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Clinical Medicine 4 > Lecture 5 (GI)-Exam 2 > Flashcards

Lecture 5 (GI)-Exam 2 Flashcards

1
Q

Types of abdominal pain: Pain from a hollow viscera
* How is the patient like?
* What are two examples? (2)

A
  • Patient move around and cannot sit still. Can wait to go to OR.
  • Gastroenteritis
  • Kidney stones
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2
Q

Types of Abdominal Pain: Pain from peritoneal irritation
* What is the patient like? What are two examples?

A

Patient lie very still, severe guarding, rebound tenderness etc.
* Surgical abdomen
* Peritonitis

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3
Q

What are examples of surgical abdomen? (6)

A
  • Ectopic pregnancy
  • Appendicitis
  • Diverticulitis
  • Ulcers rupture
  • Ruptured spleen
  • Trauma (stab, gun shot)
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4
Q

Fill for the different radiation of abdominal pain

A
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5
Q

Classic Presentations - Acute Appendicitis
* What is the first sign?
* What are the gastroenteritis signs?
* What are the appendicitis signs?
* What can McBurney’s point be tender in?

A
  • Periumbilical pain – 1st sign.
  • GE – nausea before the abd pain.
  • Appendicitis – periumbilical pain before the nausea. Patients aren’t hungry – negative hamburger sign.
  • McBurney’s point can be tender in: Meckels, UC, Crohn’s, cecal volvulus, ovarian cysts etc.
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6
Q

Classic Presentations - Acute Appendicitis
* What are all the special tests?(5)

A

Test McBurney’s, Psoas, Rovsign, obturator sign, rectal exam with pain and tenderness on the right side.

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7
Q

Classic Presentations - Acute Cholecystitis
* What are the RFs?

A

Female, fat, forty, fertile, fair, flatulent, family Hx.

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8
Q

Classic Presentations - Acute Renal Colic
* What are the sxs?(5)

A

Typically abrupt flank pain radiating to the groin, nausea, vomiting, labor pains, hematuria (gross or micro).

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9
Q

Overview
* What are the major goals of abdominal pain? (3)

A
  • Identify life-threatening situations quickly
  • Differentiate surgical from non-surgical cases
  • Narrow diagnostic possibilities with a thorough H&P

  • Abdominal pain represents ~ 5% of all Emergency Department chief complaints
  • Diagnosis is challenging
  • Approximately 50% do not have a definitive diagnosis at time of discharge.
    *
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10
Q

What are the life threatening situations that you need to ID quickly? (5) These patients are generally what?

A

Examples:
* Aortic dissection
* Ruptured viscous/Organ injury
* Ischemic bowel
* Bowel obstruction
* Peritonitis

These patients are generally SICK and usually have abnormal vital signs or physical findings

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11
Q

Differentiate surgical from non-surgical cases among these examples:
* Cholecystitis v.s. Pancreatitis
* Appendicitis v.s. mesenteric adenitis (epiploic appendagitis)
* Bowel obstruction v.s. fecal impaction
* Ectopic pregnancy v.s. ruptured ovarian cyst

A
  • Cholecystitis (surgical) v.s. Pancreatitis (no)
  • Appendicitis (surgical) v.s. mesenteric adenitis (epiploic appendagitis-> omentum fat hanging off and causing inflammation)
  • Bowel obstruction (surgical) v.s. fecal impaction (no)
  • Ectopic pregnancy (surgical) v.s. ruptured ovarian cyst
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12
Q

Surgery is necessary for some abdominal pathology and not for others-
* What will happen if you miss a surgical pathology?

A

IF YOU MISS A SURGICAL PATHOLOGY THE PATIENT WILL USUALLY GET VERY SICK VERY QUICKLY

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13
Q

What are ways to narrow diagnostic possibilities with a thorough H&P? (4)

A
  • Have patient “SHOW YOU” where pain is-
  • Acute v.s. Chronic
  • Traumatic?
  • Associated symptoms: Vaginal discharge, dysuria, fever, diarrhea etc.

Ex: Hypotensive, belly pain and just fell off a horse-> Spleen rupture

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14
Q

Abdominal Pain Types: Explain the pain for each
* Somatic:
* Visceral (colicky):

A

Somatic
* Sharp with a more specific location

Visceral (Colicky)
* dull and/or cramping, intermittent
* poorly localized

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15
Q

Abdominal Pain Types: Explain the pain for each
* Parietal:
* Referred:

A

Parietal
* Refers to surrounding wall (typically musculoskeletal)
* Sharp, dull, achy
* Typically have point tenderness, reproduced by mechanical stimulation

Referred
* pain is distant from site of involved organ

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16
Q

What do you need to get for HPI?

A
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17
Q

Abdominal Exam:
* What do you need to look for Physical examination?
* What do you need to inspect for?

A

Physical Examination
* Appearance: Does the patient look sick?
* VITAL SIGNS

Inspection
* scars, distension, discoloration, rashes, trauma, striae, caput medusa

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18
Q

Abdominal Exam
* What do you need to ausculate for?
* Percuss for what?
* Palpate for what?

A

Auscultation
* bruits, bowel sounds +/- “tinkling”, high pitched

Percussion
* organomegaly, peritonitis, dullness

Palpation
* pain location, rebound, guarding, rigidity, masses, referred pain

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19
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the RUQ?(5)

A
  • Duodenal Ulcer (right flank)
  • Hepatitis
  • Acute Cholecystitis
  • Biliary issues/colic
  • Pneumonia/effusion

PHABD

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20
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the LUQ?(6)

A
  • Ruptured Spleen
  • Gastric Ulcer
  • Aortic aneurysm
  • Splenic thrombosis/injury
  • Perforated colon
  • Pneumonia/effusion
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21
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the RLQ? (11)

A
  • Appendicitis
  • Salpingitis
  • Ovarian Cyst/torsion
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Meckel diverticulitis
  • Backwash ileitis
  • Regional Ileus
  • Perforated cecum
  • Testicular problems
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22
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the LLQ? (10)

A
  • Sigmoid diverticulitis
  • Salpingitis
  • Ovarian cyst
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Perforated colon
  • Regional Ileus
  • Ulcerative colitis
  • Testicular problems
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23
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain that is periumbilical or diffuse? (9)

A
  • Intestinal obstruction/perforation/peritonitis
  • Acute pancreatitis
  • Early appendicitis
  • Mesenteric thrombosis
  • Aortic aneurysm
  • Diverticulitis
  • Enteritis/AGE
  • Ischemia/thrombosis
  • Parietal wall problems
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24
Q
A
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25
Q

Classic Signs
* What is murphy’s sign?
* Suggestive of what?

A

Murphy’s sign
* Pressure applied to RUQ during inspiration causes pain and cessation of inspiratory effort
* suggestive of gallbladder inflammation

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26
Q

Classic Signs
* What is kehr’s sign? What is it suggestive of?

A
  • Left shoulder pain referred from diaphragm
  • suggestive of free intaperitoneal blood (splenic injury)
27
Q

Classic Signs
* What the mcburney’s point? What is it suggestive of?

A
  • tenderness with palpation of abdomen 2/3 of the way between the umbilicus and right iliac crest
  • suggestive of appendicitis
28
Q

What is the Psoas sign? What is it suggestive of?

A
  • patient flexes right hip against resistance and experiences RLQ pain
  • suggestive of appendicitis
29
Q

What is the obturator and rovsing’s sign? What is that suggestive of?

A

Obturator sign
* internal and external rotation of patients leg while right hip flexed causing RLQ pain
* suggestive of appendicitis

Rovsing’s sign
* Palpation into the LLQ causes RLQ pain
* suggestive of appendicitis

30
Q

What is grey turner’s sign and cullen’s sign? What is the suggestive of?

A

Grey-Turner’s sign
* ecchymosis of flanks
* suggests hemorrhagic pancreatitis

Cullen’s sign
* ecchymosis of periumbilical area
* suggests hemorrhagic pancreatitis

31
Q

What is Lloyd’s sign? What does it suggest?

A

Lloyd’s sign (CVA tenderness)
* percussion of flank elicits pain
* suggests renal inflammation
*

32
Q

Explain how to do the mc burney’s point? (spider senses is telling me to know this)

A
33
Q

What is this?

A

Grey-turner’s sign
* Flank ecchymosis from pancreatitis or retroperitoneal bleeding

34
Q

What is this?

A

Cullen’s Sign
* Periumbilical ecchymosis from intraperitoneal hemorrhage

35
Q

Bedside Exam for Peritonitis
* What can you do? What is the false positive and negatives?

A

Rebound Tenderness
* False Positive ~ 20% of the time
* False Negative ~ 15% of the time

36
Q

Complete/cursory PE
* What do you need to rule out for cardiopulmonary and pelvic?

A

Cardiopulmonary exam
* Rule out referred pain

Pelvic exam
* PID, ectopic pregnancy, ovarian mass, etc.

37
Q

Complete/Cursory Physical Examination
* What do you need to rule out for genital and rectal exam?

A

Genital exam
* testicular torsion, epididymitis, hernias, etc.

Rectal exam
* guaiac, masses, abscess, hemorrhoids, etc.

38
Q

The most important diagnostic study in a FEMALE with abdominal pain is what?

A

PREGNANCY TEST

  • Any female with a uterus that is not post-menopausal gets one!!!!
  • Some providers refer to this as “6-60”
39
Q

Pregnant Yes/No???
* What is this is major factor in?
* Must be done when?
* What can be done?

A
  • This is a major determining factor in disposition and treatment
  • Must be done rapidly upon patient presentation
  • Urine or serum testing is equivalent in most cases
40
Q

Common Diagnostic Studies
* What is the workup for abdominal pain?(6)

A
  • Complete Blood Count
  • Complete Metabolic Profile (Chem 8 and Liver enzymes)
  • UA (with C&S as appropriate)
  • Amylase and Lipase
  • Guaiac
  • Vaginal and Cervical specimens if indicated
41
Q

Common Diagnostic Studies
* What is some imaging that needs to be done? What are they looking for?(4)

A

KUB (Kidney/Ureters/Bladder) or AAS (Acute Abdominal Series-Obstruction Series)
* Renal calculi, free air, obstruction/ileus, air/fluid levels

Ultrasound
* Pregnancy (ectopic or intrauterine), gall bladder, ovarian cyst/abscess, AAA, obstructive uropathy

CT of abdomen/pelvis

42
Q

When do you need contrast and not?(3)

A

WITHOUT IV: Kidney Stones, Fractures, Foreign Bodies

WITH IV: Obstruction, appendix, diverticulitis-(When you want to light up the plumbing or find tissue tumors)
* Need oral and IV for low BMI

43
Q

General management principles
* Treat what?
* Who should you involve?

A
  • Treat the underlying process
  • Involve the surgical team ASAP when you believe it’s a surgical problem
44
Q

What you need to do when discharging a patient? (3)

A
  • Provide complete follow up instructions
  • Always tell patient to come back if clinical situation worsens
  • Involve primary doctor, specialist consultants liberally
45
Q

Ectopic Pregnancy
* What does work up usually include?
* Who should be involved early?
* Clinically unstable patients need to go where?

A
  • Work up usually includes blood tests and Ultrasound
  • Gyn consultants should be involved early
  • Clinically unstable patients go directly to surgery (skip US)
46
Q

Tubal ligation + positive HCG =

A

ECTOPIC

47
Q

Aortic Aneurysm/Dissection
* What is an aneurysm?
* What is a dissection?

A

Aneurysm is enlargement

Dissection is tear
* Intima is just inner lining
* Complete rupture = dead

48
Q

ANY PAIN ABOVE AND BELOW THE DIAPHRAGM OR “TEARING” IN NATURE SHOULD PROMPT what?

A

PROMPT SUSPICION OF AORTIC ANEURYSM OR DISSECTION

49
Q

Dissecting AAA do not always present with what?

A

Dissecting AAA do not always present with palpable pulsatile masses or bruits that can be auscultated

50
Q

Appendicitis
* Cecal _
* Variable what? What does that cause?

A

Cecal Diverticulum or fecalith: MCC

Variable Anatomical Positions
* Symptoms and Signs are inconsistent
* Retrocecal: side pain

51
Q

Appendicitis: MC surgical problem
* what is the risk of population during their lifetime?
* Common in who?
* What is not common? What ages does it have a higher risk in?

A
  • 7 - 10% of population during their lifetime
  • 10 - 30 year olds (3M:2F); after 30 yo ~1M:1F
  • Perforation - not uncommon (up to 20% of cases)
  • Perforation more common < 12 yo and > 65 yo
52
Q

Appendicitis:
* What are the common causes?

A
  • Luminal obstruction: fecalith; lymphoid hyperplasia
  • Mucosal edema
  • Infarction and tissue necrosis
53
Q

Appendicitis
* Infarction and tissue necrosis which can lead to what (3)

A
  • Abscess formation
  • Perforation
  • Peritonitis

This is considered complicated

54
Q

Clinical Manifestations of appendicitis
* What happens with pain?
* Abdominal complaints?
* What about temp?
* WBC?

A
  • Periumbilical-> RLQ pain (occurs in 50 – 80%)
  • Anorexia->Nausea->Vomiting
  • Low Grade Fever
  • Mild Leukocytosis (10 - 17.5K)
55
Q

Clinical Manifestations of appendicitis
* What are the classic findings?
* What about UA?

A

Classic findings (present in minority of patients)
* McBurney’s Point; Rovsings sign
* Obturator sign; Psoas Sign

Urinalysis – usually negative (although microhematuria is typically seen)

56
Q

Appendicitis: Management
* What do you need to do for surgery?
* Control what? How?
* Give what?
* Repeat what?

A
  • NPO
  • PAIN CONTROL-> morphine or fentenyl
  • IV Fluids and usually antibiotics
  • Repeat Physical Examinations
57
Q

Appendicitis: Management
* What imaging should be done?
* What consult?
* What is the surgery?

A
  • Ultrasound; CT Scan-usually WITH contrast (low bmi: oral constrast too)
  • Surgical consult
  • Appendectomy
58
Q

What is the difference between incarcerated vs strangulated hernia?

A

Incarcerated
* A hernia that is not able to be reduced on exam
* The vascular supply of the bowel is not compromised

Strangulated
* Ischemia and necrosis of the hernia and bowel

59
Q

What is the groin hernia anatomy? (ex hesselbach’s triangle)

A
  • Medial border: Lateral edge of the rectus abdominis muscle (also known as the linea semilunaris).
  • Lateral border: Inferior epigastric vessels (artery and vein).
  • Inferior border: Inguinal ligament (Poupart’s ligament).
60
Q

Hernia:
* What is a Pantaloon/Sadlebag hernia?
* What is a hiatal hernia?
* What is a incisional/ventral hernia?

A
  • Pantaloon/Sadlebag hernia: double hernia (direct + indirect) mc following a laprascopic procedure
  • Hiatal – protrusion of the stomach through the diaphragm
  • Incisional/Ventral – seen more commonly with vertical incisions
61
Q

Inguinal
* What is indirect hernia?
* What is direct hernia?
* What is femoral hernia?

A
  • Indirect (most common) – passes through the internal inguinal ring down the inguinal canal and may pass into the scrotum
  • Direct – passes through the external inguinal ring at Hesselbach’s triangle, rarely enters the scrotum.
  • Femoral – passes through the femoral ring (least common & occur almost exclusively in females)
62
Q

What is an umbilical hernia?
What is the age cutoff for observation vs surgical repair?

A

Umbilical – generally congenital and appears at birth
* 5 year old

63
Q
A
  1. Air fluid levels: NG tube suction, pain control, CAT scan, gen surgery consult, NPO, abx (bowel obstruction)
  2. Sigmoid volvus (older, psych pt, emergency): labs, fluids, abx, gen surg consult
  3. Emergency: Fluids, abx, labs, gen surg consult, type and screen

Clinical Medicine 4 (13 decks)

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