisted ovarian tumor
  3. Ruptured ovarian follicle cyst
  4. Acute salpingitis*
  5. Dysmenorrhea
  6. Endometriosis
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7
Q

List the 3 vascular disorders presenting as acute abdomen.

A
  1. Rupture aortic and visceral aneurysms
  2. Acute ischemic colitis
  3. Mesenteric thrombosis
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8
Q

List the 3 peritoneal disorders presenting as acute abdomen.

A
  1. Intra-abdominal abscesses
  2. Primary peritonitis
  3. Tuberculous peritonitis
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9
Q

List the 1 retroperitoneal disorder presenting as acute abdomen.

A
  1. Retroperitoneal hemorrhage
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10
Q

DDx - epigastric abdominal pain (4)

A
  1. PUD
  2. Pancreatitis
  3. Biliary disease
  4. MI
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11
Q

DDx - umbilical/diffuse abdominal pain (7)

A
  1. IBD
  2. Bowel obstruction or ischemia
  3. Appendicitis
  4. AAA
  5. IBS
  6. DKA
  7. Gastroenteritis
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12
Q

DDx - RUQ abdominal pain (3)

A
  1. Biliary disease (
  2. Hepatitis
  3. Renal colic
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13
Q

DDx - RLQ abdominal pain (4)

A
  1. Appendicitis
  2. Ovarian disease
  3. PID
  4. Ruptured ectopic pregnancy
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14
Q

DDx - LUQ abdominal pain (2)

A
  1. Splenic injury

2. Renal colic

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15
Q

DDx - LLQ abdominal pain (4)

A
  1. Ovarian disease
  2. PID
  3. Ruptured ectopic pregnancy
  4. Diverticulitis
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16
Q

DDx - Acute first episode (18)

A
  1. AAA
  2. Acute mesenteric ischemia
  3. Appendicitis
  4. Biliary disease
  5. Diverticulitis
  6. DKA
  7. Ectopic pregnancy
  8. Gastroenteritis
  9. Ischemic colitis
  10. MI
  11. Ovarian torsion
  12. Nephrolithiasis
  13. Pancreatitis
  14. Peritonitis
  15. PID
  16. SBO
  17. LBO
  18. Splenic rupture
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17
Q

DDx - Acute recurrent episode

A
  1. Biliary disease
  2. DKA
  3. Diverticulitis
  4. Nephrolithiasis
  5. Pancreatitis
  6. PID
  7. SBO
  8. LBO
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18
Q

DDx - sub-acute/chronic

A
  1. Chronic mesenteric ischemia
  2. IBD
  3. IBS
  4. Hepatitis
  5. PUD
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19
Q

Review the general outline of the history.

A
  1. HPI
  2. Medical Hx (adult illnesses, Ob/Gyn, injuries/accidents, sexual history)
  3. Surgical Hx
  4. Meds
  5. Allergies
  6. Psychosocial (alcohol/tobacco/drugs, travel)
  7. Family History
  8. ROS
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20
Q

Review the ROS categories.

A
  1. Constitutional
  2. Skin
  3. HEENT
  4. Breasts
  5. Respiratory
  6. Cardiac
  7. GI
  8. GU
  9. MSK
  10. Neuro
  11. Psych
  12. Endocrine
  13. Heme/Lymph
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21
Q

Referred pain to the R shoulder?

A

Acute cholecystitis

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22
Q

Referred pain to the groin?

A

Ureteral colic

23
Q

Referred pain to the back or flank?

A

Ruptured aneurysm

24
Q

Referred pain to the back?

A

Acute pancreatitis

25
Q

Obstipation?

A

Mechanical bowel obstruction

26
Q

Physical exam steps?

A
  1. Global assessment
  2. Vitals
  3. HEENT (pallor, icterus, jaundice)
  4. Thorax/back (CVA tenderness)
  5. Lungs
  6. Heart
  7. Abdomen
  8. Peripheral pulses
  9. GU/pelvic exam
  10. Rectal exam
27
Q

Steps of the abdominal exam?

A
  1. Inspection (distention, scars, etc.)
  2. Auscultation (bowel sounds, bruits)
  3. Palpation
  4. Liver, spleen, kidneys
  5. Femoral pulses
  6. Special signs
    - Psoas - raise leg against resistance while supine
    - Obturator - flex leg at hip and knee and internally rotate
    - Rovsing - LLQ, quick release
    - Murphy sign - RUQ pain during inspiration
28
Q

General labs to consider ordering?

A
  1. CBC
  2. BMP (+glucose)
  3. LFTs
  4. ABG
  5. Lactate
  6. Amylase/lipase
  7. Beta-hcg
  8. UA
  9. Occult fecal blood testing
  10. Stool samples for culture if suspected
  11. PT/INR
  12. Type and screen
29
Q

General imaging to consider?

A 
Upright CXR
Abdominal XR/KUB
U/S
CT
Angiography
Proctosigmoidoscopy
Colonoscopy
30
Q

Work-up for appendicitis?

A

U/S (first)

CT (most accurate, useful if uncertain)

31
Q

Management for appendicitis?

A

Observation (urinary output, vitals)
IV fluid resuscitation
Broad-spectrum ABX (GN/anaerobe coverage) - cefoxitin, amp-sulbactam, etc.
Urgent appendectomy (emergent if generalized peritonitis)

32
Q

Work-up for pancreatitis?

A

Serum lipase, liver enzymes

U/S - ALL patients (gallstones/CBD dilation)
CT (if dx unclear or complications suspected)
MRCP/ERCP/EUS if suspicious of gallstones

33
Q

Management for acute pancreatitis?

A

Observation (vitals, orthostatics, urinary output, O2, electrolytes, glucose)
IV fluids (critical)
NPO
Opioids for pain
NG tube (if recurrent vomiting)
FNA and culture if infection suspected (start broad-spectrum if confirmed)
Alcohol abstinence
Etiologies (gallstones -. elective cholecystectomy, IOC or ERCP for choledocholithiasis), cholangitis/bilairy obstruction -> urgent ERCP with sphincterotomy)

34
Q

Work-up for bowel obstruction?

A

CBC, electrolytes, ABG
Plain XR - air-fluid levels and distention
LBO: barium enema or colonoscopy
SBO: CT (test of choice to diagnose); consider bedside U/S, gastrografin small bowel series

35
Q

Management of LBO?

A

Aggressive rehydration and monitoring of urinary output
Broad-spectrum ABX
Consult for possible surgery, stents, balloon dilation
If sigmoid volvulus and no evidence of infarct -> sigmoidoscopy allows decompression and elective surgery
Emergent surgery if perf/ischemia

36
Q

Management of SBO?

A

Fluid resuscitation (IV hydration)
Monitor vitals, orthostasis, urine output
Careful frequent observation, serial exams
NG suction
Broad-spectrum ABX
Frequent plain XR and CBC
Surgery if signs of ischemia, CT findings of infarct, caused by hernia, no hx abdominal surgery

37
Q

Work-up of biliary disease?

A

General test of choice: U/S
Other labs: CBC, LFTs, BCx (ascending cholangitis)

Acute chole: U/S; if negative, but high suspicion -> HIDA
Choledocholithiasis/Pancreatitis/ascending cholangitis: U/S, EUS, MRCP/ERCP

Who gets an ERCP?
High-risk patients for suspected ascending cholangitis, documented CBd stones, bili>4, or bili 1.8-4 + dilated CBDs

Who gets MRCP or EUS followed by selective ERCP?
Moderate-risk patients with documented choledocho + dilated CBD on U/S, elevated bili, galls-stone associated pancreatitis, elevated LFts, age >50

Who gets lap chole right away?
Low-risk patients

38
Q

Management of:

  • Asymptomatic cholelithiasis
  • Symptomatic cholelithiasis (biliary colic)
  • Acute cholecystitis
  • Choledocholithiasis without ascending cholangitis
  • Ascending cholangitis
A
  • Asymptomatic cholelithiasis - nothing
  • Symptomatic cholelithiasis (biliary colic) - elective cholecystectomy
  • Acute cholecystitis - admit, parenteral ABX, cholecystectomy
  • Choledocholithiasis without ascending cholangitis - intraoperative CBD or ERCP (remove stones)
  • Ascending cholangitis - BCx, IV broad-spectrum ABX, IV hydration, drainage with ERCP urgently (moderate to severe disease), electively if more stable; if unavailable, percutaneous transhepatic drainage or surgical decompression
39
Q

Work-up for AAA?

A

Abdominal CT scan

If screening -> U/S
If suspecting ruptured -> CT angio

40
Q

Management of AAA?

A

If rupture -> OR
Elective repair if 5.5+ cm in diameter, tender, increased in size by 1+ cm in 1 year
U/S surveillance if small (4.0-5.4 cm)
Med management - smoking cessation, BP control, aspirin and statins

41
Q

Work-up for acute mesenteric ischemia?

A

CT angiography

Gold standard - catheter angiography (can be therapeutic, but is invasive, time-consuming, not available emergently)

42
Q

Management of acute mesenteric ischemia?

A

Emergent revascularization (thromboembolectomy, thrombolysis, vascular bypass or angioplasty) + surgical resection of necrotic bowel (prompt)
Broad-spectrum ABX
Volume resuscitation
Pre/post-op anticoagulation to prevent thrombus propagation
Intar-arterial papaverine

43
Q

Work-up of ischemic colitis?

A

Colonoscopy without preparation

44
Q

Management of ischemic colitis?

A 
Supportive therapy (bowel rest, IV hydration, broad-spectrum ABX)
Surgery if infarct, peritonitis, sepsis, free air on radiographs, clinical deteriration, strictures
45
Q

Work-up of renal colic?

A

UA, non-contrast renal CT (if pregnant -> U/S)

UA, culture, basic serum chemistries, calcium, analyze retreivewed stones

46
Q

Management of nephrolithiasis?

A

Pain control (NSAIDs)
Hydration (oral if tolerated)
Hospitalize if unctonrolled pain, persistent N/V, AKi, signs of infection
Sepsis or AKI 2/2 bilateral obstruction -> emergent drainage
If sepsis -> broad spectrum ABX
Nifedipine and tamsulosin increase likelihood of stone passage
Lithotripsy or ureteroscopy if persistent

47
Q

Work-up of diverticulitis?

A

CT scan (test of choice)

48
Q

Management of diverticulitis (outpatient)?

A

Cipro + metronidazole for 7-10 days
Liquid diet
High-fiber diet after attack resolves
Follow-up colonoscopy

49
Q

Management of diverticulitis (inpatient)?

A

Broad-spectrum IV ABX
NPO
CT-guided drainage for abscesses >5 cm
Emergent surgery if peritonitis, uncontrolled sepsis, clinical deterioration despite med management, obstruction or large abscesses that cannot be drained

50
Q

Work-up chronic mesenteric ischemia?

A

Duplex U/S (initial, very sensitive)

CT/MR angio if needed

51
Q

Rx chronic mesenteric ischemia?

A

Revascularization

52
Q

Work-up PUD?

A

EGD
Urea breath test for H. pylori
Stool Ag assay

53
Q

Rx PUD?

A

Stop NSAIDs
Eradicate H. pylori
Use PPIs
Biopsy if gastric ulcers

Surgery Clerkship (1 decks)

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