Pearson: Clinical Case Flashcards
McBurney's point tenderness Rovsing's sign (referred pain from left side) Obturator sign (Leg maneuvers)
Appendicitis
Cholecystitis
+ Murphy’s sign (illiciting pain while try to palpate gallbladder below the costal margin on an inspiration)
Protuberant abdomen w/ bulging flanks, positive fluid wave or shifting dullness
Ascites
Ventral hernias
Valsalva
abdominal pressure/sit-up to produce
AAA
pulsating mass
Tense protuberant abdomen tympanitic to percussion
Perforated viscera
All women who present w/ abdominal pain should receive this unless they are post-hysterectomy.
Serum quantitative bHCG (VERY sensitive, picks up almost all pregnancies)
*Urine pregnancy test may miss early ectopics
Lab ordered on most cases of abdominal pain to rule out infection
CBC w/ UA
Labs ordered to evaluate abdominal pain w/ vomiting and diarrhea
Electrolytes
BUN
creatinine
BMP (I think this is equivalent to chem 7)
Glucose, Calcium
Electrolytes
Kidney function (BUN, Cr)
CMP (chem 21?)
Glucose, Calcium
Electrolytes
Kidney function +
Protein
Liver tests
Lab to rule out DKA and hyperglycemia
Glucose and Ca
Labs for upper abdominal pain
Liver function tests
LIver enzymes
amylase
lipiase
Imaging for appendicitis
CT of abdomen and pelvis w/ contrast
Female w/ R or L LQ abdominal pain imaging
abdominal or transvaginal ultrasound of pelvis to evaluate pregnancy, complications w/ pregnancy and rule out reproductive tract pathology
suspected in women w/ vaginal bleeding and lower abdominal pain
Ectopic pregnancy
location of most ectopic pregnancies
97% in FT (55% in ampulla)
Do most pts presenting w/ an ectopic pregnancy have an indentifiable RF?
NO!
What may be some RF associated w/ ectopic pregnancy?
PID prior hx of ectopic pregnancy tubal surgery fertility drugs older smoker endometriosis
First steps to evaluate a pt w/ suspected ectopic pregnancy
- quantitative serum HCG
- CBC
- transvaginal US (can be used to visualize an intrauterine pregnancy 24 days post ovulation–about 1 week earlier than transabdominal)
how do you proceed w/ a pt who’s bHCG <1500 and US is negative
US may not show a gestational sac. If pt is stable and US is negative follow up with them at later date. DO NOT assume benign course w/ low bHCG. It is still possible to rupture an ectopic if one is present
how do you proceed w an bHCG > 1500?
an intrauterine pregnancy should be detectable by transvaginal US in 95% of cases.
If an intrauterine sac is NOT visible, than suspicion of ectopic is increased.
how should you proceed w/ a stable, reliable pt is US is unable to exclude ectopic pregnancy
Obtain serial quantitative b-HCG ever 48 hrs>
bHCG should DOUBLE in 48 hours (and continue to do this until it reaches its peak in the first 8-11 weeks of pregnancy)
If bHCG rises by 66% in 48 hrs, pregnancy is CONTINUING, repeat US when bHCG is >1500 to differentiate between ectopic and intrauterine.
If still indeterminate, follow up w/ repeat quantitative bHCG and US in another 48 hrs.
how should you proceed w an unreliable pt and an US unable to exclude ectopic pregnancy
presume ectopic
what should you do if bHCG levels are not rising or falling?
pregnancy is NON viable and D&C should be done to look for chorionic villi
primary tx for ectopic pregnancy?
Surgical
-tube sparing technique (laparoscopic salpingostomy)
Methotrexate injection
effective for small ectopics
no fetal heart motion
hCG levels <5000
What should you remember to give Rh- women w/ ectopic or spontaneous abortion?
Rhogam
