medical abdomen Flashcards
Three choices in Abdominal Pain
surgeon, admit, home
what is the workup for medical abdomen
Hx, PE, labs, diagnostics = no surgeon
when can you send an abdomen case home?
i. Home if: pain improved (not “gone”), can take PO’s, can walk, stable home, stable vitals, they look better
what to do with “Non-specific abdominal pain”
12-24hr f/u: cause may reveal itself
Strict return precautions, document understanding
RUQ abd pain think
PNA HEPATIC TUMOR HEPATIC ABSCESS HEPATITIS RETROCAECAL APPENDICITIS BILIARY COLIC CHOLANGITIS PYLONEPHRITIS RENAL COLIC RENAL INFARCTION
Epigastric pain think
duodenal ulcer oesophagitis gastritis gastric ulcer pancreatitis
LUQ pain think
PNA splenic infarction pancreatitis pylonephritis renal colic renal infection
central painthink
aortic aneurysm Meckle's diverticulitis infarction enteritis obstruction intussusception
LLQ causes
renal colic UTI diverticulitis sigmoid volvulus diverticulitis colitis ovarian cycst salpingitis ectopic pregnancy
suprapubic pain causes
pelvic appendicitis diverticulitis uterine fibroid ovarian cyst salpingitis cystitis
RLQ
renal colic UTI Meckle's diverticulitis chorn's disease acute appy perforated caecal carcinoma ovarian cyst salpingitis ectopic prenancy
Meckle’s diverticulum
true diverticulum of small bowel
Congenital, present 2% at birth
Incomplete obliteration/vestigial remnant of the Vitelline duct
how do they present and what is the big symptom
- Asymptomatic until a complication – obstruction, inflammation, perforation
Kids w/ hematochezia – think Meckel’s
esophagus think
GERD PUD Motility barret's hiatal hernia immune cancer
Bowel think
GIB diverticulosis UC Crohn's hernias gastroentritis
solid organ infection/unflammation
pancrease, liver, spleen, kidney, prostate
stones
GB
Kidney
something not working
urinary retention
ascites
gastroparesis
pseudoobstruction
metabolic
DKA (almost always seen with abd pain)
vasculitis
sickle cell
toxicology
etoh
cocaine
other
tricky pain
PNA
Pleural effusion
AMI/ACS
RIGHT SHOULDER referred pain from
biliary tree,
GB,
diaphragm irritation
epigastric referred pain from
Cardiac
esophagus
ipsilateral groin referred pain from
renal colic
hernia
ipsilateral flank
lower abdomen
or thigh
Testicles, female reproductive
back pain can be referred from the
Aorta, pancreas
sacrum can be referred from
rectum
prostate
female gYN
physical exam for an abdominal complain should include
skin heart lungs CVAT Gyn/GU rectal
WATCH THEM WALK
why do you want to watch an abdominal pain walk
because if they can walk properly they are not retroperitoneal
how to inspect the abdomen on a physical exam
one finger ask patient to point to it
look at it is it distended or shiny or is the pt holding onto it
listen to bowel sounds
percuss organs for tympany, ascites, bladder
palpate soft hard or flat or distended
do all special moves
how should we think about guarding
involuntary is
involuntary
muscles are rigid
hard
think peritoneal
how can you fatigue muscles on exam in a pt with peritoneal pain
Won’t be able to fatigue their muscles on exam if it’s peritoneal
what is voluntary guearding
abd is soft but pt is resisting touch
treat pain
need to treat pain
can’t hide surgical abd
IV fluids
1L bolus
THN 200 cc/hr x 1L crystalloid
why do we give fluids to a abd complain
get dehydrated with gut stuff and will benefit form IVF
hot oto treat pain
ketorolac
IV acetaminophen
know 3 opiates to use for pain
morphine 4-8 mg IV/IM
diluadid .5-1mg IV/IM
fentanyl 50-100mcg mcg iV/IM
Remember hypotension!
three antiemetics
IV
IM
SL
Zofran 4-8mg compazine 5-10mg reglan 10 mg anzemet 12.5 mg phenergran 12.5-25 mg
how to approach vomiting-hx
OLDCARTS
abd pain cough chest pain dysuria stool melena GY PREGNANT VERTIGO HA sick contacts diet? vomiting or pain first
important PMH with vomiting
hx same? Also – trauma, psych, cancer, etc
red flags for vomiting
Abnormal VS like HoTN blood old/young/pregnant cancer HA neuro findings psych
IV choices for vomiters
what are you worried about
IV NS or LR: dehydration, ketosis, alkalosis
vomiting without abdominal pain think
ICP
CNS issues
toxicology
exposure
what is diarrhea
Diarrhea – 8-10 stools in a 24 hr period
diarrhea questions
think outbreaks
OPQRST, assoc sx’s, PMH, meds, foods, sick contacts, travel, laxatives, recent abx (think C.Diff), gut surgery, sex habits, day care, food handlers
inflammatory diarrhea is classified by
blood in stool
fever
abd pain
non-inflmmatory diarrhea looks like
blood rare, n/v prominent, mild abdominal pain (crampy)
red flags with diarrhea
VS fever old young pregnant altered PMH hyperthyroid HIV Endocrine renal failure GI issues cancer
what do you worried about in a elderly pt with diarrhea
fecal impaction, mesenteric ischemia
constipation is a dx of
Diagnosis of exclusion for abdominal pain in the ED
hx of BM you want to ask with constipation
frequency, character, pain, blood, fever, obstipation, tenesmus, sudden onset, weight loss
what do you want to do for fecal impaction
DRE
what would you want to do for fissures
Anoscopy for fissures –> to visualize hemorrhoids, mass
labs for the constipated pt
: anemia (chronic dz), thyroid, electrolytes, LFT’s, lactic acid if sick - no radiology unless considering secondary diagnosis or older
when can’t you dx a pt with constipation
Abnormal VS, ill appearance or peritonitis should NOT be blamed on constipation
what are the belly labs
CBC w/ diff, CMP, lipase, UA, Upreg
when would you get a lactic acid
Lactic acid? Significant pain, Hx/PE, fever, hypotension, older
when would you order a EKG
EKG? >40, epigastric pain, tachycardia, chest pain, cardiac risk
when would you treat with antibiotics
antibiotics? Early if fever, high lactic acid
KUB, flat/upright ordered if
ordered much less d/t CT but would order in BO or foreign body
Gold standard for obstructed bowel
CT
When would you get a CXR
ii. Chest x-ray - everyone if admitted
Bedside ULS IF
Billiary ascites free fluid female pelvis hydronephrosis appy aorta trauma
special tests you would want to order if signs of septic or CVA tenderness
- Blood cultures (get if they are septic), urine culture (cath) – get if pyelonephritis
special tox tests
- ETOH, Urine tox
when would you order a PT or a INR
anticoagulated, liver Dz, going to surgery
order a LDH for
LDH for severe pancreatitis
surgery prep labs
- Type and Screen or Type and Cross
a. Blood products, surgery prep
NG tube would be ordered if
gastric decompression (SBO), sample contents (GI bleed), bowel rest (protracted vomiting)
- Specific indications, less common these days in ED
when would you order antibiotics
infection, obstruction, perforation, inflammation
what do you want to cover with belly antibiotics (what pathogens)
Cover anaerobes, enterococci, gram neg’s
PUD/Gastritis/GERD presentation
Epigastric pain, burning/aching, +/-n/v, radiates to chest, triggers, night pain, “sour brash”, belching. Recurrent
Not acute abdomen (if so – think perf)
GI cocktail
Mylanta 30cc, 2% Viscous Lidocaine 15cc
Donnatol 10cc (that makes it green) is falling out of favor
Dx test that might be needed for a presentation that looks like GERD
+/-IV fluids; pain control, antiemetics, H2’s, PPI’s (usually PO)
Red Flags following GERD suspicion
abrupt change in sx’s, VS, bleeding/melena, elderly
- D/C if stable w/ follow-up
burning/sharp/ache
epigastric and chest,
may radiate
weight loss, recurrent, occurs at rest
Esophagitis
Look in their mouth – look for thrush for HIV
chronic GERDà Barrett’s Esophagitis – pre-cancerous
workup for esophagitis
Labs, EKG, CXR; GI cocktail
D/C esophagitis if
F/U with
D/C home if stable, outpatient f/u
Dysphagia +/- barium; both endoscopy
Hiatal hernia
Often asx’atic: relation to GERD
Delays esophageal acid clearanceà esophagitis, increase risk Barrett’s
Hiatal hernia tx
CXR, endoscopy. Tx like GERD
upper GIB sxs
hematemesis, melena (melena is foul)
lowerr GIB sxs
hematochezia, BRBPR
bright red blood per rectum
key to a GIB workup
How much/how long? Painful or painless? Retching/vomiting prior? Vomit/stool appearance, recent surgery/procedure, other bleeding, PMH, meds, habits, Hx same
labs for UGIB or BRBPR
CBC
Chem
PT/INR
EKG if tachy
UPPER GIB +/-NG tube trial w/ irrigation
tx of minor UGIB
oral PPI’s, surgery referral LGIB or rectal issues
workup of big UGIB or melena
Add 2 IV’s Type/Screen lactic acid CXR O2 monitor NG tube
workup of big UGIB
IV PPI’s with drip, urgent endoscopy
octreotide for varicies;
GI, surgery consult
when to d/c GIB
may d/c minor bleed/stable/low risk pt’s w/ return precautions, f/u endoscopy/colonoscopy
common ddx with abdominal pain in alcoholics
etoh gastritis, pancreatitis, GI bleed
workup of alcoholic with abd pain
: undress, be thorough: head to toe
Labs:
CBC, Chem, lipase, PT/INR, UA, Upreg, CXR, EKG
tx for alcoholic with abd pain
IV hydration, “banana bag” (multivitamins w/ Mg++ and thiamine), pain control ok, antiemetics
red flags for an alcoholic with abd pain
a. Fever, VS not resolving
b. Persistent ALOC – think head trauma
i. If Etoh has worn off then think about something going on in the brain
c. Bleeding, pettechiae, acidosis
d. Signs of EtOH withdrawl (tongue wag, fever, tremor)
e. Low CO2, AG: alcoholic metabolic acidosis (part of MUDPILES
what do you see in gastroenteritis
Vomiting = gastritis;
diarrhea = enteritis: need both
how can you rule out other things in gastroenteritis
Hx key. Exam not impressive: dehydrated, miserable
Not peritoneal or “sick”: presumptive dx, self-limiting
RF in gastroenteritis
a. VS that don’t normalize after IV fluids
b. Old/young/pregnant/immunocompromised
c. Serial abdominal exams with persistent pain
d. Blood in stool, fever, rash, ALOC
tx of gastroenteritis
Tx: IV NS or LR, antiemetic. No imaging unless 2nd diagnosis; d/c home if stable w/ antiemetics, return precautions
prodrome of hepatitis
malaise, fatigue, anorexia, n/v; then abdominal pain, jaundice, dark urine, “light colored” stool
Mild sx’s to fulminant liver failure
hepatitis RF
Hx key for risk: travel, exposures, sex hx, sick contacts, EtOH/drugs
labs for hepatitis or jaundice
Labs
Upreg
Hep serologies,
ULS biliary tract
CT if suspect cancer/mets
Painless jaundice is the HALLMARK for
a. Painless jaundice is the HALLMARK for pancreatic CA
RF in a juandice workup
jaundice plus – EtOH w/d, altered, ascites, asterixis, bleeding
when can you d/c a jaundice pt
Can d/c select, stable pt’s. If admit - GI or Surgery consult (depends on Dx)
what do you see with a hep A panel
First fecal HAV
then
increase igM early anti HAV
Then IgG ANTI hav
increase in ALT
HAV in seruM
heb B panel
see increase in ALT HBeAG and then anti HBe HBV DNA early HBsAG
anti HBs throughout life
cause of pancreatitis
= Gallstone 40%, hx ETOH 40%, previous pancreatitis, post trauma
presentation of pancreatitis
- Epigastric pain, +/- radiates to back, vomiting, anorexia
labs for pancreatitis
: lipase up x3 for dx; LDH, glucose, AST, WBC’s all increased
4. First test = ULS for gallstones, and then CXR, EKG, CT
how do you make a pancreatitis dx
a. CT scan is how you make the diagnosis
i. Fat stranding, fluid, inflammation
RF in pnacreatitis
peritoneal, fever, hypotension = very sick!!
admission f/u for pancreatitis
– NPO, watch ETOH w/d
ranson criteria -on admission
i. Age >55
ii. Glucose >200
iii. WBC >16k
iv. SGOT (AST) >250
v. LDH >350
what does the ranson score tell you about pancreatitis
> /= 3: pancreatitis Dx likely, <3: unlikely
48 hours after onsent the ranson criteria score tells you
11 criteria
3-4 = 15%, 5-6 = 40%, 7-8 = 100%
Malaise, fever, vomiting, abdominal, back or flank pain, CVAT, usually dysuria or irritated voiding, hematuria
pyelonephritis
best test for pyelo in females
in/out cath best in females, send culture,
other than a UA what should you order in suspected pyelo
ULS kidneys (hydronephrosis), RUQ if pain on R. CT only if uncertain dx
UPREG
red flags for pylo
Hypotension, signs of sepsis Pregnant + pyelo Stone + pyelo Intractable vomiting Preexisting renal dz
treatment of pylonephritis
ADMIT
IVFluoroquinolones, Amikacin, +/- Ceftriaxone
outpatient – 10-14 day course fluoroquinolone, return precautions
presentation of
Middle age/older, often Hx same, gradual onset, constant, diarrhea, +/-n/v, lower abd pain; LLQ pain common
red flags of diverticulosis
i.VS abnormal, fever/chills, guarding, old/young/pregnant
diverticular disease tx
IV fluids, antibiotics, CT abd/pelvis w/ con
Outpt abx (Augmentin or Cipro/Flagyl) if not sick; clear liquid diet, close f/u, colonoscopy referral
Sudden, sharp, excruciating, unilateral pain; radiates around abdomen or to groin, diaphoresis, n/v common, can’t lie still, hematuria (15% do not)
renal colic
lab work up for renal colic
i. Labs, UA, bedside US for hydronephrosis
ii. CT w/o contrast if first episode (not KUB) to confirm
RF for renal colic
i. VS remain abnormal after pain controlled
ii. Stone + fever or infected urine
iii. Hydronephrosis + fever or infected urine
iv. Stone >6mm on CT (won’t pass on own)
v. One kidney or transplant pt
vi. Risks for AAA, ectopic, appy, torsion, PID/TOA, etc…
renal colic tx
Can d/c home if: resolves, not infected, not sick, peeing
ii. Oral pain meds, @ blocker, urology f/u
iii. IV fluids, pain control (Ketorolac great), antiemetics
RF for ascites
SBP: subacute bacterial peritonitis
Fever or painful: must consider SBP
Hypotension, altered, GI bleed, EtOH withdrawl
Ascites
liver failure, cirrhosis, malignancy
when would you do a Paracentesis for ascites
diagnostic and/or therapeutic
ULS first; take off 3-5 liters not unusual
Recurrent ascites/stable; tap for comfort, home
ascites
First time ascites? Admit for w/u.
Fever/SBP? Sick. IV abx, monitor, admit
Common causes of urinary retention
prostate, meds, hematuria (clot) from bladder CA
Urinary Retention tx
Tamsulosin (Flomax), Doxazosin (Cardura), etc
labs for DKA
: d-stick first; Chem for CO2, Anion Gap, Na, K+; lipase; search for infection (UA, CBC, CXR, ULS RUQ), EKG; serum/urine ketones, mag, phosphorous, upreg
DKA
Begin IV NS 2L bolus, add K+, protocol, monitor, admit
gastroparesis rf
DM autonomic neuropathy, Parkinson’s, MS, post surgical
Emptying of stomach is delayed
gastroparesis sxs
Emptying of stomach is delayed
causes cycling vomiting syndrome
chronic marijuana use, migraines, stress, anxiety, infection
Labs for SS
CBC, reticulocytes, UA, CXR
Search for infection from H.Flu, E.coli, M. Pneumoniae, Salmonella, S. Aureus
They are functionally asplenic
Sickle Cell Crisis tx for
: IV hydration, pain control, +/-opiates
RF for ssc
VS, fever, sepsis, SOB, jaundice, neuro sx’s
Older pt’s, LLQ abd pain - CT
Document risk factors
AAA
RF for constipation
old/young, sudden onset, anemia, weight loss, neuro deficit, change in stool caliber
