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GEN MED III > Acute Abdominal Pain > Flashcards

Acute Abdominal Pain Flashcards

1
Q

Pressure, Bloaty Pain

A

Bowel Obstruction

Worst Cases: Volvulus & MegaColon

Get a KUB. Look for:
-Air under diaphragm in perforation. This is a surgical 911

  • Air/Fluid lines and loops of bowel for small bowel obstruction
  • Twists for volvulus
  • Distention for megacolon.

Insert NG and vacuum out air to relieve pressure on that bowel

May need surgery. May self resolve. Get an EKG, CBC & CMP just in case

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2
Q

Prior Abdominal Surgery causes

A

ADHESIONS…

Adhesions cause: Small Bowel Obstruction and volvulus

N/V/crampy pain like something getting stuck

NG Tube & supportive care
KUB, EKG, CBC, BMP

Surgery is avoided with adhesions as going in again will undoubtably create more adhesions…

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3
Q

What two questions do we ALWAYS ask about abdominal pain, no matter where it is or what its like?

A

When was your last BM?

Have you had Abdominal Surgery?

 - Appendix?
 - Hysterectomy?  Ovarectomy?
 - Splenectomy?

If the thing is GONE we can cross related problems off our Ddx list from the beginning!!!

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4
Q

Diarrhea signals what?

A

Colitis
Enteritis
Some kind of inflammation

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5
Q

Colitis vs Enteritis

A

Inflammation of the Colon= colitis
Inflammation of the Sm Intsestine is Enteritis

Both can be bacterial in nature but could also be crohns/uncerative colitis

Both have diarrhea

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6
Q

Tenesmus

A

Sense of incomplete emptying of the rectum.

Think Inflammatory Diseases of the Bowel:

IBD: Crohns/Ulcerative Colitis
Diverticulitis

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7
Q

IBD vs IBS

A 
IBD= Chronic Inflamm of the 
          Intestines.  
  BLOOD IN THE STOOL, ANAL/MOUTH SORES
          ESR and 
          C-Reactive Protein will be +
          d/t the inflammation
          a)Crohns Dz
          b)Ulcerative Colitis
          c) Other or Ideopathic Colitis
IBS= No Inflammation/No known 
         Cause (Idiopathic)
   PAIN WORSTENS WITH STRESS
         - In IBS ESR and CReactive
           Protein will be normal as 
           there is no inflammation
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8
Q

Constant, Unrelenting, Chronic Abdominal Pain, Think

A

Malignancy

Chronic Pancreatitis

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9
Q

Pain relieved by defecation, especially in young people

A

Irritable Bowel SYNDROME

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10
Q

RECTAL BLEEDING?

A

COLONOSCOPY

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11
Q

MELENA

A

UPPER GI ENDOSCOPY

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12
Q

Coronary Artery Dz, Carotid Bruits, BIG with pain an hour or so after eating…

A

Think about atherosclerosis of the mesentery. Digestion is the “exertion” that triggers ischemic pain. This is essentially angina of the bowel.

Start with a KUB you are unlikely to find ischemic mesentery on one but you might find something else.

CT-Angiography will be diagnostic or can rule out ischemic mesentery AND… CT Guided Angiography can FIX IT by delivering clot dissolving medications directly to the affected area.

Do It Early as this can deteriorate as fast as unstable angina, especially if the pt is prone to clotting. AN

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13
Q

Hirshsprung Dz

A

Congentital Lack of enteric nervous system in the colon/rectum. Constipation will result, then bloating, possibly infection and ultimately toxic megacolon.

Evacuate gas via NG Tube and rectal lavage until resection can be done. Resection is done through the anus. Rectum is cut inside the anus and the diseased colon is advanced through the anus and cut at it’s upper limit. That upper limit is sutured to the remaining anus and voila! a colon with enteric nerves all along its length all the way to the anus. No rectum, but it works.

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14
Q

How does a high sugar diet cause diarrhea?

A

The sugar just pulls water INTO the intestine to dilute it. This is how JUICE causes diarrhea but Soda can do it as well.

Electrolyte rehydrations formulas should not be high in sugar for this reason.

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15
Q

Psoas Sign is specific for what?

Describe test

A

Retrocoecal Appendicitis

Pt does a leg raise against your resistance on his thigh. Should hurt at McBurney’s Pt.

Ilio-Psoas runs down the ventral side of the abdomen into the pelvis and is RIGHT THERE if the appendix is pointing backwards

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16
Q

Obdurator sign can be (+) on either side - what is the test and discuss side differences

A

Obdurator sign is elicited by Flexing both knee and hip and rotating knee inward. This stretches the obdurator muscle which lies close to the appendix on the RIGHT. An inflamed appendix will hurt at McBurney’s Point.

If there is a pain on the LEFT side of the abdomen, you can try obdurator as well - it lies beneath the rectum and could be irritated by diverticulitis or PID were it low enough.

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17
Q

Internal Obdurator Muscle lies where?

A

It’s tendon attaches to the medial aspect of the greater tuberosity. the ligament passes over the lesser sciatic notch at the posterior ischium, enters the pelvic bowl posteriorly &passes between the sacrotuberous ligament and the ischial tuberosity. Its fan shaped head spreads over the interior aspect of the ischial tuberosity

This just happens to be RIGHT BENEATH THE APPENDIX, if it isn’t retrocoecal.

18
Q

Catch all Dx that includes Salpingitis?

A

PID

Test for it by locating pain to the lower quadrants, then slipping finger beneath the cervix on pelvic exam - if this elicits pain,

19
Q

Most likely Bugs in PID?

A

Chlamydia and Gonorrhea

Gonorrhea Rx: Ceftriaxone IM
Chlamydia Rx: 1mg oral before
she leaves the office.

20
Q

Dull achy crampy pain is constant- low in the pelvis and BILATERAL. Hurts during coitus often also during exercise. There may be purulent discharge and this is a sign of substantial & later infection.

A

Think PID

CDC wants this treated empirically as LAPROSCOPY/ Biopsy is the only definitive test.

If there is Uterine/Adenxexal tenderness or pain on cervical motion …

Rule out Ectopic with a preg test
         If pregnant get a sono AND 
         a CBC.  She might be preen
         AND have PID.  
Rule out Appendicitis w/abd exam
Rule out UTI w/UA + UC
Then:

TREAT THIS with standard STD Rx (Cephtriaxone 250 IM & Azithromycin 1gram) BUT….

DO send her out the door with a DOXY script ALSO: 100 mg BID X 14 days, just to KEEP killing the chlamydia and to cover Syphillis, which is also a player in PID.

If she isn’t better in 72 hrs, she should come back in - laproscopy would be the next step as any of the usual bugs SHOULD have been knocked out by that triple Abx regimen.

21
Q

Dull achy crampy pain is constant- low in the pelvis and UNI-lateral. Hurts during coitus often also during exercise.

A

Think Ovarian Cyst or Torsion if it’s UNI-lateral.

22
Q

Murphy Sign for? Describe Test

A

Cholecystitis

Locate lower Hepatic Margin, while Pt inhales press in UNDER the LIVER

Pain is a (+) murphy sign. DO be CAREFUL though, this can and does elicit vomit and violent run if there IS cholecyctitis

23
Q

Biliary Colic

A

Gallbladder discomfort/ pain after eating

Biliary Sludge - thick bile
        Gallbladder has to work
         harder to push this
         This is uncomfortable after
         meals but manageable
Gallstone - hardened bile
       This is more painful
       These are sharp and the 
        gallbladder contractions
        around sharp stones HURT

Since low pH in the duodenum triggers CCK release and CCK release triggers Gallbladder contraction, the biliary colic pain can go on until duodenal pH normalizes after a meal and no more CCK is being released, often up to 3 hours.

24
Q

Other names for GASTROENTERITIS:

Hx, Exam, Ddx + Rx

A

Stomach Flu
Infectious Diarrhea

Usually this is viral

Ask Onset, Frequency & Color of Diarrhea, BLOODY? Mucusy?

25
Q

Bloody, Mucusy Diarrhea with pain that began in the rectum and spread upwards. Tenesmus & Pseudopolyps

characterize which Inflammatory Bowel Disease?

A

Ulcerative Colitis

Bottom Up, but only to the ileocoecal sphincter

Ulcerative Colitis is CONTINUOUS, not patchy like Crohns

26
Q

Cobblestoning of membranes & perianal fistulae and PATCHY transmural ulcerations

A

Crohns

Crohns can go from perianal area to the mouth, forming ulcers all the way but Crohns is PATCHY, not continuous

27
Q

Crohns

A

Patchy, entire GI at risk

28
Q

Ulcerative Colitis

A

Continuous, colon only

29
Q

Shoulder Pain with abdominal complaint or in the absence of MSK cause…

A

Irritation on same side (ipsilateral) by air, blood or infection in the peritoneal cavity.

It gives you an idea which side if abdominal discomfort is VAGUE

30
Q

Flank Pain

A

Back to Front - Kidney/Pyelo

Front to back - Gallbladder, might also just go THRU, hard to tell which direction.

31
Q

Groin pain and along the Inguinal Canal Hip

A

Ureters travel there: UTI/Stones?

Testicular Torsion?

32
Q

Abdominal complaint with HYPOTENSION or other signs of SHOCK?

A

Open 2 -14 gauge IVs anticubital

Run in Ringers until Bp stabilizes

Since you’re giving fluid, insert a Foley to measure output

Get your labs asap: CBC, BMP, HCG, UA/UC + Blood Cultures if fever

Get an EKG-12 Lead, Bedside KUB and an Abd/Pelvic CT w/contrast and

For God’s Sake if pt is FEMALE
DO A PREGNANCY TEST!!!

33
Q

IV Fluid to Stabilize Bp:

A

1 Liter over 20 Min

You can run a liter into EACH arm this way

34
Q

What do you always check before running in lots of IV fluids?

A

Lung Sounds

Looking for pulmonary edema: Crackles & Rales that do not clear after a cough

You’ll still need to run in the fluid but do add Lasix to get it back out again without worsening the edema.

And you might get an echo and let cardiac output guide your fluid input

35
Q

Anascara

A

Extreme
Generalized
Edema

Often from Over IV Hydration

Pleural Effusion on CXR is a very late sign of over hydration if it wasn’t already there when you started. Try not to over hydrate to this point!

Admittedly though, volume overload is hard to measure until Anascara or Pulm Edema occurs, just get the Bp back to a reasonable level if you can and keep it there.

If fluid alone isn’t doing it, add vasopressors or, if septic, IV antibiotics!

36
Q

What can you add to IV NS in sepsis to counter 3rd spacing through dilated vessel walls?

A

Albumin

37
Q

Most common STD bug in college girls

A

Chlamydia is #1

Moreso than Gonorrhea

Most common signs of Chlamydial Infection are:

1) None - its most often asymptomatic and just discovered
on pap smear
2) White/Yellow discharge that isn’t yeast
3) Pain on Sex - possibly bloody show after sex
4) UTI sxs - often causes UTI

RX is…. 1gram (4 250mg pills) of Azythromycin

If not a single dose of AZithro, then give Doxy 100mg BID X 7 days (half the usual duration but even so, Doxy’s long treatment time reduces compliance) making Azithromycin 1gram the preferred treatment.

38
Q

Decerebrate

A

Extends from Painful Stimuli

De-Cerebrate, away from head

GCS 7

39
Q

DeCorticate

A

Flexes from Painful Stimuli

DeCorticate is better than DeCerebrate

GCS 8

40
Q

GCS Points:

A

Eye Opening 4
Verbal Response 5
Motor Response 6

EVM 456

Below 8 is comatose

41
Q

Treatment of choice for Testicular Torsion?

A

Ultrasound

42
Q

Painless Jaundice

A

Pancreatic Cancer

GEN MED III (7 decks)

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