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Emergency Med rotation > GI/nutritional part 1 > Flashcards

GI/nutritional part 1 Flashcards

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1
Q

PMH for abdomen

A

Prior medical problems related to abdomen: hepatitis, cirrhosis, gallbladder problems, pancreatitis

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2
Q

Social hx for abdomen

A 
Tobacco
EtOH (cirrhosis)
Illegal drugs (IVDA- hepatitis)
Medication hx (NSAIDs)
Recent travel
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3
Q

ROS for abdomen

A 
Fever
Vomiting
-Frequency, dry heaves vs vomiting, type
Bowel movements
-Diarrhea, frequency, last BM
-Consistency, color: bloody (hematochezia)/black, tarry (melena/ dark stools/ BRB/ white or grey (can indicate liver or gallbladder etiology))
-Painful BM
GU sx
-Dysuria, hematuria, frequency, dark urine
-Vaginal d/c, pelvic pain, testicular pain/swelling, penile d/c
-Flank pain
CP, SOB
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4
Q

What does melena indicate?

A

Upper GI source

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5
Q

PE of abdominal complaints

A

Vitals: febrile, hypotension, tachycardia (that triad is sepsis until proven otherwise)
General appearance: toxic or ill-appearing, pallor, or jaundice
Abdomen:
-Inspect: scars, distention, pulsations, hernia, striae
-Auscultate
–normal BS vs hyperactive vs hypoactive vs absent
—Early obstruction: high-pitched, tinkling bowel sounds
-Percussion
–Tympany (hollow sounds) vs dull
–Estimating size of liver and spleen
-Palpation
–Tenderness, guarding, rebound, rigidity, masses, organomegaly

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6
Q

Carnett sign

A

Indicator of abdominal wall cavity abnormalities
Pt lies supine and points to where they absolutely hurt the worst
Palpate the area
Have them sit up
Pain getting worse with sitting up is a positive sign

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7
Q

Labs for abdominal pain: CBC

A

Leukocytosis: infection (nl WBC does not r/o infectious process)
Anemia: GI bleed

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8
Q

Labs for abdominal pain: CMP

A

Dehydration
Endocrine or metabolic d/o: DKA, pancreatitis
Abnl LFTs: cholecystitis, cholelithiasis, hepatitis
Abnl renal function: ARF, dehydration

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9
Q

Labs for abdominal pain: UA, urine hCG, +/- urine C&S

A

Nitrites, leukocytes: UTI, pyelonephritis
Send a culture when treating d/t abx resistance
Culture if unsure about amount of bacteria in urine, etc.
RBCs: uterolithiasis
hCG +: ectopic
Every menstruating woman needs urine hCG

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10
Q

Labs for abdominal pain: lipase

A

Elevated in pancreatitis

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11
Q

Labs for abdominal pain: serum lactate

A

Possible mesenteric ischemia

Take a serum lactate when toxic, septic, high white count

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12
Q

What should be done while you wait for lab results for abdominal pain

A 
Treat nausea/vomiting
-Zofran (ondansetron)
-Phenergan (promethazine)
Control pain
-Morphine
-Dilaudid
-Toradol
Fluid resuscitation
-Caution in large bolus of fluids in elderly or hx of CHF
NPO if warranted
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13
Q

RLQ pain differential

A 
Aortic aneurysm
Appendicitis
Crohn's disease
Diverticulitis (cecal)
Ectopic pregnancy
Endometriosis
Hernia
Ischemic colitis
Meckel diverticulum
Ovarian cyst or torsion
PID
Testicular torsion
Ureteral calculi
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14
Q

Etiology of appendicitis

A

Occurs when obstruction of appendix leads to inflammation and infection
MCC- fecalith

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15
Q

Presentation of appendicits

A

Non-specific sx that progress with time
Early: vague periumbilical pain, anorexia, N/V
Later: classic presentation- pain migrates to RLQ: McBurney’s point, fever is late finding
Siogns: McBurney, Rovsing, Psoas, obturator, bump sign
Location of abdominal pain depends on location of appendix
If sudden decrease in pain, consider perforation

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16
Q

Workup of appendicitis: labs

A

CBC
UA
Urine hCG
Nl WBC does not r/o appendicitis

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17
Q

Workup of appendicitis: imaging

A

CT is study of choice
CT with IV AND oral contrast
Indicators on results: pericecal inflammation, abscess, periappendiceal phlegmon or fluid collections

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18
Q

Workup of appendicitis: u/s

A

High sensitivity but limited by operator and if abnormally located appendix or ruptured appendix
Preferred modality in kids and pregnant pt

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19
Q

Tx of appendicitis

A

Surgery: appendectomy
Abx: cover for anaerobes, enterococci and gram neg
-Zosyn (piperacillin/tazobactam)
-Unasyn (ampicillin/sulbactam)

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20
Q

RUQ pain differential

A 
Cholecystitis
Cholangitis
Biliary colic
Hepatitis
Hepatic abscess
Myocardial infarction/ischemia
Perforated duodenal ulcer
Retrocecal appendicitis
Fitz-Hugh Curtis syndrome
21
Q

Etiology of acute cholecystitis

A

Caused by obstruction of the bile duct, usually by a gallstone, leading to inflammation

22
Q

Presentation of acute cholecystitis

A

RUQ or epigastric pain that is colicky and becomes steady and increases in intensity
Lasts longer than the typical 5 hours
Pain may radiate to R shoulder or subscapular area
Typically worse after eating, esp a high-fat meal
Usually with associated n/v, low-grade fever, anorexia
Signs: Murphy

23
Q

Workup of acute cholecystitis: labs

A 
CBC, CMP, UA
Nl to elevated WBC
Nl to elevated LFTs
Nl to elevated serum bilirubin
-After 24 hrs, bilirubin levels increase in blood and urine
24
Q

Workup of acute cholecystitis: imaging

A

U/s is study of choice
-Indicators on u/s: thickened GB wall, gallstones, GB distention, pericholecystic fluid
-Positive sonographic Murphy’s sign is very sensitive for dx
CT is good too

25
Q

Tx of acute cholecystitis

A

Surgery: cholecystectomy
Abx: 3rd gen cephalosporin and metronidazole

26
Q

Ascending cholangitis: etiology

A 
Complete biliary obstruction (CBD stone or tumor) + bacterial superinfection
Ascending infection (E. coli, enterococcus, Klebsiella, enterobacter)
27
Q

Presentation of ascending cholangitis

A

Charcot’s triad: fever + jaundice + RUQ pain
Reynold’s pentad: Charcot’s triad + hypotension + AMS
-Indicates sepsis; rapidly fatal

28
Q

Workup for ascending cholangitis: labs

A

CBC, CMP, UA
Leukocytosis
Elevated bilirubin and alkaline phosphatase

29
Q

Workup for ascending cholangitis: imaging

A

U/s

ERCP is optimal for dx and tx but should not be done until pt stable

30
Q

Tx of ascending cholangitis

A

Abx: triple coverage
-Ampicillin + gentamicin + clindamycin
-Or metronidazole + 3rd gen cephalosporin or Zosyn + fluoroquinolone
Immediate surgical consult
-ERCP for drainage, sphincterotomy, stone removal, stent placement

31
Q

Epigastric pain differential

A 
Pancreatitis
Swallowed foreign body
GERD
Esophageal perforation
Aortic dissection
MI
Peptic ulcer
Gastritis
Esophagitis
32
Q

Etiologies of acute pancreatitis

A

> 50% secondary to EtOH abuse, others include:
Cholelithiasis
Meds (APAP, erythromycin, steroids, HCTZ, anti-retrovirals, etc)
Severe hyperlipidemia (esp hypertriglyceridemia)

33
Q

Presentation of acute pancreatitis

A

Epigastric pain that bores to the back with associated n/v that is constant and worse in supine and improves with leaning forward
Epigastric or upper abdominal tenderness with palpation
May have low-grade fever, tachycardia, hypotension
If severe, could present with signs of shock, renal failure, AMS

34
Q

Workup of acute pancreatitis: labs

A

CBC, CMP, amylase, lipase
Lipase (at least 2-3x nl) is preferred diagnostic test, more sensitive/specific
-Nl amylase does not exclude dx- no benefit to order both tests
Elevated liver enzymes, esp alkaline phosphatase, suggests biliary dz and gallstone pancreatitis
Leukocytosis generally present

35
Q

Workup for acute pancreatitis: imaging

A

Abdominal CT preferred over u/s

36
Q

Ranson criteria

A 
Indicates poor prognosis for pancreatitis- the higher the score, the worse the prognosis
Leukocyte count >16K
Glucose >200
Lactate dehydrogenase >350
AST >250
Arterial pO2 <60
Base deficit >4
Calcium falling
BUN rising
37
Q

Cullen sign

A

Ecchymosis around umbilicus

38
Q

Grey-turner sign

A

Ecchymosis around flank

39
Q

Tx of acute pancreatitis

A

NPO
Fluid resuscitation, anti-emetics, pain management
Consider abx, esp for abscess, infected pseudocyst
Admission (usually) with GI consult
-Pts with mild dz, no systematic complications, or biliary tract dz + can tolerate clear liquid and PO pain meds can be managed with close f/u; advance PO intake ast tolerated
–Advise pts to return if fever, pain, can’t tolerate meds

40
Q

LLQ pain differential

A 
Diverticulitis
Ectopic pregnancy
Endometriosis
Ischemic colitis
PID
Ovarian cyst or torsion
Testicular torsion
Ureteral calculi
41
Q

Diverticulosis

A

Small herniations through wall of colon

42
Q

Diverticulitis

A

Inflamed/infected diverticula

43
Q

Complicated diverticulitis

A

Acute diverticulitis + bowel obstruction, abscess, fistula, or perforation

44
Q

RFs of diverticular dz

A

Age
Low fiber/high fat diet
Obesity
Tobacco use

45
Q

Presentation of diverticulitis

A 
Steady deep discomfort- typically in LLQ
Tenesmus, change in bowel habits
N/V
Low-grade fever
Signs of peritonitis with abscess, perforation
46
Q

Workup of diverticulitis: labs

A

CBC, CMP, UA to help exclude other diagnoses, hemoccult may be positive

47
Q

Workup of diverticulitis: imaging

A

CT abd/pelvis with IV and oral contrast is diagnostic

48
Q

Tx of diverticulitis

A

IV fluids, anti-emetics, pain control
Abx: cipro + metonidazole
Clear liquid diet advance as tolerated to high fiber diet with avoidance of obstructing or constipating foods
Close f/u
Admission and surgical consult for complicated diverticulitis

49
Q

DDx of diffuse abdominal pain

A 
Aortic dissection
AAA
Early appendicitis
Bowel obstruction
Gastroenteritis
Mesenteric ischemia
Bowel perforation
Peritonitis
Volvulus
IBS/UC/Crohns
Spontaneous bacterial peritonitis

Emergency Med rotation (12 decks)

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