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
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
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
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
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
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
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
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
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
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)
- IV hydration for most: pain/vomiting, need meds/IV contrast
- 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?)
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”
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
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
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
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
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)
