Clinical Case #4 - Pearson Flashcards
What is important patient history in the case of a female patient with abdominal pain? How does each direct your DDx?
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o Weight loss, which might indicate malignancy or malabsorption.
o Vomiting as with a small bowel obstruction or volvulus (obstruction especially if fecal).
o Diarrhea and constipation, which might indicate infection, inflammatory bowel disease, cancer, obstipation, malabsorption.
o Melena or blood per rectum: check with Hemoccult. If negative, consider foods (Kool-Aid, beets) or medicines (iron). If positive, consider source of GI bleeding.
o Jaundice. Consider pancreatic cancer (painless), hepatitis, hemolysis (sickle cell, G6PD deficiency, transfusion reaction), alcoholic hepatitis, choledocholithiasis, primary biliary cirrhosis, etc.
o Urinary symptoms. Dysuria, frequency, urgency, hematuria. Renal problems often present as a complaint of abdominal pain. Consider urolithiasis, UTI
o Sexual activity, last period, birth control, history of venereal disease, vaginal discharge, spotting or bleeding. Consider ectopic pregnancy, PID, ovarian torsion, ruptured ovarian cyst, etc.
o Past medical history: Medical problems that can present as abdominal pain include DKA, hypercalcemia, Addison’s disease, pneumonia, cardiac disease and acute angle glaucoma. History should include other major illnesses, prior surgeries, prior studies performed for evaluation of abdominal problems, family history of any similar complaints.
o Medications. Especially digoxin, theophylline, steroids, tetracycline/alendronate (esophageal ulcers), analgesics, antipyretics, antiemetics, barbiturates, and diuretics.
What are adequate physical exam maneuvers in the evaluation of abdominal pain? What is the reasoning behind each?
o Vital signs. Observe for signs of shock, elevated temperature.
o Abdominal exam: Inspection. Scaphoid appearance or distension, point of most severe pain, hernia, scars.
o Auscultation. High-pitched bowel sounds are suggestive of an obstructive process. Absent bowel sounds are suggestive of an ileus.
o Palpation and percussion. Tympanitic, muscle rigidity (voluntary/involuntary), localized tenderness, masses, pulsation, hernias, peritoneal irritation (rebound: cough or jumping also may elicit “rebound”), involuntary guarding, liver and spleen size.
o CVA tenderness.
o Pelvic exam in women.
o Rectal exam. To rule out GI bleeding, trauma, prostatitis, etc. The absence of rectal tenderness does not preclude the diagnosis of appendicitis nor does it make the diagnosis of appendicitis.
What special physical exam special tests may be performed if concerned about: appendicitis, cholecystitis, ascities, hernias, or AAA?
Appendicitis: McBurney’s point tenderness, Rovsing’s sign, Psoas/Obturator sign
Cholecysitis: + Murphy’s sign
Ascites: protuberant abdomen with bulging flanks, positive fluid wave or shifting dullness
Ventral Hernia’s: Valsalva, abdominal pressure/sit-up to produce
AAA: pulsating mass
What diagnostic laboratory tests are appropriate in the setting of female abdominal pain?
o ***Pregnancy test on all reproductive-age females unless status-post hysterectomy. Sexual history is often unreliable in the emergency setting and tubal ligations can fail!! Urine pregnancy test may miss very early ectopics. Serum Quantitive BHCG is very sensitive and picks up virtually all pregnancies.
o CBC with differential and urinalysis is routinely done on most cases of abdominal pain.
o Electrolytes, BUN, creatinine with vomiting or diarrhea.
o Glucose and calcium to rule out DKA and hypercalcemia respectively.
o Liver function tests and liver enzymes; amylase and lipase for upper abdominal pain.
What diagnostic imaging tests are appropriate in the setting of female abdominal pain?
In women with R or L LQ abdominal pain, first consider abdominal or transvaginal ULTRASOUND to evaluate pregnancy, complications of pregnancy and/or reproductive tract pathology.
Appendicities/Crohn’s/Diverticulitis/Mesenteric Ischemia => CT preferred
What is the the underlying pathophysiology in ectopic pregnancy?
anything that hampers the migration of the embryo to the endometrial cavity could predispose women to ectopic gestation
3% in abdominal cavity, 97% in fallopian tubes (55% in ampulla, 25% in isthumus, 17% in fimbria)
Usually occurs 6-8 weeks after LMP.
What are the risk factors for ectopic pregnancy?
Previous pelvic infection • Pelvic inflammatory disease • Hx of prior ectopic pregnancy • Hx of tubal surgery and conception after tubal ligation • Use of fertility drugs/assisted reproductive technology • Increasing age • Smoking • Endometriosis • Birth defects of the fallopian tubes
What is the typical clinical presentation of ectopic pregnancy?
Abdominal pain (75-98%), amenorrhea (65%), palpable adnexal mass (50%), vaginal bleeding/spotting (50-80%), with or without symptoms of early pregnancy.
Patients may have nausea, vomiting, dizziness, syncope, hypovolemic shock, referred shoulder pain, tenesmus and low-grade fever.
What are the management options for ectopic pregnancy?
- Primary treatment is surgical. Tube-sparing surgical techniques such as laparoscopic salpingostomy allow for preservation of fertility with little increase in risk for recurrent ectopic.
- Methotrexate injection is a nonsurgical treatment, most effective for small ectopics (
What is the utility of beta-hCG testing and the correlation with transvaginal ultrasound findings in management of pregnancy related conditions?
UPT may miss a very early ectopic (limit 50 mIU/ml).
A serum quantitative beta-hCG is sensitive to 5 mIU/ml.
If possible, a quantitative serum HCG should be done.
Transvaginal US, with its greater resolution, can be used to visualize an intrauterine pregnancy by 24 days postovulation, or 38 days after last menstrual period, which is about 1 week earlier than transabdominal US.
***Correlate ultrasonography with the serum quantitative HCG:
o Beta-hCG 1500. If the beta-hCG is above 1500 mIU/ml and the sonographer is reasonably skilled, an intrauterine pregnancy should be detectable by transvaginal ultrasonography in 95% of cases. If an intrauterine sac is not visible with a serum beta-hCG >1,500, suspicion of ectopic is markedly increased.
When should follow-up be recommended in a patient where the diagnosis of ectopic cannot be proven or ruled out on the first visit?
obtain serial quantitative beta-hCG every 48 hours and follow clinical exam
The beta-hCG should approximately double in 48 hours. In an unreliable patient, treat as presumed ectopic.
o If beta-hCG rises by >66% in 48 hours, the pregnancy is continuing; repeat the ultrasound when the beta-hCG is >1,500 to differentiate between ectopic and intrauterine (should see intrauterine at this point). If still indeterminate, follow-up in another 48 hours with repeat quantitative beta-hCG and ultrasound. If the beta-hCG is not rising or is falling, the pregnancy is likely non-viable and a D&C should be done to look for chorionic villi.
