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medical abdomen Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Three choices in Abdominal Pain

A

surgeon, admit, home

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2
Q

what is the workup for medical abdomen

A

Hx, PE, labs, diagnostics = no surgeon

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3
Q

when can you send an abdomen case home?

A

i. Home if: pain improved (not “gone”), can take PO’s, can walk, stable home, stable vitals, they look better

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4
Q

what to do with “Non-specific abdominal pain”

A

12-24hr f/u: cause may reveal itself

Strict return precautions, document understanding

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5
Q

RUQ abd pain think

A 
PNA
HEPATIC TUMOR 
HEPATIC ABSCESS
HEPATITIS
RETROCAECAL APPENDICITIS
BILIARY COLIC
CHOLANGITIS
PYLONEPHRITIS
RENAL COLIC
RENAL INFARCTION
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6
Q

Epigastric pain think

A 
duodenal ulcer 
oesophagitis
gastritis
gastric ulcer
pancreatitis
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7
Q

LUQ pain think

A 
PNA
splenic infarction
pancreatitis
pylonephritis
renal colic
renal infection
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8
Q

central painthink

A 
aortic aneurysm 
Meckle's diverticulitis
infarction
enteritis
obstruction
intussusception
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9
Q

LLQ causes

A 
renal colic
UTI
diverticulitis
sigmoid volvulus 
diverticulitis
colitis 
ovarian cycst
salpingitis
ectopic pregnancy
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10
Q

suprapubic pain causes

A 
pelvic appendicitis
diverticulitis
uterine fibroid
ovarian cyst
salpingitis cystitis
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11
Q

RLQ

A 
renal colic
UTI
Meckle's diverticulitis
chorn's disease
acute appy
perforated 
caecal carcinoma
ovarian cyst
salpingitis
ectopic prenancy
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12
Q

Meckle’s diverticulum

A

true diverticulum of small bowel

Congenital, present 2% at birth

Incomplete obliteration/vestigial remnant of the Vitelline duct

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13
Q

how do they present and what is the big symptom

A
  1. Asymptomatic until a complication – obstruction, inflammation, perforation

Kids w/ hematochezia – think Meckel’s

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14
Q

esophagus think

A 
GERD
PUD
Motility
barret's
hiatal hernia
immune cancer
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15
Q

Bowel think

A 
GIB
diverticulosis
UC
Crohn's 
hernias
gastroentritis
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16
Q

solid organ infection/unflammation

A

pancrease, liver, spleen, kidney, prostate

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17
Q

stones

A

GB

Kidney

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18
Q

something not working

A

urinary retention
ascites
gastroparesis
pseudoobstruction

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19
Q

metabolic

A

DKA (almost always seen with abd pain)

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20
Q

vasculitis

A

sickle cell

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21
Q

toxicology

A

etoh
cocaine
other

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22
Q

tricky pain

A

PNA
Pleural effusion
AMI/ACS

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23
Q

RIGHT SHOULDER referred pain from

A

biliary tree,
GB,
diaphragm irritation

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24
Q

epigastric referred pain from

A

Cardiac

esophagus

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25
Q

ipsilateral groin referred pain from

A

renal colic

hernia

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26
Q

ipsilateral flank
lower abdomen
or thigh

A

Testicles, female reproductive

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27
Q

back pain can be referred from the

A

Aorta, pancreas

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28
Q

sacrum can be referred from

A

rectum
prostate
female gYN

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29
Q

physical exam for an abdominal complain should include

A 
skin
heart
lungs
CVAT
Gyn/GU
rectal

WATCH THEM WALK

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30
Q

why do you want to watch an abdominal pain walk

A

because if they can walk properly they are not retroperitoneal

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31
Q

how to inspect the abdomen on a physical exam

A

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

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32
Q

how should we think about guarding

involuntary is

A

involuntary

muscles are rigid
hard

think peritoneal

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33
Q

how can you fatigue muscles on exam in a pt with peritoneal pain

A

Won’t be able to fatigue their muscles on exam if it’s peritoneal

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34
Q

what is voluntary guearding

A

abd is soft but pt is resisting touch

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35
Q

treat pain

A

need to treat pain

can’t hide surgical abd

IV fluids
1L bolus
THN 200 cc/hr x 1L crystalloid

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36
Q

why do we give fluids to a abd complain

A

get dehydrated with gut stuff and will benefit form IVF

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37
Q

hot oto treat pain

A

ketorolac

IV acetaminophen

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38
Q

know 3 opiates to use for pain

A

morphine 4-8 mg IV/IM
diluadid .5-1mg IV/IM
fentanyl 50-100mcg mcg iV/IM

Remember hypotension!

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39
Q

three antiemetics
IV
IM
SL

A 
Zofran 4-8mg 
compazine 5-10mg
reglan 10 mg
anzemet 12.5 mg 
phenergran 12.5-25 mg
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40
Q

how to approach vomiting-hx

A

OLDCARTS

abd pain
cough
chest pain
dysuria
stool
melena 
GY
PREGNANT
VERTIGO
HA
sick contacts 
diet?
vomiting or pain first
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41
Q

important PMH with vomiting

A

hx same? Also – trauma, psych, cancer, etc

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42
Q

red flags for vomiting

A 
Abnormal VS like HoTN
blood
old/young/pregnant
 cancer
HA
 neuro findings
psych
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43
Q

IV choices for vomiters

what are you worried about

A

IV NS or LR: dehydration, ketosis, alkalosis

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44
Q

vomiting without abdominal pain think

A

ICP
CNS issues
toxicology
exposure

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45
Q

what is diarrhea

A

Diarrhea – 8-10 stools in a 24 hr period

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46
Q

diarrhea questions

A

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

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47
Q

inflammatory diarrhea is classified by

A

blood in stool
fever
abd pain

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48
Q

non-inflmmatory diarrhea looks like

A

blood rare, n/v prominent, mild abdominal pain (crampy)

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49
Q

red flags with diarrhea

A 
VS
fever
old
young
pregnant
altered
PMH
hyperthyroid
HIV
Endocrine
renal failure
GI issues
cancer
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50
Q

what do you worried about in a elderly pt with diarrhea

A

fecal impaction, mesenteric ischemia

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51
Q

constipation is a dx of

A

Diagnosis of exclusion for abdominal pain in the ED

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52
Q

hx of BM you want to ask with constipation

A

frequency, character, pain, blood, fever, obstipation, tenesmus, sudden onset, weight loss

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53
Q

what do you want to do for fecal impaction

A

DRE

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54
Q

what would you want to do for fissures

A

Anoscopy for fissures –> to visualize hemorrhoids, mass

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55
Q

labs for the constipated pt

A

: anemia (chronic dz), thyroid, electrolytes, LFT’s, lactic acid if sick - no radiology unless considering secondary diagnosis or older

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56
Q

when can’t you dx a pt with constipation

A

Abnormal VS, ill appearance or peritonitis should NOT be blamed on constipation

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57
Q

what are the belly labs

A

CBC w/ diff, CMP, lipase, UA, Upreg

58
Q

when would you get a lactic acid

A

Lactic acid? Significant pain, Hx/PE, fever, hypotension, older

59
Q

when would you order a EKG

A

EKG? >40, epigastric pain, tachycardia, chest pain, cardiac risk

60
Q

when would you treat with antibiotics

A

antibiotics? Early if fever, high lactic acid

61
Q

KUB, flat/upright ordered if

A

ordered much less d/t CT but would order in BO or foreign body

62
Q

Gold standard for obstructed bowel

A

CT

63
Q

When would you get a CXR

A

ii. Chest x-ray - everyone if admitted

64
Q

Bedside ULS IF

A 
Billiary
ascites
free fluid
female pelvis
hydronephrosis
appy
aorta
trauma
65
Q

special tests you would want to order if signs of septic or CVA tenderness

A
  1. Blood cultures (get if they are septic), urine culture (cath) – get if pyelonephritis
66
Q

special tox tests

A
  1. ETOH, Urine tox
67
Q

when would you order a PT or a INR

A

anticoagulated, liver Dz, going to surgery

68
Q

order a LDH for

A

LDH for severe pancreatitis

69
Q

surgery prep labs

A
  1. Type and Screen or Type and Cross

a. Blood products, surgery prep

70
Q

NG tube would be ordered if

A 
gastric decompression (SBO),
 sample contents (GI bleed), 
bowel rest (protracted vomiting)
  1. Specific indications, less common these days in ED
71
Q

when would you order antibiotics

A

infection, obstruction, perforation, inflammation

72
Q

what do you want to cover with belly antibiotics (what pathogens)

A

Cover anaerobes, enterococci, gram neg’s

73
Q

PUD/Gastritis/GERD presentation

A

Epigastric pain, burning/aching, +/-n/v, radiates to chest, triggers, night pain, “sour brash”, belching. Recurrent

Not acute abdomen (if so – think perf)

74
Q

GI cocktail

A

Mylanta 30cc, 2% Viscous Lidocaine 15cc

Donnatol 10cc (that makes it green) is falling out of favor

75
Q

Dx test that might be needed for a presentation that looks like GERD

A

+/-IV fluids; pain control, antiemetics, H2’s, PPI’s (usually PO)

76
Q

Red Flags following GERD suspicion

A

abrupt change in sx’s, VS, bleeding/melena, elderly

  1. D/C if stable w/ follow-up
77
Q

burning/sharp/ache
epigastric and chest,

may radiate
weight loss, recurrent, occurs at rest

A

Esophagitis

Look in their mouth – look for thrush for HIV

chronic GERDà Barrett’s Esophagitis – pre-cancerous

78
Q

workup for esophagitis

A

Labs, EKG, CXR; GI cocktail

79
Q

D/C esophagitis if

F/U with

A

D/C home if stable, outpatient f/u

Dysphagia +/- barium; both endoscopy

80
Q

Hiatal hernia

A

Often asx’atic: relation to GERD

Delays esophageal acid clearanceà esophagitis, increase risk Barrett’s

81
Q

Hiatal hernia tx

A

CXR, endoscopy. Tx like GERD

82
Q

upper GIB sxs

A

hematemesis, melena (melena is foul)

83
Q

lowerr GIB sxs

A

hematochezia, BRBPR

bright red blood per rectum

84
Q

key to a GIB workup

A

How much/how long? Painful or painless? Retching/vomiting prior? Vomit/stool appearance, recent surgery/procedure, other bleeding, PMH, meds, habits, Hx same

85
Q

labs for UGIB or BRBPR

A

CBC
Chem
PT/INR

EKG if tachy

UPPER GIB +/-NG tube trial w/ irrigation

86
Q

tx of minor UGIB

A

oral PPI’s, surgery referral LGIB or rectal issues

87
Q

workup of big UGIB or melena

A 
Add 2 IV’s
Type/Screen
lactic acid
CXR
O2
monitor
NG tube
88
Q

workup of big UGIB

A

IV PPI’s with drip, urgent endoscopy
octreotide for varicies;
GI, surgery consult

89
Q

when to d/c GIB

A

may d/c minor bleed/stable/low risk pt’s w/ return precautions, f/u endoscopy/colonoscopy

90
Q

common ddx with abdominal pain in alcoholics

A

etoh gastritis, pancreatitis, GI bleed

91
Q

workup of alcoholic with abd pain

A

: undress, be thorough: head to toe

Labs:

CBC, 
Chem,
 lipase, 
PT/INR, 
UA, 
Upreg, 
CXR, 
EKG
92
Q

tx for alcoholic with abd pain

A

IV hydration, “banana bag” (multivitamins w/ Mg++ and thiamine), pain control ok, antiemetics

93
Q

red flags for an alcoholic with abd pain

A

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

94
Q

what do you see in gastroenteritis

A

Vomiting = gastritis;

diarrhea = enteritis: need both

95
Q

how can you rule out other things in gastroenteritis

A

Hx key. Exam not impressive: dehydrated, miserable

Not peritoneal or “sick”: presumptive dx, self-limiting

96
Q

RF in gastroenteritis

A

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

97
Q

tx of gastroenteritis

A

Tx: IV NS or LR, antiemetic. No imaging unless 2nd diagnosis; d/c home if stable w/ antiemetics, return precautions

98
Q

prodrome of hepatitis

A

malaise, fatigue, anorexia, n/v; then abdominal pain, jaundice, dark urine, “light colored” stool

Mild sx’s to fulminant liver failure

99
Q

hepatitis RF

A

Hx key for risk: travel, exposures, sex hx, sick contacts, EtOH/drugs

100
Q

labs for hepatitis or jaundice

A

Labs

Upreg

Hep serologies,

ULS biliary tract

CT if suspect cancer/mets

101
Q

Painless jaundice is the HALLMARK for

A

a. Painless jaundice is the HALLMARK for pancreatic CA

102
Q

RF in a juandice workup

A

jaundice plus – EtOH w/d, altered, ascites, asterixis, bleeding

103
Q

when can you d/c a jaundice pt

A

Can d/c select, stable pt’s. If admit - GI or Surgery consult (depends on Dx)

104
Q

what do you see with a hep A panel

A

First fecal HAV

then

increase igM early anti HAV

Then IgG ANTI hav

increase in ALT
HAV in seruM

105
Q

heb B panel

A 
see increase in ALT 
HBeAG 
and then anti HBe
HBV DNA early 
HBsAG

anti HBs throughout life

106
Q

cause of pancreatitis

A

= Gallstone 40%, hx ETOH 40%, previous pancreatitis, post trauma

107
Q

presentation of pancreatitis

A
  1. Epigastric pain, +/- radiates to back, vomiting, anorexia
108
Q

labs for pancreatitis

A

: lipase up x3 for dx; LDH, glucose, AST, WBC’s all increased
4. First test = ULS for gallstones, and then CXR, EKG, CT

109
Q

how do you make a pancreatitis dx

A

a. CT scan is how you make the diagnosis

i. Fat stranding, fluid, inflammation

110
Q

RF in pnacreatitis

A

peritoneal, fever, hypotension = very sick!!

111
Q

admission f/u for pancreatitis

A

– NPO, watch ETOH w/d

112
Q

ranson criteria -on admission

A

i. Age >55
ii. Glucose >200
iii. WBC >16k
iv. SGOT (AST) >250
v. LDH >350

113
Q

what does the ranson score tell you about pancreatitis

A

> /= 3: pancreatitis Dx likely, <3: unlikely

114
Q

48 hours after onsent the ranson criteria score tells you

A

11 criteria

3-4 = 15%, 5-6 = 40%, 7-8 = 100%

115
Q

Malaise, fever, vomiting, abdominal, back or flank pain, CVAT, usually dysuria or irritated voiding, hematuria

A

pyelonephritis

116
Q

best test for pyelo in females

A

in/out cath best in females, send culture,

117
Q

other than a UA what should you order in suspected pyelo

A

ULS kidneys (hydronephrosis), RUQ if pain on R. CT only if uncertain dx

UPREG

118
Q

red flags for pylo

A 
Hypotension, signs of sepsis
Pregnant + pyelo
Stone + pyelo
Intractable vomiting
Preexisting renal dz
119
Q

treatment of pylonephritis

A

ADMIT
IVFluoroquinolones, Amikacin, +/- Ceftriaxone

outpatient – 10-14 day course fluoroquinolone, return precautions

120
Q

presentation of

A

Middle age/older, often Hx same, gradual onset, constant, diarrhea, +/-n/v, lower abd pain; LLQ pain common

121
Q

red flags of diverticulosis

A

i.VS abnormal, fever/chills, guarding, old/young/pregnant

122
Q

diverticular disease tx

A

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

123
Q

Sudden, sharp, excruciating, unilateral pain; radiates around abdomen or to groin, diaphoresis, n/v common, can’t lie still, hematuria (15% do not)

A

renal colic

124
Q

lab work up for renal colic

A

i. Labs, UA, bedside US for hydronephrosis

ii. CT w/o contrast if first episode (not KUB) to confirm

125
Q

RF for renal colic

A

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…

126
Q

renal colic tx

A

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

127
Q

RF for ascites

A

SBP: subacute bacterial peritonitis
Fever or painful: must consider SBP
Hypotension, altered, GI bleed, EtOH withdrawl

128
Q

Ascites

A

liver failure, cirrhosis, malignancy

129
Q

when would you do a Paracentesis for ascites

A

diagnostic and/or therapeutic

ULS first; take off 3-5 liters not unusual
Recurrent ascites/stable; tap for comfort, home

130
Q

ascites

A

First time ascites? Admit for w/u.

Fever/SBP? Sick. IV abx, monitor, admit

131
Q

Common causes of urinary retention

A

prostate, meds, hematuria (clot) from bladder CA

132
Q

Urinary Retention tx

A

Tamsulosin (Flomax), Doxazosin (Cardura), etc

133
Q

labs for DKA

A

: 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

134
Q

DKA

A

Begin IV NS 2L bolus, add K+, protocol, monitor, admit

135
Q

gastroparesis rf

A

DM autonomic neuropathy, Parkinson’s, MS, post surgical

Emptying of stomach is delayed

136
Q

gastroparesis sxs

A

Emptying of stomach is delayed

137
Q

causes cycling vomiting syndrome

A

chronic marijuana use, migraines, stress, anxiety, infection

138
Q

Labs for SS

A

CBC, reticulocytes, UA, CXR
Search for infection from H.Flu, E.coli, M. Pneumoniae, Salmonella, S. Aureus
They are functionally asplenic

139
Q

Sickle Cell Crisis tx for

A

: IV hydration, pain control, +/-opiates

140
Q

RF for ssc

A

VS, fever, sepsis, SOB, jaundice, neuro sx’s

141
Q

Older pt’s, LLQ abd pain - CT

Document risk factors

A

AAA

142
Q

RF for constipation

A

old/young, sudden onset, anemia, weight loss, neuro deficit, change in stool caliber

Emergency Medicine (28 decks)

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