ECEs: Chest, abdo, pelvis Flashcards
What is the DDx for abdo pain in the RUQ?
Hepatitis Biliary colic, Cholecystitis/Cholangitis Pancreatitis Pneumonia, Pleural effusion, PE DEADLY: Chole, pancreatitis, PE
What is the DDx for abdo pain in the LUQ?
Pancreatitis
Gastritis
Pneumonia, Pleural effusion, PE
DEADLY: Pancreatitis, PE
What is the DDx for abdo pain in the RLQ?
Appendicitis
Ectopic pregnancy, PID, tubo-ovarian abscess, ovarian torsion
Testicular torsion, epidiymitis, orchitis
Renal colic
DEADLY: ectopic pregnancy
What is the DDx for abdo pain in the LLQ?
Diverticulitis
Ectopic pregnancy, PID, tubo-ovarian abscess, ovarian torsion
Testicular torsion, epidiymitis, orchitis
Renal colic
DEADLY: Diverticulutis, ectopic pregnancy
What is the DDx for epigastric abdo pain?
Gastritis, dyspepsia, PUD, duodenitis
Pancreatitis
ACS (Cardiac)
DEADLY: Pancreatitis, ACS
What is the DDx for periumbilical abdo pain?
Colitis, Perforation, Obstruction
Aortic dissection, AAA
DEADLY: … all except colitis.
What is the DDX for suprapubic abdo pain?
UTI, renal colic
Obstruction
Deadly: none.
What is the DDx for R or L flank abdo pain?
Colitis, perforation, Obstruction
Renal colic, pyelonephritis
AAA
DEADLY: Perforation, obstruction, AAA
What are the risk factors for ruptured ectopic pregnancy?
Hx of STI/PID Recent IUD previous ectopic Fallopian tube surgery, tubal ligation Smoking
What are the risk factors for ruptured AAA?
Elderly, HTN/DM, smoking, trauma
What are the risk factors for pancreatitis?
EtOH, biliary pathology
What is the classic clinical presentation of cholangitis?
Charcot’s triad: fever, RUQ pain, jaundice
What are the risk factors for mesenteric ischemia?
Elderly, CAD, CHF, dehydration, infection
What are the risk factors for bowel obstruction?
Operative or malignant history, elderly
What are the risk factors for bowel perforation?
Risk factors for diverticulitis or ulcer; malignancy; instrumentation (eg colonoscopy)
What are the risk factors for complicated diverticulitis?
Elderly, low-fibre diet, Western population
What would you elicit on Hx for acute abdo pain?
OPQRST
Associated Sx: N/V, fever, chills; BM; urinary Sx; pelvic discharge/bleeding
What labs would you order for acute abdo pain?
CBC, lytes, BUN/Cr, LFTs, lipase, lactate, B-hCG
Consider: CK, troponin
What imaging & other Ix would you order for acute abdo pain?
ECG, CXR, consider bedside US
Consider formal US (biliary, ectopic, AAA); consider CT abdo/pelvis
How do you acutely manage acute abdo pain, in general?
ABCs
Analgesics
Anti-emetics
NPO; consult surgery as needed
What is the “deadly six” DDx for acute chest pain?
PET MAT: Pulmonary embolism Esophageal rupture/mediastinitis Tension pneumothorax Myocardial infarction Aortic dissection Tamponade
What are the cardiac causes of acute CP?
DEADLY: MI, aortic dissection, tamponade
Pericarditis, Myocarditis, Endocarditis
What are the respiratory causes of acute chest pain?
DEADLY: PE, tension pneumo Pneumonia Pleural effusion Acute chest syndrome (sickle cell) Lung or mediastinal mass
What are the GI causes of acute chest pain?
DEADLY: Esophageal rupture/mediastinitis
Esophagus: Mallory-Weiss tear, esophageal spasm
Stomach: GERD, ulcer
Pancreas: pancreatitis
GB: biliary colic, cholecystitis, cholangitis
What is dyspepsia?
sensation of pain or discomfort in the upper abdomen, often recurrent. Not specific to etiology (can be recurent postprandial, could be MI, could be ulcer).
(may be described as indigestion, gassiness, early satiety, postprandial fullness, gnawing, or burning)
What are the MSK, neuro, & psych causes of acute chest pain?
Intramuscular pain Rib pathology Herpes zoster Rib pathology None deadly.
What history do you want to elicit for acute chest pain?
OPQRST, cardiac risk factors, PE risk factors, recent trauma, neuro Sx
What parts of the physical exam are important for acute chest pain?
General appearance
Cardiac & resp exams
Neuro screen
Vitals, Pulse
What are the initial Ix for acute chest pain?
Tests: ECG, CXR; consider CT pulmonary angio
Labs: CBC, lytes, abdo panel, cardiac markers; consider D-dimer
What are the cardiac markers? (bloodwork)
CK and TnI (Creatine kinase & troponin I)
What is the general management for acute chest pain?
ABCs Monitors Oxygen Vitals IV access Gather equipment
What is the acute management for ACS?
ASA Nitro (avoid in RV infarct) Clopidogrel/ticagrelor LMWH code STEMI (PCI vs thrombolytics)
mnemonic:
ANCLE: ASA, Nitro, Clopidogrel, LMWH, Emergent cardio consult
What is the acute management for PE?
Anticoagulation
Consider thrombolysis for massive PE
What is the acute management for esophageal rupture?
Urgent thoracic surgery consult
IV Abx
NPO
Further imaging
What is the acute management for tension pneumothorax?
Needle decompression (2nd intercostal space at midclavicular line) Chest tube (4th or 5th intercostal space)
What is the acute management for cardiac tamponade?
Pericardiocentesis
What is the acute management for aortic dissection?
Urgent vascular surgery consult
IV labetolol (to reduce BP & HR)
Surgery vs medical management
What is the HEART score?
Risk stratification score for acute chest pain.
For pt ≥21 presenting with Sx suggestive of ACS
H: History
E: ECG
A: Age
R: Risk factors
T: Troponin (initial)
What are the risk factors that increase the HEART score?
HTN Hypercholesterolemia DM Obesity Smoking FHx (parent/sibling with CVD <65) Atherosclerotic disease 1-2: +1 3 or more: +2
What features add points to the ECG part of the HEART score?
+1: LBBB, LVH, repolarization changes
+2: ST depression/elevation (not due to LBBB, LVH, digoxin)
What troponin levels are suspicious for ACS, according to the HEART score?
Initial troponin 1-2X normal limit: +1 point
Initial troponin >2X normal limit: +2 points
How does the HEART score deal with age and history? (points)
History: slightly/moderately/highly suspicious gets 0/1/2 points
Age: <45 / 45-64 / ≥65 gets 0/1/2 points
What is the risk of major adverse cardiac event (MACE) with different HEART score ranges?
Scores 0-3: 1-2%
Score 4-6: 12-17%
Score ≥ 7: 50-65%
What is the HEART pathway?
HEART score + 0h and 3h troponin; decision aid to ID patients that are safe for early discharge.
What is the PERC rule?
Rules out PE in patients who are already considered low-risk: if negative, patients do not require further workup for PE.
What are the PERC rule criteria?
Age ≥ 50 HR ≥ 100 SaO2 < 95% on RA Unilateral leg swelling Hemoptysis Recent surgery or trauma (<4w out) Prior PE or DVT Hormone use (OCP, estrogen, HRT) If the patient has none of the above, and is considered low risk for PE, no further testing for PE is needed.
What is tachypnea?
RR > 18 in adults
What is hyperpnea?
High minute ventilation to meet metabolic demands
What are the DDx categories for shortness of breath?
Pulmonary
Cardiac
Toxic-Metabolic
Neuro-endocrine
What is the pulmonary DDx for shortness of breath?
Airway obstruction Respiratory failure Anaphylaxis Pulmonary embolism Tension pneumothorax
What is the cardiac DDx for shortness of breath?
Pulmonary edema (LV failure) MI Tamponade Pericardial effusion Arrythmias
What is pulmonary edema?
acute, severe left ventricular failure with pulmonary venous hypertension and alveolar flooding
What is the toxic-metabolic DDx for shortness of breath?
Toxin ingestion (Organophosphates, CO)
Sepsis
DKA