Clin Med- Acute abdomen Flashcards

1
Q

Visceral Pain

  • what causes it
  • how does it related to timing of parietal pain
A
  • distention of hollow organs
  • capsular stretching of solid organs
  • typically before parietal pain
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2
Q

Visceral pain sx

A
  • intermittent
  • dull
  • crampy
  • poorly localized
  • usually midline

ex. mesenteric ischemia or early appedicitis

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3
Q

Parietal Pain

  • what causes it
  • location
  • pt rxn on PE
A
  • ischemia, inflammation, stretching of parietal peritoneum
  • specific pain - on the same side/area pain originates from
  • rebound, guarding, rigidity on exam
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4
Q

Parietal pain

- sx

A
  • sharp
  • constant
  • worse with movement & palpation

ex. acute appendicitis

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5
Q

History

A

take a look at the slide, much like phys di information we already know

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6
Q

What is one of the most important parts of the PE??

A

VITAL SIGNS

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7
Q

What else to look for on PE

A
  • gen appearance: pallor, distress (laying still or writhing in pain)
  • inspection: distention or discoloration
  • auscultation: absent or tinkling bowel sounds, bruits
  • palpation: be gentle, localize pain
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8
Q

Rebound tenderness

  • kid specific way to test
  • classic example of dz
A
  • jump up and down

- appendicitis

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9
Q

Guarding

- describe

A

reflex spasm of abd wall in response to palpation/peritoneal irritation

*distract pt while palpating to distinguish true guarding from purposeful

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10
Q

What must you do with every female who presents with undifferentiated abd pain?

A

pelvic exam

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11
Q

What must you do to every male who has lower abd pain?

A

GU exam to check for strangulated hernia or testicular torsion

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12
Q

Inspection of the rectum

A
  • prostate exam
  • blood
  • abscess
  • foreign body
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13
Q

List 5 special tests for abd exam

A
  1. Psoas
  2. Murphy’s
  3. Obturator
  4. Rovsing’s
  5. Heel Tap

*BAM we know these already!

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14
Q

Important PMH for pt with abd pain

A
  • prior surgery: obstruction from adhesions
  • questions to ascertain risk for mesenteric ischemia and AAA (CAD, HTN, a. fib)
  • ETOH abuse (pancreatitis)
  • meds: NSAIDS, abx, steroids
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15
Q

what test should be ordered if intestinal obstruction is top of ddx?

A

oral contrast (for CT?) to help surgeon delineate the obstruction point

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16
Q

Kehr Sign

A
  • pain from gallbladder or spleen radiates to shoulders or scapula due to irritation of the diaphragm
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17
Q

Tests to order for abd pain (8)

A
  1. EKG
  2. CBC (don’t base dx on CBC!!)
  3. BMP/CMP for kidney/liver function
  4. Lipase
  5. UA/uHCG (don’t miss ectopic pregnancy!!)
  6. abd series (overused)
  7. CT
  8. US
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18
Q

Appendicitis

  • cause
  • pain location
A
  • obstruction of lumen from food or adhesions

- periumbilical pain that migrates to RLQ

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19
Q

Appendicitis

  • sx
  • PE
A
  • anorexia, nausea, vomiting, fever

- guarding, rebound tenderness, +McBurney’s, Rovsings, Psoas, obturator, and heel tap

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20
Q

Appendicitis

  • what to order
  • tx
A
  • CT of abdomen pelvis pref with contrast
  • US children/pregnant
  • abx, general surgery
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21
Q

Appendicitis on CT

A
  • look at slides
  • normal is clearly delineated, smooth, air is normal
  • abnormal is stranding (inflamed), may see appendicolith
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22
Q

Biliary colic, cholecystitis, ascending cholangitis

  • location of pain
  • sx
A
  • RUQ or epigastric
  • crampy, colicky pain, postprandial
  • radiates to sub scapular area
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23
Q

sx specific to cholecystitis and cholangitis

A

fever and chills

24
Q

Biliary colic, cholecystitis, ascending cholangitis

  • PE findings
  • what to order
A
    • Murphy’s
  • Charcot triad (fever, jaundice, RUQ pain)
  • US, LFTs, Lipase
25
What pentad is found in severe cases of ascending cholangitis?
reynolds pentad: - charcot (fever, jaundice, RUQ pain) - hypotension - AMS
26
Biliary Colic | - tx
- anti-cholinergic for pain control and gallbladder relaxation - ex benadryl or promethazine
27
Acute cholecystitis and ascending cholangitis- | - tx
- hosp admission - broad spectrum abx - sx consult
28
PUD - cause - sx
- H. pylori, NSAIDS | - burning epigastric pain, n/v, vomit red blood, melena
29
PUD - complications - TX
- anemia, perforation, gastric outlet obstruction - PPI, dc NSAIDs, NG tube, endoscopy (tx volume loss, fluids, blood)
30
Bowel obstruction - sx - frequent cause
- diffuse crampe pain, n/v, bloating | - prior sx or obstruction
31
bowel obstruction - PE findings - what to order
- abd distention, tenderness - Acute abd series for air fluid levels - CT abd/pelvis with oral & IV contrast
32
MCC - SBO - LBO
- SBO: adhesions from previous sx | - LBO: neoplasm
33
List the three radiographs in an acute abd series
1. AP supine view: bowel loop width 2. Upright abd: air fluid levels 3. Upright chest film: free air
34
Diverticulitis - describe - cause
- acute inflammation of wall of a diverticulum and surrounding tissue - increased pressure from poor motility or obstruction causes inflammation
35
Diverticulitis - sx - what to order
- pain (MC), diarrhea, constipation, n/v, fever - Labs, UA, CT - AAS is little help
36
Diverticulitis | - tx
depends on severity: - no systemic sx: output abx (cipro, flagyl) - vomiting or toxic: admission, fluids, abx
37
diverticulitis two major complications
perforation | abscess
38
Intussusception - describe - common age, sex
- portion of bowel telescopes into another segment - 3mo to 6yr - M>F
39
Intussusception | - sx
- sudden, intermittent colicky abd pain - Henoch-Schonlein purpura (small vessel vasculitis) - blood stool-current jelly (late finding) - episodes of crying, drawing legs up - episodes usually spontaneously resolve
40
Intussusception | - tests to order
- air contrast enema: dx & therapeutic
41
Pancreatitis - cause - sx
- ETOH abuse, cholelithiasis | - severe epigastric or LUQ pain, radiation to back
42
Pancreatitis | - lab test to dx
- lipase: 3X upper limit normal value | - amylase is less sensitive
43
Pancreatitis - Criteria used on admission - tx
- Ranson criteria - Fluids, NPO, pain med - NO anticoagulation for inpts
44
Mesenteric Ischemia - describe - sx
- ischemia dt obstruction of mesenteric artery from embolism or thrombosis - gradual to acute onset, pain out of proportion to exam, soft abdomen - poorly localized pain - hypovolemia - low BP - sepsis
45
Mesenteric Ischemia | - risk factors
- A. fib - HTN - CAD - CHF
46
Mesenteric Ischemia - dx tests - tx
- CT abdomen/pelvis - angiography - admission, broad spectrum abx, sx
47
Abdominal Aortic Aneurysm (AAA) - risk factors - cause
- connective tissue disorder, family hx, atherosclerotic risk factors - stress on connective tissue causes dilation
48
AAA - sx - dx tests
- severe abd pain, flank or back pain - syncope, abd bruit, low BP - ED US, CT abd/pelvis
49
what should you never skip before dx an elderly pt with renal colic
abd US to measure aorta for AAA
50
Stable AAA - f/u - what increases risk for rupture
- f/u closely, serial US | - >5 cm size increases risk of rupture
51
AAA | - tx
- stabilization - fluids? controversial - emergent cardiothoracic consult
52
AAA | - survival rate of sx
- 50% die | - those who survive likely to have multi-organ failure in ICU
53
General tx of abd pain
- volume repletion - pain relief - antiemetics - antibiotics - +/- NPO - +/- NG tube
54
when get sx consult
- acute abdomen - appendicitis - obstruction - perforated ulcer - acute cholecystitis
55
If discharge pt with abd pain from ED, what sort of fu is recommended
- 12 hr recheck - close fu with PCP * esp children high suspicion for appendicitis