Pearson: Clinical Case

Question 1

McBurney's point tenderness
Rovsing's sign (referred pain from left side)
Obturator sign (Leg maneuvers)

Answer 1

Appendicitis

Question 2

Cholecystitis

Answer 2

+ Murphy’s sign (illiciting pain while try to palpate gallbladder below the costal margin on an inspiration)

Question 3

Protuberant abdomen w/ bulging flanks, positive fluid wave or shifting dullness

Answer 3

Ascites

Question 4

Ventral hernias

Answer 4

Valsalva

abdominal pressure/sit-up to produce

Question 5

AAA

Answer 5

pulsating mass

Question 6

Tense protuberant abdomen tympanitic to percussion

Answer 6

Perforated viscera

Question 7

All women who present w/ abdominal pain should receive this unless they are post-hysterectomy.

Answer 7

Serum quantitative bHCG (VERY sensitive, picks up almost all pregnancies)

*Urine pregnancy test may miss early ectopics

Question 8

Lab ordered on most cases of abdominal pain to rule out infection

Answer 8

CBC w/ UA

Question 9

Labs ordered to evaluate abdominal pain w/ vomiting and diarrhea

Answer 9

Electrolytes
BUN
creatinine

Question 10

BMP (I think this is equivalent to chem 7)

Answer 10

Glucose, Calcium
Electrolytes
Kidney function (BUN, Cr)

Question 11

CMP (chem 21?)

Answer 11

Glucose, Calcium
Electrolytes
Kidney function +

Protein
Liver tests

Question 12

Lab to rule out DKA and hyperglycemia

Answer 12

Glucose and Ca

Question 13

Labs for upper abdominal pain

Answer 13

Liver function tests
LIver enzymes
amylase
lipiase

Question 14

Imaging for appendicitis

Answer 14

CT of abdomen and pelvis w/ contrast

Question 15

Female w/ R or L LQ abdominal pain imaging

Answer 15

abdominal or transvaginal ultrasound of pelvis to evaluate pregnancy, complications w/ pregnancy and rule out reproductive tract pathology

Question 16

suspected in women w/ vaginal bleeding and lower abdominal pain

Answer 16

Ectopic pregnancy

Question 17

location of most ectopic pregnancies

Answer 17

97% in FT (55% in ampulla)

Question 18

Do most pts presenting w/ an ectopic pregnancy have an indentifiable RF?

Answer 18

NO!

Question 19

What may be some RF associated w/ ectopic pregnancy?

Answer 19

PID
prior hx of ectopic pregnancy
tubal surgery
fertility drugs
older
smoker
endometriosis

Question 20

First steps to evaluate a pt w/ suspected ectopic pregnancy

Answer 20

1. quantitative serum HCG
2. CBC
3. transvaginal US (can be used to visualize an intrauterine pregnancy 24 days post ovulation–about 1 week earlier than transabdominal)

Question 21

how do you proceed w/ a pt who’s bHCG <1500 and US is negative

Answer 21

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

Question 22

how do you proceed w an bHCG > 1500?

Answer 22

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.

Question 23

how should you proceed w/ a stable, reliable pt is US is unable to exclude ectopic pregnancy

Answer 23

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.

Question 24

how should you proceed w an unreliable pt and an US unable to exclude ectopic pregnancy

Answer 24

presume ectopic

Question 25

what should you do if bHCG levels are not rising or falling?

Answer 25

pregnancy is NON viable and D&C should be done to look for chorionic villi

Question 26

primary tx for ectopic pregnancy?

Answer 26

Surgical

-tube sparing technique (laparoscopic salpingostomy)

Question 27

Methotrexate injection

Answer 27

effective for small ectopics
no fetal heart motion
hCG levels <5000

Question 28

What should you remember to give Rh- women w/ ectopic or spontaneous abortion?

Answer 28

Rhogam