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Eval of abdomen pain in PC Flashcards

1
Q

What is the 2nd mc pain in PC?

A

GI complaint

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2
Q

What is the mc GI complaint?

A

Constipation then diarrhea

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3
Q

What % of abd complaints are not referred to GI

A

75%

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4
Q

What % eventually get dx with IBS?

A

50%

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5
Q

What % of acute abdominal pain has no clinical dx?

A

34%

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6
Q

Review slide 6

A

-

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7
Q

Whats the goal with GI complaint?

A

Determine who needs a work-up for their abd pain (and how extensive that work up should be!)

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8
Q

What are the treatment options for GI complaint?

A
  1. Symptomatic care / watch and wait
  2. Lab and diagnostic work up – outpatient or emergent?
  3. Referral
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9
Q

What % will stay in PCP?

A

80%

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10
Q

T/F We need to determine which pt are appropriate for “watch & wait” vs who you think has an underlying organic cause that needs to be treated

A

T

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11
Q

Whats the most imp squeale from diarrhea?

A

Dehydration

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12
Q

How is constipation dx?

A

Clinical, dont need KUB!

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13
Q

Whats the common PC diagnoses?

A

Diarrhea
Constipation
Gastroenteritis
Food related (Celiac disease, Lactose intolerance)

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14
Q

Do you always need a formal dx test?

A

No

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15
Q

Whats the most common s/e of ulcer?

A

Perforation - suden onset of severe pain

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16
Q

MC cause of obstruction?

A

adhesion from abdmen surgery

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17
Q

if they have severe, pain out of proportion?

A

Acute ischemia, mc in elderly

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18
Q

Whats the approach to pts with abd pain?

A

Determine whats unstable vs stable

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19
Q

What do you do with unstable pt?

A

toxic, in extreme pain, or present with a potentially surgical complaint need to be sent to the emergency room

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20
Q

What do you do with pts who are stable?

A

Non-toxic should be worked up in the office

A systematic approach by abdominal quadrant is the best step

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21
Q

If pt comes with RUQ, what should you do?

A

focus on differentiating between pulmonary, urinary, and hepatobiliary pain

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22
Q

If pt comes with RUQ and think its pulm causes what do you do?

A
  • Imaging, labs
  • Go down that roads
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23
Q

If pt comes with RUQ and think its Urinary causes what do you do?

A
  • think about UTI, Nephrolithiasis
  • Urinalysis is starting point
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24
Q

If pt comes with RUQ and think its hepatobiliary pain causes what do you do?

A

Patients with colic, fever, steatorrhea, or a positive Murphy’s sign should receive ultrasonography

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25
Q

If you are unsure of RUQ pain, what should you do?

A

Ultrasonography test of choice for evaluation of RUQ

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26
Q

What do we need to do with cholecystitis?

A

Need to differentiate between cholelithiasis vs acute cholecystitis

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27
Q

Murphy’s sign is present in what % of population

A

65%

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28
Q

T/F just because we see a gallstone does not mean we need a surgery

A

True!!

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29
Q

What are PE thats helpful with cholecystitis

A
  • abdomen tenderness
  • Murphy sign
  • Pain
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30
Q

is fever a strong factors with cholecystits?

A

No!

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31
Q

What labs/dx should you order with cholecystitis?

A

CBC
CMP + Lipase
US

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32
Q

Should all biliary complaints need lipase?

A

If with GERD, uncontrolled vomiting but other than not, not sure

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33
Q

if pt is 10/10 crappy, vomiting, sick what would you order?

A

Lipase for pancreatitis

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34
Q

If a pt is ok, US with nl labs, what should you do? (Cholelithiasis)

A

Watch and wait

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35
Q

What % of pt will gallstone does NOT require cholecystectomy?

A

50%

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36
Q

If they have abnormal labs, with cholecystits, what should you do?

A

Get US

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37
Q

What is US for?

A

Stone, structure and acute

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38
Q

What does HIDA scan for?

A

Contraction/function of gallbladder

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39
Q

T/F HIDA scan is the 1st line of gallballder

A

NO

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40
Q

What should you do if you have + US and abnormal labs?

A

ER bc gallbladder will prob be taken out

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41
Q

What should you do for pain control?

A
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42
Q

Whats your large ddx for epigastric pain?

A

PUD, GERD, esophagitis, gastric/esophageal cancer, biliary disease, gastritis, pancreatitis, medication SE, Cardiopulmonary – ACS, AAA

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43
Q

If you are unsure of about epigastric pain, where should you start?

A

Start by focusing on cause of dyspepsia

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44
Q

What is dyspepsia?

A

epigastric pain, discomfort, burning, nausea, and vomiting

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45
Q

Whats causes of dyspepsia? (5)

A
  • Acid-related disorders (GERD)
  • Peptic ulcer disease (PUD)
  • helicobacter pylori gastritis
  • (NSAID) related erosions
  • Upper abdominal cancer
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46
Q

Whats the two most common cause of epigastric pain?

What %?

A

GERD
PUD

40%

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47
Q

If heartburn and regurgitation are the dominant symptoms, whats the likely dx?

A

GERD

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48
Q

if they have regurg with epigastric pain, whats the mc dx?

A

GERD

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49
Q

Whats important hx for PUD?

A

H/O ulcers? Stress? Caffeine intake? Melena? Worse/better with food? OTC meds alleviating? Smoker?

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50
Q

Whats important hx for GERD?

A

Burning? Belching? Chronic cough? Food related? Worse when lying down? OTC meds alleviating?

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51
Q

Whats important hx for biliary dz?

A

Jaundice? Dark urine? Worse after eating?

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52
Q

Whats important hx for pancreatitis

A

Stabbing pain radiates to back?
ETOH?
H/O similar?
Severe, abrupt pain?

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53
Q

Whats important hx for CA?

A

Weight loss?
F/C/night sweats?
Dysphagia?
Age > 50?
Prolonged vomiting?
Smoker?

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54
Q

if they had pancreatitis and they said yes, can you get it again?

A

yes, high chance for re-accurance

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55
Q

Which dx has severe abrupt pain?

A

Pancreatitis

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56
Q

is early saiety a red flag?

A

True, for CA

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57
Q

if they have melena, what do you need to do?

A

DRE for PUD

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58
Q

Whats GERD associated with PE?

A

Dental erosions

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59
Q

Whats hard to do with pancreatitis?

A

Difficult to control pain

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60
Q

PE clues for cancer?

A
  • Weight loss
  • a positive fecal occult blood test
  • a palpable mass
  • signal nodes (Virchow’s nodes)
  • acanthosis nigricans are signs of possible malignancy
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61
Q

What do you need to order for alarming symptoms?

A

GI referral for EGD

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62
Q

What are the alarming symptoms for GI referral for EGD?

A

age > 50, dysphagia, weight loss/f/c/night sweats, GI bleeding, prolonged vomiting

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63
Q

What is the advantage of EGD? (5)

A
  • Gold standard test to exclude gastroduodenal ulcers, reflux esophagitis and upper gastrointestinal cancers.
  • Beneficial because up to 40 percent of patients have an organic cause of dyspepsia.
  • Provides adequate patient reassurance.
  • Test of choice for targeting therapy.
  • Endoscopic complications are rare.
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64
Q

What is the disadvantages of EGD?

A
  • Expensive.
  • Invasive.
  • Not cost-effective or practical in young patients without alarming symptoms.
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65
Q

Whats the advantage of empiric tx with acid suppression?

A
  • Least expensive strategy.
  • Rapid relief of symptoms.
  • High response rate.
  • May reduce the number of endoscopies
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66
Q

Whats the disadvantage of empiric tx with acid suppression?

A
  • High rate of symptom recurrence.
  • May promote inappropriate long-term medication use.
  • May delay diagnostic testing.
  • May mask the symptoms of malignancy.
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67
Q

What another option work-up?

A
  • test for h.pylori and treat if positive
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68
Q

Whats the advantage of h.pylori testing?

A

EBM recommends this approach

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69
Q

Whats the disadvantage of h.pylori testing?

A
  • May increase levels of antibiotic resistance.
  • Relies on accurateH. pyloritesting.
  • May result in overtreatment because of false-positive results or under-treatment because of false-negative results.
70
Q

Whats the best testing for H. pylori?

A
  • fecal testing
71
Q

What is the gold standard for H.pylori?

72
Q

Whats the antibody testing for h.pylori?

73
Q

T/F once patients arepositiveserologically theywill remain positivefor the rest of their lives.

74
Q

Whats the advantage of empiric tx for h. pylori?

A

Avoids cost of H. pylori testing and endoscopy

75
Q

Whats the disadvantage for Empiric eradication ofH. pylori?

A
  • Most evidence does not favor this approach.
  • May increase levels of antibiotic resistance and antibiotic related complications.
  • Patient inconvenience because of complicated drug regimens.
76
Q

What is the advantage for doing endoscopy after h.pylori is positive?

A
  • Endoscopy will detect gastroduodenal ulcers, reflux esophagitis and upper gastrointestinal cancers.
  • Minimizes antibiotic resistance.
77
Q

What is the disadvantage of doing a endoscopy if H.pylori is positive?

A
  • Not cost-effective
  • Invasive & complication

Compared with testing for H. pylori followed by treatment if the test is positive. Invasive, complications.

78
Q

Empiric antisecretory therapy must be in trial for how many weeks?

79
Q

What are example of H2 blockers?

A

Ranitidine (Zantac)
Cimetidine (Tagamet)
Famotidine (Pepcid)

80
Q

If H2 blocker isn’t helping then try what?

81
Q

T/F H.pylori can’t be treated with H2 blocker

82
Q

Whats the advantage of H2 blocker?

A
  • helpful in 50-70% of pts
  • cheaper
  • less interactions than PPI
83
Q

If pt have PUD, whats important to check?

A

H.pylori testing

84
Q

What are the red flags for PUD?

A
  • Age >55
  • Weight loss/anorexia
  • Persistent vomiting
  • Jaundice/anemia
85
Q

Whats PC considerations with PUD?

A

Check for GIB
Perforation

86
Q

Whats the tx for PUD?

A
  • Avoid NSAIDs
  • Proton Pump Inhibitors have higher efficacy thanH2 Antagonists
  • H.pylori eradication
87
Q

Whats in triple therapy?

A

PPI + Clarithromycin 500mg BID x 14 days + Amoxicillin 1gm BID x 14 days (Flagyl 500mg)

88
Q

Whats in quad therapy?

A

Bismuth + tetracycline 500mg qid +Flagyl 500mg tid + Prilosec 20mg bid

89
Q

Whats important in h.pylori testing?

A

Smoking cessation and avoid ETOH

90
Q

How long will duodenal ulcers take to heal?

91
Q

How long will gastric ulcers take to heal?

92
Q

whats the causes of pancreatitis?

A

Medication SE, cholelithiasis (40%), ETOH (35%), hypertriglyceridemia, congenital

93
Q

What is the MC of pancreatitis?

A

Cholelithiasis, not alcohol!

94
Q

Whats diagnositc keys for pancreatitis?

95
Q

What another test you can do for pancreatitis but clinically, its never ordered?

96
Q

Whats the lipase limits in pancreatitis?

A

> 540, 3x more than NL

97
Q

How long does it take for lipase to return back to normal?

98
Q

Whats the amylase limits in pancreatitis?

A

Amylase >360, 3x NL

99
Q

How long does it take for amylase to return to normal?

100
Q

Whats are the complication of pancreatitis?

A

Necrosis
Pseudocysis

101
Q

Whats the leukocytosis in pancreatitis?

102
Q

T/F Abx is needed for pancreatitis?

103
Q

LFT are off, secondary to stone

104
Q

When should you get advanced imaging for pancreatitis?

A
  • Suspect or to dx first episode
  • CT abd/pel with contrast – if concern for complications or first episode
  • US if suspect stone disease
105
Q

What pts should go to the ER for pancreatitis?

A

Unstable VS, severe pain, intractable vomiting

106
Q

Who can be managed at home with pancreatitis?

A

VSS
Tolerating PO’s
Pain controlled

107
Q

Whats the outpt treatment for pancreatitis?

A

Clear liquid diet
Pain control

108
Q

For outpt pancreatitis, when should they improve?

A

improvement in 3-7 days in 90% of cases

109
Q

what should be considered with RLQ?

A

Appendicitis

110
Q

what should be considered with RLQ for a female?

111
Q

Diff Dx of urinary for RLQ

A

UTI, pyelo, nephrolithiasis

Flank pain moved to side –> stone

112
Q

Diff Dx for female RLQ

A

ovarian cyst, torsion, TOA, ectopic

113
Q

Diff Dx for colon RLQ

A

itis, obs, inflammatory bowel disease

114
Q

if you’re unsure of RLQ, what should you do?

A

CT with intravenous contrast

115
Q

Will a CT show ovarian cyst, torsion?

A

No! Only ultrasound

116
Q

T/F Appendicits can occur at any age

A

True! Mc age is 10-30 but ANY AGE!!

117
Q

T/F Appendicitis will have abd pain

A

Occurs in almost all cases but pain level is different

RLQ pain is mc hx finding

118
Q

Which comes first? Pain or vomiting with appendicitis?

119
Q

How does pain migrate for appendicitis?

A

Pain migration fromPeriumbilical PaintoRight Lower Quadrant Abdominal Pain

120
Q

What should you tell pt who you send to the ER for appendicitis?

121
Q

LLQ is with what dx?

A

Diverticulitis

122
Q

Unsure with LLQ, what should you do?

A

CT or US if female

123
Q

What % will have lifetime incidence with diverticulitis?

124
Q

What % will have LLQ with diverticulitis?

125
Q

About 68% will have what with diverticulitis?

A

Leukocytosis

126
Q

When should you get advanced imaging for diverticulitis?

A

Diagnosis unclear
Not classicLLQ painwith fever
Other diagnoses are of similar likelihood
Moderate to severe symptoms
Inability to tolerate oral fluids
Peritoneal signs
Failure to improve in 2-3 days after starting abx

127
Q

What are the indication for outpt diverticulitis?

A

VSS
Tolerating PO’s
Pain controlled

128
Q

Whats the tx for diverticulitis?

A

Clear liquid diet –> high fiber diet (for day/two)
Abx
Pain control

129
Q

What abx should you put for diverticulitis?

A

Flagyl + FQ is MC combo

130
Q

Which ABX combo does she like?

A

Flagyl + Cipro

131
Q

When do pt usually get better with diverticulitis?

A

48-72 hours

132
Q

What is MC condition seen by GI?

133
Q

What is dx key for IBS?

A
  • Bowel alterations
  • Mucous stools in 40%
  • Sensation of incomplete emptying in 70%
134
Q

What is un-helpful with IBS?

A

“Piece-meal” work up, bc higher chance of repeat of work

135
Q

Whats the diagnostic criteria?

A

ROME III, Manning)
If meet criteria just treat

136
Q

What is red flag with IBS?

A
  • Stool incontinence
  • Nighttime awakenings (pain or BMs)
  • Weight loss, fever, night sweats
  • Heme +
  • Family h/o colon cancer
  • Laboratory abnormalities – leukocytosis, anemia, +ESR
137
Q

T/F stool incontinence is neurosurgical emerg

137
Q

T/F stool incontinence is neurosurgical emerg

138
Q

Whats the tx for IBS?

A

Diet, stress reduction, symptom directed

139
Q

What is the risk of reoccurrance for nephrolithiasis?

A

Risk of reoccurrence 50%, 10% have >3 episodes

140
Q

Whats the mc age for nephrolithiasis?

141
Q

Whats the dx key for nephrolithiasis?

A

Unilateral flank pain
Hematuria 90% of cases

142
Q

When do you need to get advanced imaging for nephrolithiasis?

A

First time or uncertain dx

143
Q

Whats the complication of nephrolithiasis?

A
  • Obstruction
  • AKI
  • Infection
144
Q

What is the dx choice for kidney stone?

A

CT abd without but if they get it every time then they dont need a CT every single tine.

145
Q

Whats a good dx choice for hydronephrosis?

146
Q

if you see stone in KUB, do you need CT?

147
Q

What does KUB not show with kidney stones?

A

Hydronephrosis

148
Q

whats PC consideration with kidney stones?

A

Make sure no concurrent UTI

149
Q

Whats indication for outpt kidney stone?

A

Does not have a h/o CKD
VSS
Tolerating PO’s
Pain controlled
Does not have a h/o CKD

150
Q

Where is stone stuck most of the time?

151
Q

Whats the treatment for kidney stones?

A
  • Fluids
  • Pain control (NSAID’s Toradol IM, narcs)
  • Alpha blockers X 14 days (Flomax??)
152
Q

Who gets sent to the ER for kidney stone?

A

UTI, AKI, sig hydro, VS unstable, intractable pain

153
Q

When do you refer to urology?

A
  • complicated stones
  • Stone not passed in few days
  • Stone >7mm with hydro
  • All pts with stones > 10mm
154
Q

What is cause of SBO?

A

Postop Adhesions but don’t need to recent have surgery

155
Q

Are BS good predicitive?

156
Q

Whats the MC sx for SBO?

A

Constipation

Colicky abd pain with idstension and tympany on percussion

157
Q

What is the initial BS for SBO?

A

Initial high pitched, hyperactive BS

158
Q

Whats the later BS for SBO?

A

hypoactive or absent BS

159
Q

Whats the workup for SBO?

A

Labs: CBC, CMP, lactate

  • Mild/stable start with KUB
    - Test Sensitivity: 60% (up to 80-90% in high grade obstruction). False negative early in process

High suspicion –> CT abd/pel with contrast
90% sensitive

160
Q

Whats the tx for SBO?

A

Imaging +  send to ER
NPO
NG tube for decompression
Surgery

161
Q

Is SBO always a surgical?

A

No, not always, can be decompressed.

162
Q

when will sx for ectopic start?

A

7 weeks of gestation

163
Q

Whats the dx key for ectopic?

A
  • Symptoms typically start around 7 wks of gestation
  • Abd pain may be non-specific, poorly localized
  • 30% will have no vaginal bleeding
164
Q

if pregnancy is positive, and pt has abd pain what should you get?

A

US, can be ectopic

165
Q

if pregancy is negative, can it be ectopic?

A

NO LOL but still get a pregnancy

166
Q

Whats PC consideration for ectopic?

A

+ Bhcg + pelvic pain +/- vag bleed needs r/o ectopic —–> ER

167
Q

Whats the tx for ectopic?

A

Tx directed by OBGYN or ER

168
Q

Why/what should you be careful in abd pain in elderly?

A

Diminished sensation of pain in the elderly
Comorbid diseases
Polypharmacy
Combinations of above result in many more vague, nonspecific presentations
Age 65 Twice as likely to require surgery

169
Q

T/F Diagnoses more common or often missed in older patients

170
Q

Look at slide 35 pearls!

CDM II Fall Block (9 decks)

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