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Emergency Medicine 2 > Medical Abdomen > Flashcards

Medical Abdomen Flashcards

1
Q

the medical abdomen

A
  • Common; know the “story”, the diagnostics; serial exams
  • Three choices in Abdominal Pain: surgeon, admit, home
  • Medical Abd = Hx, PE, labs, diagnostics = no surgeon
    • May have Red Flags, need admission, but not surgery
  • No Red Flags and no need to admit?
    • Home if: pain improved (not “gone”), can take PO’s, can walk, stable home, stable vitals, they look better
  • “Non-specific abdominal pain”
    • Unknown Dx – resolved or improved, pt stable as above
    • 12-24hr f/u: cause may reveal itself
    • Strict return precautions, document understanding
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2
Q

Meckel’s diverticulum

A

Meckel’s Diverticulum: diverticum of small bowel. Congenital, present 2% at birth. Incomplete obliteration/vestigial remnant of the Vitelline duct. Asymptomatic until a complication – obstruction, inflammation, perforation. Kids w/ hematochezia – think Meckel’s

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3
Q

Medical abdomen neighborhood

A
  • Esophagus, stomach
    • GERD, PUD, motility, Barrett’s, hiatal hernia, immune, cancer
  • Bowel – large or small
    • GI bleed, diverticulosis, UC, Crohn’s, hernias, gastroenteritis
  • Solid organ infection/inflammation
    • Pancreas, liver, spleen, kidney, prostate
  • Stones – GB or kidney
  • Something doesn’t work:
    • Urinary retention, ascites, gastroparesis, pseudoobstruction
  • Metabolic – DKA, etc
  • Vasculitis – sickle cell, etc
  • Tox – etoh, cocaine, other
  • Female pelvic pain
  • Male GU
  • Tricky – pneumonia, pleural effusion, AMI/ACS
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4
Q

referred pain

A
  • Right shoulder -> biliary tree, GB, diaphragm irritation
  • Epigastric -> cardiac, esophagus
  • Ipsilateral groin -> renal colic, hernia
  • Ipsilateral flank, low abdomen or thigh -> testicles, female reproductive
  • Back pain -> aorta, pancreas
  • Sacrum -> rectum, prostate, female gyn
  • skin hurts? think herpes zoster
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5
Q

physical exam

A
  • Don’t focus only on the abdomen!
    • Skin, lungs, heart, CVAT, Gyn/GU, rectal
    • Watch them walk if possible
  • The Abdomen
    • One finger – point to where it hurts
    • Look at it. Then listen: Bowel sounds? Quality?
    • Percuss - organs, tympany, ascites, bladder
    • Palpation – Soft or hard? Flat or distended?
      • Do all the special moves on first pass
    • Guarding?
      • Involuntary = muscles rigid, hard = peritoneal
      • Voluntary = abd is soft, but pt resists touch
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6
Q

treating pain and N/V

A
  • Pain is a valuable indicator but Tx it - serial exams
  • IV fluid helps - 1L bolus* then 200cc/hr x1L (crystalloid)
  • Ketorolac? IV Acetaminophen? Ketamine?
  • Opiates, IV (not po if vomiting, surgery) - know 3
    • Morphine 4-8mg IV/IM, Dilaudid 0.5-1mg IV, Fentanyl 25-50mcg IV/IM
    • Remember hypotension!
  • Antiemetics IV/IM/SL (not po) - know 3
    • Zofran 4-8mg, Phenergan 12.5-25mg, Compazine 5-10mg, Reglan 10mg, Anzemet 12.5mg
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7
Q

vomiting

A
  • Hx: nail it down – OPQRST
  • Associated sx’s: abd pain, cough, chest pain, dysuria, stool, melena, GU, pregnant, rash, vertigo, HA, sick contacts, diet? Vomiting first or pain first?
  • PMHx: hx same? Also – trauma, psych, cancer, etc
  • Red Flags: VS, blood, old/young/pregnant, cancer, HA, neuro findings, psych
    • Cannot tolerate PO’s at all – can’t go home
  • IV NS or LR: dehydration
  • Know 3 antiemetics – IV, IM, SL routes
  • Beware vomiting without abdominal pain
    • Think increased ICP, CNS issue, toxicology/exposure
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8
Q

diarrhea

A
  • Worldwide issue, outbreaks common
  • Hx key: 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: blood in stool, fever, abd pain
  • Non-inflammatory: blood rare, n/v prominent, mild abdominal pain (crampy)
  • Red Flags: VS, blood, fever, old/young/pregnant, altered; PMH: HIV, hyperthyroid, endocrine, renal failure, GI issues, cancer
  • Rehydrate to correct electrolytes, met acidosis.
  • Elderly: fecal impaction, mesenteric ischemia
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9
Q

constipation

A
  • Diagnosis of exclusion for abdominal pain in the ED
  • Hx BM’s: frequency, character, pain, blood, fever, obstipation, tenesmus, sudden onset, weight loss
  • PMH, medications, hx same, change in routine, diet
  • DRE (fecal impaction); Anoscopy for fissures à hemorrhoids, mass
  • Red Flags: old/young, sudden onset, anemia, weight loss, neuro deficit, change in stool caliber
  • Labs +/- only: anemia (chronic dz), thyroid, electrolytes, LFT’s, lactic acid if sick - no radiology unless considering secondary diagnosis or older
  • Abnormal VS, ill appearance or peritonitis should NOT be blamed on constipation
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10
Q

interventions/diagnostics

A
  • Treat the Pt:
    • IV hydration for most: pain/vomiting, need meds/IV contrast
      • Admitted or going to the OR
    • Pain meds? Antiemetics? Antipyretic? (yes)
  • Orders:
    • “Belly Labs”: CBC w/ diff, CMP, lipase, UA, Upreg
    • Lactic acid? Significant pain, Hx/PE, fever, hypotension, older
    • EKG? >40, epigastric pain, tachy, chest pain, cardiac risk
    • CXR? Epigastric/ RUQ/ LUQ pain, older, fever
    • Antibiotics? Early if fever and/or high lactic acid
  • What’s on the DDx? Which imaging helps you make the Dx?
    • X-Rays? (CXR, plain films?)
    • Ultrasound?
    • CT scan? (with or without contrast?)
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11
Q

radiology

A
  • KUB, flat/upright - ordered much less d/t CT
    • You suspect bowel obstruction, foreign body
  • Chest x-ray - everyone if admitted
    • You suspect ruptured viscous, pulmonary causes
  • Bedside ULS – often first imaging
    • Billiary, ascites, free fluid, fenale pelvis, hydronephrosis, appy, aorta, trauma
  • CT Scan – “the answer machine”
    • Definitive (mostly),“mystery patient”
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12
Q

special labs/imaging

A
  • Case specific
    • ETOH: Magnesium, Phosphorous; Urine tox
    • Blood cultures, urine culture (cath)
    • PT/INR - anticoagulated, liver Dz, going to surgery
    • LDH for severe pancreatitis
    • Type and Screen or Type and Cross
      • Blood products, surgery prep
  • NG tube – gastric decompression (SBO), sample contents (GI bleed), bowel rest (protracted vomiting)
    • Specific indications, less common these days in ED
  • Belly antibiotics – infection, obstruction, perforation, inflammation
    • Cover anaerobes, enterococci, gram neg’s
    • Pip/Taz (Zosyn), 2nd gen cephalosporin, Flagyl, Levofloxacin, aminoglycoside (renal)
      • Etiology specific
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13
Q

PUD/gastritis/GERD

A
  • Epigastric pain, burning/aching, +/-n/v, radiates to chest, triggers, night pain, “sour brash”, belching. Recurrent
  • Not acute abdomen (if so – think perf)
  • Check belly labs, guaiac, EKG, H.Pylori
  • Bedside ULS RUQ; CT only if mystery pt
  • +/-IV fluids; GO cocktail, H2’s, PPI’s (usually PO), antiemetics
  • Dx suspected w/ Hx and appear well.
  • H2’s, PPI’s outpt – endoscopy if fails tx
  • Red Flags: abrupt change in sx’s, VS; bleeding/melena, elderly
  • D/C if stable w/ follow-up
  • GI cocktail (Green Goddess) = Mylanta 30cc, 2% Viscous Lidocaine 15cc. Addition of Donnatol 10cc (that makes it green) is falling out of favor
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14
Q

Esophagitis, hiatal hernia

A
  • Esophagitis
    • Older; burning/sharp/ache, epigastric and chest, may radiate, weight loss, recurrent, occurs at rest
    • Dysphagia: Solids only or both?
    • HIV (check mouth); chronic GERDà Barrett’s Esophagitis – pre-cancerous
    • Belly labs, EKG, CXR; GI cocktail, PPI
    • D/C home if stable, outpatient f/u
      • Dysphagia gets endoscopy
  • Hiatal hernia
    • Often asx’atic: relation to GERD
    • Delays esophageal acid clearanceà esophagitis, increase risk Barrett’s
    • Dx: CXR, endoscopy. Tx like GERD
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15
Q

GI bleeding

A
  • Microscopic, minor or a life-threatening mess
  • Upper: hematemesis, melena Lower: hematochezia, BRBPR
    • Where is the bleeding? Ligament of Treitz
  • Hx key: How much/how long? Painful or painless? Retching/vomiting prior? Vomit/stool appearance, recent surgery/procedure, other bleeding, PMH, meds, habits, Hx same
  • Red Flags:
    • VS: tachy, hypotensive, tachypnec – pallor, altered, shocky; melena
    • Older, liver dz, renal dz, EtOH, coumadin, fever, syncope, rash
  • Minor UGIB or BRBPR: CBC, Chem, PT/INR, EKG if tachy
    • UGIB: +/-NG tube trial w/ irrigation. Anoscopy for local issue
  • Big UGIB or melena: Add 2 IV’s, Type/Screen, lactic acid, CXR, O2, monitor, NG tube
  • Tx minor: oral PPI’s, surgery referral LGIB or rectal issues
  • Tx major UGIB: IV PPI’s with drip, urgent endoscopy, octreotide for varicies; GI, surgery consult
  • Admit all melena, acute anemia or any unstable pt - GI consult.
  • May d/c minor bleed/stable/low risk pt’s w/ return precautions, f/u endoscopy/colonoscopy
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17
Q

Abd pain in alcoholics

A
  • Could be anything…common: etoh gastritis, pancreatitis, GI bleed
  • Hx is often suboptimal. PE: undress, be thorough: head to toe
  • Labs: CBC, Chem, lipase, PT/INR, UA, Upreg, Magnesium, Phosphorous, CXR, EKG
  • Tx: IV hydration, “banana bag”, pain control ok, antiemetics
  • Red Flags:
    • Fever, VS not resolving
    • Persistent ALOC – think head trauma
    • Bleeding, pettechiae, acidosis
    • Signs of EtOH withdrawl
    • Low CO2, AG: alcoholic metabolic acidosis
  • Tincture of time, reassess, be vigilant
  • Banana Bag: Thiamine 100mg, Magnesium 2g, Multi-Vits 1 ampule
18
Q

gastroenteritis

A
  • Tricky Dx in ED – are we missing something?
  • Vomiting = gastritis; diarrhea = enteritis: need both
  • Viral vs. infectious. Abx ok for inflammatory/infectious
  • Hx key. Exam: not peritoneal but dehydrated, miserable
  • Red Flags:
    • VS that don’t normalize after IV fluids
    • Old/young/pregnant/immunocompromised
    • Serial abdominal exams with persistent pain
    • Blood in stool, fever, rash, ALOC
  • Tx: IV NS or LR, antiemetic. No imaging unless 2nd diagnosis; d/c home if stable w/ antiemetics, return precautions
19
Q

jaundice and hepatitis

A
  • Mild sx’s to fulminant liver failure
  • Prodrome – malaise, fatigue, anorexia, n/v; then abdominal pain, jaundice, dark urine, “light colored” stool
  • Hx key for risk: travel, exposures, sex hx, sick contacts, EtOH/drugs
  • Labs, Upreg, Hep serologies, ULS biliary tract. CT if suspect cancer/mets
  • Jaundice DDx: hepatitis, cirrhosis, biliary obstruction, hemolysis, pancreatic CA (painless)
  • Red Flags: VS; jaundice plus – EtOH w/d, altered, ascites, asterixis, bleeding
  • Can d/c select, stable pt’s. If admit - GI or Surgery consult (depends on Dx)
20
Q

pancreatitis

A
  • Epigastric pain, +/- radiates to back, vomiting, anorexia
  • Gallstone 40%, hx ETOH 40%, previous pancreatitis, post trauma
  • Labs: lipase up x3 for dx; LDH, glucose, AST, WBC’s all increased
  • ULS for gallstones, CXR, EKG, CT
  • Red Flags: peritoneal, fever, hypotension = very sick!!
  • Surgeon if: first time, pseudocyst, mass, hemorrhagic or sick
  • Medical admission – NPO, watch ETOH w/d
21
Q

Ranson criteria

A
  • Predicts mortality from pancreatitis (~75% sens)
  • On admission (one point each):
    • Age >55
    • Glucose >200
    • WBC >16k
    • SGOT (AST) >250
    • LDH >350
  • >/= 3: pancreatitis Dx likely, <3: unlikely
  • Mortality score 48hrs after onset: 11 criteria
    • 3-4 = 15%, 5-6 = 40%, 7-8 = 100%
22
Q

pyelonephritis

A
  • From mild pyelo to frank sepsis
  • Malaise, fever, vomiting, abdominal, back or flank pain, CVAT, usually dysuria or irritated voiding, hematuria
  • Always check a UA in abdominal pain – in/out cath best in females, send culture, do pelvic exam, upreg; men – unusual – usually structural/stone/indwelling foley
  • ULS kidneys (hydronephrosis), RUQ if pain on R. CT only if uncertain dx
  • Red Flags: In addition to old/young…
    • Hypotension, signs of sepsis
    • Pregnant + pyelo
    • Stone + pyelo
    • Intractable vomiting
    • Preexisting renal dz
  • IV fluids, lactic acid, blood/urine cultures, early IV antibiotics, admit
    • Fluoroquinolones, Amikacin, +/- Ceftriaxone
  • Outpatient – 10-14 day course fluoroquinolone, return precautions
23
Q

diverticular disease

A
  • Diverticulosis vs. Diverticulitis
  • Middle age/older, often Hx same, gradual onset, constant, diarrhea, +/-n/v, lower abd pain; LLQ pain common
  • Red Flags: VS abnormal, fever/chills, guarding, old/young/pregnant
  • Pelvic, labs, guaiac, UA, lactic acid, EKG
  • 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
24
Q

renal colic - stones

A
  • Sudden, sharp, excruciating, unilateral pain; radiates around abdomen or to groin, diaphoresis, n/v common, can’t lie still, hematuria (15% do not)
  • IV fluids, pain control (Ketorolac great), antiemetics
  • Labs, UA, bedside US for hydronephrosis
  • CT w/o contrast if first episode (not KUB) to confirm
  • Red Flags:
    • VS remain abnormal after pain controlled
    • Stone + fever or infected urine
    • Hydronephrosis + fever or infected urine
    • Stone >6mm on CT (won’t pass on own)
    • One kidney or transplant pt
    • Risks for AAA, ectopic, appy, torsion, PID/TOA, etc…
  • Can d/c home if: resolves, not infected, not sick, peeing
    • Oral pain meds, @ blocker, urology f/u
  • Alpha blockers: Tamsulosin (Flomax), Cardura (Doxazosin), Hytrin (Terazosin), etc…
25
Q

biliary colic

A
  • 4 F’s, RUQ pain, N/V, Hx stones common - dietary trigger
  • Cholelithiasis = stones present
  • Biliary colic = stones plus sx’s
  • RUQ ULS for cholecystitis: bedside + formal
  • IV, labs (lipase), pain control, antiemetics – can d/c home if stable, taking PO’s
  • Red Flags:
    • Fever, hypotension, toxic appearing
    • WBC’s up, LFT’s or lipase up
    • Jaundice, altered
  • Surgery consult for elective cholecystectomy
26
Q

ascites

A
  • Abdominal distention with free fluid
  • Think: liver failure, cirrhosis, malignancy
  • Key hx: Ever before? How long, how quickly?
    • PMH, EtOH, ROS for cancer
  • Red Flags: SBP: subacute bacterial peritonitis
    • Fever or painful: must consider SBP
    • Hypotension, altered, GI bleed, EtOH withdrawl
  • Paracentesis – diagnostic and/or therapeutic
    • ULS first; take off 3-5 liters not unusual
    • Recurrent ascites/stable; tap for comfort, home
  • Fever/SBP? Sick. IV abx, monitor, admit
  • First time ascites? Admit for w/u.
27
Q

urinary retention

A
  • Usually obvious: men>women, older, distended bladder
  • Hx: How long, how quickly, passing any urine, blood, fever, coumadin, systemic sx’s, PMH, recent surgery, procedure
  • Common causes: prostate, meds, hematuria (clot) from bladder CA
  • Foley catheter on arrival if not peeing, measure output
  • ULS for hydronephrosis and post-void residual if peeing
    • UA for infection, urine culture, Chem panel for renal function
  • Red Flags: VS or pain do not resolve with foley, brisk bleeding, coumadin, infection
  • Tx: @blockers: Tamsulosin (Flomax), Doxazosin (Cardura), etc
  • Often home w/ foley/leg bag for 2-3 weeks, Urology f/u
28
Q

DKA

A
  • Common in young kids, adolescents as presenting event for Type 1 Diabetes
  • Adults: both Type 1 and Type 2; triggers – infection, med non-compliance, trauma
  • Hx variable: poly’s, generalized abd pain, vomiting
  • Labs: 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
  • Begin IV NS 2L bolus, add K+, protocol, monitor, admit
  • Red Flags: low CO2, high AG, altered, VS not responding, AG not closing after tx, significant infection/DKA + sepsis
29
Q

Gastroparesis and Cyclic Vomiting Syndrome

A
  • Gastroparesis
    • DM autonomic neuropathy, Parkinson’s, MS, post surgical
    • Emptying of stomach is delayed
    • Sx’s: intractable n/v, abdominal fullness, pain
    • Tx: IV hydration, Metoclopramide
  • Cyclic Vomiting Syndrome
    • Severe nausea/vomiting episodes, last hours/days, recurrent and predictable, sx free periods – no other dx
    • Triggers: chronic marijuana use, migraines, stress, anxiety, infection
    • Tx: IV hydration, pain control, antiemetics, identify and avoid triggers
30
Q

sickle cell crisis

A
  • Vaso-occlusive events: severe pain, hx same
    • Triggers: Infection, dehydration, stress, altitude, cold weather
  • Easy to miss common abdominal pathology!
  • Labs for SS: CBC, reticulocytes, UA, CXR
    • Search for infection from H.Flu, E.coli, M. Pneumoniae, Salmonella, S. Aureus
    • They are functionally asplenic
  • Tx: IV hydration, pain control, +/-opiates
  • Red Flags: VS, fever, sepsis, SOB, jaundice, neuro sx’s
  • Admit unless resolves, stable
31
Q

Abdominal pain and drugs

A
  • Stimulants: risk for mesenteric ischemia
  • Opiates – think withdrawal
  • Consider all other dx’s plus: overdose
  • Hx can be suboptimal, PE should be thorough and repeat
  • Labs: Belly labs, UA, Utox, Upreg, lactic acid, EKG, CXR
  • Tx: IV hydration, pain control ok, antiemetics
  • Red Flags: VS/pain not resolving, chest pain, pregnant
  • Consider CT angio for mesenteric ischemia
32
Q

Mimics: AMI/ACS, AAA, TAD

A
  • AMI/ACS
    • Upper abd pain gets EKG
    • Document risk factors
  • AAA
    • Older pt’s, LLQ abd pain - CT
    • Document risk factors
  • TAD
    • Chest and abdominal pain, atypical
    • Document risk factors
  • Appy – always on the list

Emergency Medicine 2 (8 decks)

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