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Sasha: Module 9 GI > powerpoints CA > Flashcards

powerpoints CA Flashcards

1
Q

More adult patients visit the ED for _________ than for any other CC

A

“stomach and abdominal pain, cramps, or spasms”

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2
Q

influence both incidence and clinical expression of abdominal disease

A

Demographics (age, gender, ethnicity, family history, sexual orientation, cultural practices, geography)

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3
Q

__________ is often required to make a specific diagnosis

A

imaging

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4
Q

Best way to practice a GI exam

A

Thorough approach

Logical approach

LOCATION of the pain drives the evaluation

Begin the evaluation by ruling out serious disease and/or surgical conditions

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5
Q

what drives the evaluation

A

LOCATION

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6
Q

STEPS of Triage and Transfer

A

Step 1: Is the patient critically ill?
Check ABCs, resuscitate if needed

Step 2: Acute abdominal pain may need transfer to acute care facility if…

  • -> Suspected surgical abdomen
  • -> Requiring resuscitation or IV analgesia

Step 3: Less acute illness, often detailed history and initial assessment

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7
Q

what is life threatening in the album?

A
  • -> ruptured appendix
  • -> malignancy: not usually acute though
  • ->AAA: will radiate to back
  • -> mesenteric ischemia: block blood flow to abdomen
  • -> hypo profusion: acute blood loss… abdomen gets left out from blood flow
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8
Q

what is a sterile spot

A

stuff in the abdomen…

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9
Q 
Cognitive impairment secondary to dementia
Intoxication
Psychosis
Intellectual disability
Autism
Patients w/ aphasia or language barriers
Older adults (physical or laboratory findings may be minimal)
Spinal cord injury patients
Asplenic patients
Neutropenic patients
Transplant patients
Immunosuppressed patients (eg, HIV) 
Immune-suppressive or immune-modulating medications (eg, steroids, chemotherapy agents)
A

HIGH risk groups

this is an LO:
8. Identify and recognize high-risk patients in which critical illness may be “camouflaged” by their medical/physical/mental condition

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10
Q

Critical illness in high risk pt may be

A

camouflaged

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11
Q

Requires understanding of possible mechanisms responsible for pain

Broad differential of common causes (abdominal and extra-abdominal causes)

Recognition of typical patterns and clinical presentations

Consider unusual causes, especially in older adults and immunocompromised patients

A

Differential Diagnosis

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12
Q

Pain receptors in the abdomen respond to (2)

A
  1. Mechanical stimuli (eg, stretch, distention, contraction, traction, compression, torsion)
  2. Chemical stimuli due to inflammation or ischemia
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13
Q

TRUE or FALSE: multiple stimuli may be occurring at once

A

TRUE

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14
Q

what about not understood pain?

A

Perception of pain not completely understood:

Psychologic factors likely important factor

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15
Q

3 types of pain

A

visceral
parietal
referred

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16
Q

dull, aching, can be colicky, poorly localized; arises from distension of hollow organ (eg, bowel obstruction)

when pushing deep

A

visceral

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17
Q

sharp, very well localized; arises from peritoneal irritation (eg, appendicitis)

inflammation of peritoneum

A

parietal

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18
Q

aching, perceived to be near surface of body (eg, cholecystitis referred to right scapula)

A

referred

aka gallbladder and scapula

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19
Q

ADD PICTURE FROM SLIDE 10!

A

…..

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20
Q

What is included in the Pain Hx.?

A

Location, Location, Location!

Key to formulating DDx list!

Where does the patient POINT to?
Do they point with one finger or use their whole hand (specific vs vague)

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21
Q

what are the locations pain can be (8)

A 
RUQ
LUQ
RLQ
LLQ
Epigastric
Periumbilical
Suprapubic
Diffuse
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22
Q

add picture from slide 14

A

….

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23
Q

what organs are in the RIGHT UPPER QUADRANT

A 
Liver, gallbladder
Pylorus, duodenum
Head of pancreas
Ascending/transverse colon
Right kidney/adrenal
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24
Q

what organs are in the LEFT UPPER QUADRANT

A 
Liver (left lobe)
Spleen
Stomach
Body of pancreas
Descending/transverse colon
Left kidney/adrenal
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25
Q

what organs are in the RIGHT LOWER QUADRANT

A 
Right kidney and ureter
Cecum/appendix/ascending colon
Ovary, fallopian tube
Spermatic cord
Uterus/bladder (if enlarged)
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26
Q

what organs are in the LEFT LOWER QUADRANT

A 
Left kidney and ureter
Sigmoid/descending colon
Ovary/fallopian tube
Spermatic cord
Uterus/bladder (if enlarged)
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27
Q

ADD PICTURE FROM SLIDE 17

A

….

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28
Q 
RIGHT UPPER QUADRANT:
biliary:
Colonic:
hepatic:
Pulmonary:
Renal:
A

Biliary: Cholecystitis, Cholelithiasis, Cholangitis

Colonic: Colitis, Diverticulitis

Hepatic: Abscess, Hepatitis, Mass

Pulmonary: Pneumonia

Renal: Nephrolithiasis, Pyelonephritis

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29
Q

Left Upper Quadrant

cardiac
gastric
spleen
pancreatic
renal
A

Cardiac: Angina, Myocardial Infarction, Pericarditis
Gastric: Gastritis, Peptic Ulcer Disease
Spleen: Abscess, Infarct, Splenic Rupture
Pancreatic: Mass, Pancreatitis
Renal: Nephrolithiasis, Pyelonephritis

***stars mean emergency :)

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30
Q

Right Lower Quadrant

colonic
gynecologic
GU
Renal

A

Colonic: Appendicitis, Inflammatory Bowel Disease

Gynecologic: Ectopic Pregnancy, Fibroids, Ovarian Mass, Torsion, Pelvic Inflammatory Disease

GU: Inguinal Hernia

Renal: Nephrolithiasis

***stars mean emergency :)

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31
Q

Left Lower Quadrant

colonic
gynecologic
GU
Renal

A

Colonic: Diverticulitis, Inflammatory Bowel Disease, Irritable Bowel Syndrome

Gynecologic: Ectopic Pregnancy, Fibroids, Ovarian Mass, Torsion, Pelvic Inflammatory Disease

GU: Inguinal Hernia

Renal: Nephrolithiasis

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32
Q

Epigastric Pain

cardiac
gastric
pancreatic
vascular

A

Cardiac: *Myocardial Infarction, Pericarditis

Gastric: GERD, Gastritis, Peptic Ulcer Disease, Incarcerated Hiatal Hernia

Pancreatic: Mass, Pancreatitis

Vascular: Ruptured Aortic Aneurysm*

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33
Q

abrupt change in vital sign

A

means not stable

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34
Q

really low blood pressure

A

could be bleeding out

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35
Q

really high HR

A

warning sign for blood loss … could be dehyrdated too (hypovolemia)… could be trying to compensate

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36
Q

FEVER

A

warning sign for acute issues going on

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37
Q

Periumbilical

colonic
vascular

A

Colonic: Early Appendicitis, Gastroenteritis, Bowel Obstruction

Vascular: Ruptured Aortic Aneurysm

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38
Q

Suprapubic

colonic
gynecologic
urinary tract

A

Colonic: Appendicitis, Colitis, Diverticulitis, Irritable Bowel Syndrome

Gynecologic: **Ectopic Pregnancy*, Fibroids, Ovarian Mass, Torsion, Pelvic Inflammatory Disease

Urinary Tract: Cystitis, Nephrolithiasis, Pyelonephritis, Bladder Outlet Obstruction

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39
Q

Diffuse

colonic
metabolic
Heme
infectious

A

Colonic: Gastroenteritis, Mesenteric Ischemia, Bowel Obstruction, Peritonitis*, Irritable Bowel Syndrome

Metabolic: Diabetic Ketoacidosis

Heme: Sickle Cell Crisis, Heavy Metal Intoxication

Infectious: Malaria

***stars mean emergency :)

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40
Q

alright guys here are a bunch of cards of a summary of all the Key patterns of pain!

RUQ

A

cholecystitis, hepatitis

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41
Q

key patterns of pain RLQ

A

appendicitis (starts periumbilically)

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42
Q

Key patterns of pain LLQ

A

diverticulitis (can be midline)

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43
Q

Key patterns of pain in epigastric area

A

esophagitis, PUD

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44
Q

pain radiating to back

A

pancreatitis

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45
Q

pain radiating to R shoulder

A

cholecystitis

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46
Q

pain radiating to groin

A

renal colic

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47
Q

six important thing to remember with pain HIstory

A
  1. onset/ frequency/ duration
  2. quality
  3. severity (can be subjective)
  4. aggrevating factors
  5. relieving factors
  6. associated symptoms
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48
Q

Steady, rapid increase in pain: pancreatitis

Several days of pain prior to presentation: diverticulitis

Sudden, abrupt onset, severe: rupture of viscus (eg, appendix, aorta)

A

explaining Onset/frequency/duration of pain

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49
Q

Burning, gnawing: GERD or PUD

Colicky: gastroenteritis, bowel obstruction, nephrolithiasis

A

explaining

Quality of pain

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50
Q

High intensity: biliary or renal colic, mesenteric infarction
Lower intensity: gastroenteritis

A

explaining severity of pain

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51
Q

Pain 1 hour after eating: mesenteric ischemia (aka “intestinal angina”)

Pain w/ empty stomach: PUD

Pain w/ any movement: peritonitis

Pain worse after eating lactose: lactose intolerance

Pain worse after eating gluten: celiac disease

Pain worse after eating fatty food: cholecystitis

A

explaining some aggravating factors of pain

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52
Q
  1. Pain relieved w/ eating:
  2. Pain resolved w/ sitting up and leaning forward:
  3. Pain relieved when lying on back motionless:
A

PUD

  1. pancreatitis
  2. peritonitis
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53
Q

Weight loss: malignancy

N/V: bowel obstruction, biliary duct blockage

Change in bowel habits: colon cancer, IBS

“Cough pain”: peritonitis

example: F/C/N/V/D/C

A

examples of associated symptoms with pain history

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54
Q

PMH – risk factors for CVD (eg, atrial fibrillation – clot to spleen or mesentary), clotting d/o

Past surgical history – abdominal surgeries

FH – bowel disease

Social history – alcohol intake (ascites, pancreatitis)

Medications – NSAIDS, antibiotics

Menstrual + contraceptive hx in women
Pregnancy risk? STIs?

A

Patients History

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55
Q

_______ should be excluded in ALL women of childbearing age with abdominal pain!

A

pregnancy

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56
Q

picture from slide 31

A

…

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57
Q 
Vital signs
General appearance
Skin (color, turgor)
Heart/Lungs
Abdomen (including DRE)
Pelvic (speculum/bimanual exam)
GU (CVA tenderness)
MSK (abdominal wall)
A

Physical exam should focus on this

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58
Q

Ok to manage in the ED setting with opiated (does not cause management errors)

A

PAIN

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59
Q

what three vitals are really important to remember to get!

A
  1. Temperature – fever (infection)?
  2. Heart rate – tachycardiac?
  3. Orthostatic blood pressure – hypotension, hypovolemic (d/t GI blood loss or dehydration)?
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60
Q

can cause large amounts of 3rd spacing of fluid and intravascular volume depletion or overt shock

A

Bowel obstruction, peritonitis & bowel infarction

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61
Q

what does NOT rule out infection

A

Absence of fever in elderly or immunosuppressed does NOT r/o infection

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62
Q

what are some things to notice with patients general appearance

this stuff is common sense.. just read through it

A

Does the patient look sick?

Level of comfort/discomfort should be noted

What position (eg, sitting, lying) does the patient find most comfortable?

  • -> Strict immobility:
  • -> Writhing in agony
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63
Q

what could strict immobility make you think of

A

peritonitis

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64
Q

what would writhing in agony make you think of

A

biliary or renal colic

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65
Q

pts with IBS have
what kinda pain?

caused by?

does not have?

A

Suprapubic

lots of conctepation or lots of diarrhea and causes a ton of discomfort

there is no underlying pathology just bowel moving to slow or fast.

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66
Q

Eyes – scleral icterus
Skin – jaundice (eg, hepatitis, cholangitis), rash (eg, herpes zoster), turgor or pallor
Heart – murmurs, rubs
Lungs – signs of consolidation

A

just look for these things….

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67
Q

Signs of distention (ascites, ileus, obstruction, volvulus)

Obvious masses (hernia, tumor, aneurysm, distended bladder)

Surgical scars (adhesions), ecchymoses (trauma, bleeding diathesis)

Signs of liver disease (spider angiomata, caput medusa)

A

Inspection

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68
Q

signs of distention in ?

A

(ascites, ileus, obstruction, volvulus)

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69
Q

signs of obvious masses in?

A

(hernia, tumor, aneurysm, distended bladder)

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70
Q

surgical scares from

A

adhesions

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71
Q

ecchymoses from

A

trauma, bleeding diathesis

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72
Q

signs of liver disease

A

spider angiomata, caput medusa

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73
Q

SUDDEN AND ABRUPT PAIN… are you worried

A

HELL YES I AM! SOMETHING BAD IS GOING ON!!!

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74
Q

Normal bowel sounds occur every? and sounds like what two words

A

every 5-10 seconds

clicks and gurgles

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75
Q

how long do you need to listen for to be able to declare NO BOWEL SOUNDS

A

2 MINUTES

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76
Q

what is it if you here hyperactive, high pitches bowel sounds

A

small bowel obstruction

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77
Q

what could it be if it is decreased bowel sounds?

A

peritonitis, ileus, mesenteric infarction, narcotic use

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78
Q

what could it be if we hear friction rubs

A

splenic infarction or hepatitic metastasis

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79
Q

what has SEVERE PAIN

A

mesenteric ischemia

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80
Q

where to listen for bruits

A 
ADD PICTURE FROM SLIDE 39
aorta
renalt artery
iliac artery
femoral artery
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81
Q

what do we hear tympany in?

A

ascites (“shifting dullness” test), peritonitis, distended bowel

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82
Q

when would you hear dullness?

A

mass

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83
Q

what are some types of organomegaly?

A

liver span, splenic enlargement, bladder distention

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84
Q

what could it be if you have CVA tenderness

A

nephrolithiasis, pyelonephritis

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85
Q

ADD PERCUSSION PICTURE FROM SLIDE 41

A

….

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86
Q

What is USUALLY PALPABLE?

A

Sigmoid colon

cecum and ascending colon

normal liver distends

pulsations of the abdominal aorta are frequently visible and usually palpable

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87
Q

what does the sigmoid colon feel like

and what quadrant is it in

A

firm, narrow tube

in LLQ

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88
Q

what does the cecum and ascending colon feel like

and what quadrant is it in

A

softer, wider tube in RLQ

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89
Q

black tarry stool

A

usually issue in the upper GI… takes longer for it to come out

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90
Q

bright red blood

A

lower GI issue

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91
Q

what does the liver below the costal margin feel like

A

soft and consistency is difficult to feel

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92
Q

what is usually not palpable

A 
Stomach
Spleen
Gallbladder
Duodenum
Pancreas
Kidneys
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93
Q

how do you perform palpations

what type of pressure
where do you start

A

Perform gently (light then deep), distract patient

Start in least painful quadrant

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94
Q

what has rebound tenderness

A

appendicitis, peritonitis

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95
Q

what has a pulsatile mass

A

AAA

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96
Q

Rigidity or involuntary “guarding”

with peritoneal inflammation and diffuse

A

peritonitis

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97
Q

Rigidity or involuntary “guarding”

with inflammatory mass if focal

A

diverticular abscess

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98
Q

Rigidity or involuntary “guarding”

may be absent with deeper sources ….what 2 things could this?

A

renal colic or pancreatitis

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99
Q

Liver palpation

SPLEEN PALPATION: on left side

KIDNEY PALPATION: sweep kidneys closer to you!

A

2 techniques
ADD TO THIS

SLIDE 45

100
Q

SPECIAL TESTS OF ABDOMEN FOR APPENDICITIS

A

McBurney’s Point
Rovsing’s Sign
Psoas Sign
Obturator Sign

101
Q

SPECIAL TESTS OF ABDOMEN FOR GALLBLADDER DISEASE

A

Murphy’s Sign

For Ascites:
Shifting Dullness
Fluid Wave

102
Q

McBurney’s Point

A

for appendicitis : RLQ

it is 2 inches
ASIS to the ____
if you push downward this hurts

ADD PICTURE SLIDE 48

103
Q

ROVSING’S SIGN

A

rebound tenderness
push in LLQ
quick release
they will have rebound tenderness as hand is removed in the RLQ!!!!! for appendicitis

ADD PICTURE SLIDE 49

104
Q

PSOAS SIGN

A

lift up leg and we push down the leg…
psoas muscle is near appendix so this will hurt them!

ADD PICTURE SLIDE 50

105
Q

OBTRUATOR SIGN

A

internal obtruator sign is near appendix

so pt brings knee to 90 degree and internally rotate the hip by rotating lower leg outward this internally rotates the hip and flexes obturator muscle causing RLQ pain when we do this!

ADD PICTURE SLIDE 51

106
Q

MURPHYS SIGN

A

for cholecystitis: inflammation of gallbladder

with hands try to get under rib cage on right side and slide hands under… this hurts in the RUQ.

ADD PIC SLIDE 52

107
Q

ASCITES

A

fluid accumulation in the abdomen

fluid is heavy so when patient lays down you will see flexing of the flanks or sides

ADD PICTURE SLIDE

108
Q

SHIFTING DULLNESS

A

for ascites if you are not sure if they are just fat

have them lay on their side

and they should be tympanic on the side up toward the ceiling and then a dull sound on the side that is on the table because the fluid shifts when they lay on their side if it is ascites

ADD PICTURE SLIDE 54

109
Q

FLUID WAVE

A

not the best test

another test for ascites

need two people to do this
1 person: firmly press in the middle of the abdomen so that you don’t have fluid move from one side to the other!

so other person pushes on one side and if the person pushing down in the middle feels a wave then they have ascites

ADD PICTURE SLIDE 55

110
Q

consider this for all patients

Assess for tenderness, bleeding or masses

Fecal impaction in older adults

Check stool for occult blood (FOBT)… stool color?

A

DRE

111
Q

consider for all women w/ acute lower abdominal pain

PID, adnexal mass or cyst, uterine pathology, ectopic pregnancy

A

Pelvic exam

112
Q

what exam am i explaining

flank pain, CVA tenderness

In males, hernia, testicular, and prostate exam are indicated b/c disorders of these structures can cause lower abdominal pain

A

GU

113
Q

What exam would you find this?

abdominal wall muscles (eg, worse w/ sitting up)

A

MSK

114
Q

opioids use can cause

A

constipation and abdominal pain

115
Q

NSAIDS CAN LEAD TO

A

ULCERS

116
Q

steroids and ABX can lead to

A

CDiff

117
Q

what are some challenges with Older Adults w/ Acute Abdominal Pain

A

Symptoms may be mild, vague, underreported

Presentations may be late and atypical

Poor hearing, decreased vision, impaired cognition may affect ability to give an adequate history

↓ pain perception and ↓ febrile or muscular response to infection/inflammation

Hypotension may NOT be appreciated in hypertensive patients

Comorbid conditions (eg, CVD) more common

Higher operative risk, surgical complications are more common

Higher complication and mortality rates

118
Q

what percent of older adults with perforated appendicitis have classic presentation

A

LESS THAN 20%!!!!

119
Q

Biliary Tract Disease (eg, Cholecystitis)

Diverticulits

Mesenteric Ischemia

Small Bowel Obstruction

Ruptured Aortic Aneurysm

A

CONDITIONS MORE COMMON IN OLDER ADULTS

120
Q

WHAT DO WE consider in any patient >50yo w/ pain out of proportion to PE findings

A

Mesenteric Ischemia

121
Q

TRUE OR FALSE

misdiagnosis is high in older adults with abdominal pain

A

TRUE

122
Q

what do we get because we do not want to miss occult UIT

A

Check UA/UC

123
Q

Pelvic Inflammatory Disease

Adnexal pathology (eg, ovarian cyst, torsion, or neoplasm)

Endometriosis (dysmenorrhea, dyspareunia)

Ectopic pregnancy (vaginal bleeding, 6-8 weeks after LMP)

Endometritis

Leiomyomas – uncommon cause, d/t degeneration

A

DDx in women with acute abdominal pain

124
Q

Obtain a _____________ in ALL women of childbearing age who have NOT had a hysterectomy

A

urine hCG or serum hCG

125
Q

If hCG is POSITIVE, __________________ is the next diagnostic step

A

transvaginal ultrasound

>1,500mIU/mL hCG is the “discriminatory zone” to see gestational sac of IUP on ultrasound

126
Q

elevated bilirubin can cause

A

jaundice in eyes and palms

127
Q

protracted vomiting

what could this be from
and what does it do to the skin?

A

bowel obstruction

can be getting dehydrated so bad tugor

128
Q

Usual Hx + uterine contractions, vaginal bleeding, leaking (rupture of membranes)

Usual PE + fetal heart rate, pelvic (√uterine tenderness and/or contractions, cervical dilation/effacement)

Additionanl DDx: labor, placental abruption, uterine rupture, intraamniotic infection, severe preeclampsia, HELLP syndrome

A

Pregnant Patients w/ Acute Pain

129
Q

PICTURE FROM SLIDE 65

A

….

130
Q

who May present w/ predominant symptoms other than pain, including vomiting, fever, irritability, or lethargy

A

Children with acute abdominal pain

131
Q

in children with abdominal pain Stillness suggests conditions that

A

irritate the peritoneum, such as appendicitis

132
Q

in children writhing for a comfortable position suggest

A

suggests obstruction (eg, intussusception or renal colic)

133
Q

Emergent and non emergent issues in children at different ages

A

ADD PICTURE FROM SLIDE 67

134
Q

_________ relieves pain and will NOT obscure PE findings, delay diagnosis, or lead to increased morbidity/mortality

A

Opioid analgesia

135
Q

Administer ________, as needed for symptomatic relief

A

antiemetics

136
Q

what is the most important thing with the PE for GI issues

A 
AUSCULTATION 
OR
PALPATION?
*** ugh  i missed what she said
i think auscultation?
137
Q

Consider placement of nasogastric

Nasogastric aspirate may confirm:

A

Upper GI bleeding

138
Q

Consider placement of nasogastric

Nasogastric suction may:

A

decompress a bowel obstruction

139
Q

what are some reasons we would consider placement of urinary catheters? (2 reasons)

A

Relieve bladder obstruction

Hourly urine output helps to gauge renal perfusion

140
Q

____________ does NOT take the place of a detailed history and physical examination!

A

Laboratory testing

141
Q

Lab testing helps with

A

Helps narrow DDx or alter plan of treatment

142
Q

does normal WBC result rule out infection

A

NOOOOOO

143
Q

can lab values decrease later on….

A

YESSSSSSS

SO BE AWARE OF LIMITATIONS

144
Q

REBOUND TENDERNESS

What the heck is this!?

A

push down on abdomen does not hurt it is the lifting up of the hand that hurts the patients…

ie. appendicitis
peritonitis

145
Q

involuntary guarding:

A

overlying musculature begins rigid and tense

THIS IS INVOLUNTARY!!!!!

146
Q

what are the labs commonly ordered

A

CBC w/ differential, electrolytes, BUN, creatinine, glucose, ALT/AST, alkaline phosphatase, bilirubin), lipase, UA, hCG

PICTURE FROM SLIDE 71, 72

147
Q

Diagnostic imaging does ________ take the place of a detailed history and physical examination!

A

NOT

148
Q

TRUE OR FALSE

All patients w/ abdominal pain require imaging

A

FALSE

CORRECT ANSWER: Not all patients w/ abdominal pain require imaging

149
Q

If clinical impression suggests that need for surgery is obvious, IS IT necessary to wait for diagnostic imaging before surgical consultation is pursued!

A

nope

If clinical impression suggests that need for surgery is obvious, it is NOT necessary to wait for diagnostic imaging before surgical consultation is pursued!

150
Q

Plain Radiographs positioning and views

A

Flat (supine) & upright views

151
Q

plain radiographs should be limited to screening for: (4)

A
  1. obstruction (dilated loops of bowel)
  2. sigmoid volvulus (coffee bean)
  3. perforation (free air)
  4. severe constipation
152
Q

what can you visualize on ultrasound?

A 
gallbladder
pancreas
kidneys
ureters
urinary bladder volume 
GYN and aortic dimensions
153
Q

what is the preferred modality to evaluate biliary tract (eg, cholecystitis) and GYN (eg, ectopic pregnancy) conditions

A

ultrasound

154
Q

pros of CT of abdomen/pelvis

A

sensitive and specific diagnostic tool

155
Q

cons of CT of abdomen/pelvis

A

delay in surgical management, radiation exposure, cost, IV/PO contrast (√creatinine)

156
Q

what are the different options for different types of CT of abdomen/pelvis

what to assess with one of these first and what lab to get to assess this

A

contrast and/or noncontrast, protocols available

for contrast want to assess kidneys first and get a sCr

157
Q

what are indications for CT of abdomen/pelvis

A

appendicitis, nephrolithasis, diverticulitis, many more…

158
Q

UA/UC is _______ in older adults

A

STANDARD!

GET IT ….

159
Q

WHAT SHOULD WE CONSIDER IN PATIENTS WITH:
High-risk patients w/ acute abdominal pain

Patients who appear ill

Have intractable pain or vomiting

Unable to comply w/ discharge or follow-up instructions

Lack appropriate social support

A

Consider hospital admission or observation

160
Q

HCG HAS TO BE ABOVE ______ TO BE ABLE TO SEE ANYTHING IN THE UTERINE SAC

A

1,500-2,000

COME BACK TO THIS CARD!!!!

161
Q

Patients w/ unclear diagnosis at discharge should return for re-evaluation within ____ hours

A

12 hours

162
Q

what are reasons the patient should return for another appointment? (5 things)

A

Return if… increased/different pain, fever, vomiting, syncope, bleeding

163
Q

what if you REALLY just cant figure out what is going on? (5)

A

“Wait and watch” – consider hospital admission or observation in ED

Call for help!

Rule out serious or life-threatening conditions

Obtain a detailed H&P, and lab/imaging if warranted, and DOCUMENT these findings (including pertinent negatives)

Patient education critical (“return if…”, provide written information too and document)!

164
Q

REMEMBER TO ALWAYS DOCUMENT…

A

PERTINANT NEGATIVE FINDINGS AS WELL!

165
Q

views of normal abdominal x-rays

A

Virtually every abdominal plain film X-ray is an AP (anterior to posterior). Film (the beam passes from front to back with the cassette behind the patient, who is lying down with the X-ray machine overhead). These are occasionally accompanied by erect or even decubitus (pt on their side) views.

166
Q

five basic densities are normally present on X-rays

what are they

A 
Gas……. black
Fat……... dark grey
Soft tissue/fluid………. light grey
Bone/calcification………. white
Metal …………….intense white
167
Q
  1. Visible or not visible, and therefore whether present or potentially absent
  2. Normal, too large or too small
  3. Distorted, dilated, or displaced
  4. Abnormally calcified
  5. Containing abnormal gas, fluid or discrete calculi.

Remember plain film xrays can’t always see clearly certain abdominal structures; ie appendix, gallbladder etc

A

Abdominal contents are often described as noted

168
Q

Pelvic phleboliths – normal finding.

Joint space narrowing in the hips (normal for this age?).

Granular texture of the fluid fecal matter containing pockets of gas in the caecum.

The ‘R’ or ‘L’ marked low down on the right or left side. The marker can be anywhere on the film and you often have to search for it.

(All references to ‘right’ and ‘left’ refer to the patient’s right and left.

A

list of signs you will become aware of with repeated viewing of plain film x-rays

169
Q

Check that the ‘R’ marker is compatible with the visible anatomy, e.g. (5 ways to tell)

A 
– liver on the right
– left kidney higher than the right
– stomach on the left
– spleen on the left , when visible
– heart on the left
170
Q

Intraluminal gas is usually minimal, centrally located within numerous tight loops of small diameter (2.5–3.5 cm), distinguished by valvulae that stretch all the way across the ________ loops.

A

small bowel

171
Q

A mixture of gas and feces located within loops
of larger diameter (3–5 cm) around the
periphery, with haustra, that stretch only
part-way across the diameter of the __________
loops.

A

large bowel

172
Q

more than 5 fluid levels, greater than 2.5 cm in length is abnormal and associated with obstruction, ileus, ischemia and or gastroenteritis.

A

Air–fluid levels on erect AXR

abnormal findings

173
Q

Intramural gas

A

ischemic colitis

abnormal findings

174
Q

perforated viscus or penetrating abdominal injury.(However the sensitivity for detecting perforation on AXR is low and is best confirmed as subdiaphragmatic air on erect CXR or with a CT scan).

A

Intraperitoneal gas

abnormal findings

175
Q

within the soft tissues, retroperitoneal structures or chest in infection or trauma (often seen with penetrating trauma….gun shots, knife wounds etc)

A

Extraperitoneal gas

abnormal findings

176
Q

Dilated loops of small or large bowel

A

abnormal findings

177
Q

Identify the retroperitoneal shadow of the psoas muscles. Bulging of the lateral margin or obliteration of the psoas shadow may indicate

A

retroperitoneal pathology

178
Q

_______% of renal tract stones are radio-opaque, but will require non-contrast CT or USS to confirm their position in the ureter.

A

80–90%

179
Q

Examine the RUQ for evidence of gallstones (15% radio-opaque) or pancreatic calcification. Again, confirmation with _____ or _____ is indicated.

A

USS or CT

180
Q

technology that uses computer-processed x-rays to produce tomographic images (virtual ‘slices’) of specific areas of a scanned object, allowing the user to see inside the object without cutting.

A

X-ray computed tomography (X-ray CT)

181
Q

This processing is used to generate a three dimensional image of the inside of the object from a large series of two-dimensional radiographic images taken around a single axis of rotation.

A

X-ray computed tomography (X-ray CT)

182
Q

has evolved into one of the primary diagnostic tools of the abdomen.

A

X-ray computed tomography (X-ray CT)

183
Q

When first unveiled by Sir Godfrey Hounsfield in 1972

A

X-ray computed tomography (X-ray CT)

184
Q

_____ produces a volume of data that can be manipulated in order to demonstrate various bodily structures based on their ability to block the X-ray beam.

A

X-ray CT

185
Q

the scan is taken slice by slice. After each slice the scan stops and moves down to the next slice (from the top of the abdomen down to the pelvis). This requires patients to hold still to avoid movement artefact.

A

Conventional CT scan

186
Q
  • this is a continuous scan which is taken in a spiral fashion. It is a much quicker process and the scanned images are contiguous.
A

Spiral/helical CT scan

187
Q

have steadily increased the number of rows of detectors (slices) they deploy. 16 multi-slice scanner and 64 multislice scanners are on the market. These can produce images in less than a second.
can obtain images of the heart and its blood vessels (coronary vessels) as if frozen in time.

A

Helical scan CT machines

188
Q

works by obtaining a block of raw data in a spiral (helical) rather than a planar manner, with the patient moving in a continuous z-axis direction while in the ‘tube’.
Detector arrays rotate around the patient. This continuous motion allows for a much larger volume to be covered, with less radiation exposure per volume covered when compared with sequential CT.

A

Spiral CT

189
Q

allowed for better three-dimensional imaging.
Allows for increased table speed and more distinct longitudinal resolution.
This increase in table speed is valuable in a trauma setting.
Significantly reduces the amount of radiation exposure to the patient for any continuous area.

A

Spiral CT

X-Ray Computed Tomography

190
Q

In order to differentiate between different types of fluid and tissue in the abdomen, it is important to understand the concept of _________________ and how they are derived.
Sir Godfrey Hounsfield, developed a method to standardize the density measurements between different machines.

A

Hounsfield units (HU)

191
Q

__________ absolute density scale defined air as the minimum density, with a value of -1000 HU, and placed water as the benchmark of 0. The most dense material in the human body, bone, has an upper limit of +1000 HU.

A

Hounsfield’s

192
Q

has a heterogeneous appearance and is generally between 45 and 70 HU. tends to congregate close to the original hemorrhage site, producing the so-called “sentinel clot.“

A

Clotted blood

193
Q

will have a less dense appearance, and typically ranges from 20 to 45 HU.

A

Freely flowing blood

194
Q

Blood can also be identified by __________________, which can accumulate in the abdominal cavity or demonstrate sites of vascular disruption.

A

extravasation of contrast material

195
Q

provides images in shades of grey - occasionally the shades are similar, making it difficult to discern between two areas. Contrast enhancement can be used to try to overcome this problem.

A

CT scanning

196
Q

_________________ are iodine-based and there is a risk of anaphylaxis with these and worsening of renal impairment.
Newer agents are non-ionic and are less likely to cause allergic reactions. However, they are more expensive.

A

Intravenous contrast agents

197
Q

Abdominal CT scans can be done without the use of oral radiopaque contrast agents (termed a non-contrast enhanced CT or NECT).
The advantage of NECT is that the intense radiodensity of these contrast agents can obscure areas of abnormality, like small renal or ureteral stones.
Conversely, the use of a contrast enhanced CT, or CECT, can provide better distinction between tissues and various structures. Most abdominal CT scans are done with intravenous radiocontrast as this approach helps in the identification of inflammatory and neoplastic processes.
Intravenous contrast agents use iodine as the radiopaque agent bound to either an organic (non-ionic) or ionic compound

A

the pros and cons

198
Q

_________, an insoluble powder suspended in water is a common radiocontrast used to fill the lumen of gastrointestinal structures during radiography.
agent can be administered by mouth, nasogastric tube, or rectal enema, depending on the structures to be visualized.

A

Barium sulfate

199
Q

Many hospitals are using a ______________ product before CT scanning when visualization of the gastrointestinal lumen is desired.
agent can be administered by mouth, nasogastric tube, or rectal enema, depending on the structures to be visualized.

A

water soluble iodine

200
Q

Injections are usually given rapidly and can cause a feeling of warmth in the arm, or even severe pain.

Contrast can be extravasated, which can be severe enough to require skin grafting.

Anaphylaxis with bronchospasm, laryngeal edema and hypotension can infrequently occur.

Renal failure: contrast is cleared renally and patients with pre-existing renal impairment may develop worsening renal function and even renal failure requiring dialysis.

Urticaria.

A

Side-effects of intravenous contrast

201
Q

Generally, good ________ prior to contrast will reduce the risk of developing renal impairment.

A

hydration

202
Q

________ is usually withheld before a CT scan
Continued intake of _______ after the onset of renal failure results in a toxic accumulation of this drug and subsequent lactic acidosis…..(remember from pharm)

(This rare complication occurs only if the contrast medium causes renal failure, and the patient continues to take _________ in the presence of renal failure)

the blanks are all the same word!

A

Metformin

203
Q

The routine use of both ________ and __________ for abdominal CT scanning has been greatly debated. Because CT technology has dramatically improved, it is important to consider the costs versus the benefits of oral contrast using current machines.

A

intravenous and oral contrast

204
Q

ED time studies typically find that the use of __________ adds 90 to 180 minutes of extra time until the CT scan is completed…
Conversely, radiology-based studies on CT helical scan accuracy find that __________ improves sensitivity and specificity for a variety of conditions, such as appendicitis, by 2-3%. 5
It is often the radiologist who wants _________ to
improve his or her interpretive accuracy!!!

all the blanks are the same word

A

oral contrast

205
Q

Each institution has developed an approach for the use of intravenous and/or gastrointestinal contrast according to the patient’s suspected clinical condition as well as discussions with the practicing clinicians for which CT scanning is being done.

so just asking your supervising physician and radiologist about what they suggest to use

A

okay this was just to read…

206
Q

An important consideration in the use of CT is the radiation exposure to the patient, especially in pregnant patients and children.

Radiation risks are difficult to quantify and predict.

Some studies state the amount of radiation from a CT is 150 to 1,000 times greater than a single chest x ray.

These values are difficult to quantitate. The bottom line is………..Don’t carelessly order these tests!

A

Radiation Exposure Concerns.

207
Q

As in any other imaging analysis, it is important to take a ________ approach when reading abdominal computed tomography (CT).
Always begin cranial and gradually move caudally. Likewise, assess structures from superficial to deep, first analyzing the tissues or abdominal wall and then progressing to the internal structures.

A

systematic

208
Q

ways to read a scan from when you are first starting out to when you are an expert :)

long card… just read it :)

A

For physicians with limited experience reading CT scans, it is best to begin by following one organ and tracking it through the entire sequence.

With experience, the next step is to follow organs that lie in the same transverse plane (axial), such as the liver and spleen, pancreas and adrenals, and the kidneys.

As the CT tracks caudally, identify the appropriate anatomical landmarks, such as the celiac trunk, the superior mesenteric artery, the renal arteries, and the aortic bifurcation.

Follow the major vessels to assure that the IVC and the aorta are intact and without major pathology.

209
Q

The use of CT scans are increasing almost daily due to the increased availability of CT scans on an emergent basis and the increased quality of diagnostic imaging.

With the number of various imaging technologies available to the practicing clinician it is important to consider when to rely on options that involve less radiation exposure and less cost and when to opt for CT

A

blessings

blessington said to remember this.. so when blessington says that … it is typically a good idea to remember it…

:)

210
Q

TONS OF IMAGES IN BLESSINGTON’S PPT. I’m not putting them in the cards … wayyyyy tooooo mannnnyyyyyy

A

…..

211
Q

abdominal examination to includes

A

inspection, auscultation, percussion and palpation of the abdomen and assessment of its organs including the liver, spleen, kidneys, bladder and aorta

212
Q

After percussing border of tympany and dullness w/ patient supine, ask patient to turn onto one side then percuss and mark borders again

A

Shifting dullness test to assess for ascites

213
Q

In ascites, dullness shifts to the more _______ side, whereas tympany shifts to the ______.

A

dependent

top

214
Q

Ask patient or assistant to press edges of both hands firmly down the midline of abdomen. While you tap one flank sharply w/ your fingertips, feel on the opposite flank for a “wave” transmitted through the fluid

Findings: An easily palpable “wave” suggests ascites

A

Fluid wave test to assess for ascites

215
Q 
Find point (lies 2” from ASIS on an imaginary line drawn to umbilicus)	
Findings: Positive if tender w/ guarding, rigidity and rebound tenderness
A

McBurney’s point tenderness to assess for appendicitis

216
Q

Press deeply and evenly in LLQ then quickly withdraw your fingers
Findings: Positive if pain in RLQ during left-sided pressure

A

Rovsing’s sign to assess for appendicitis

217
Q

Place hand just above patient’s right knee and ask patient to raise thigh against your hand
Findings: Positive if pain increases

A

Psoas sign to assess for appendicitis

218
Q

Flex patient’s right thigh at hip, w/ knee bent, and rotate leg internally at hip (swing lower leg laterally)

Findings: Positive if right-sided pain

A

Obturator sign to assess for appendicitis

219
Q

Hook your left thumb or fingers of your right hand under costal margin of RUQ and ask patient to take deep breath

Findings:Positive if sharp increase in pain w/ sudden stop in inspiratory effort or wincing. Less pronounced pain may indicate liver inflammation

A

Murphy’s sign to assess for acute cholecystitis

220
Q

Ask patient to raise the head and shoulders off the table

FIndings:Bulge of hernia will usually appear

A

Ventral hernia assessment (umbilical or incisional)

221
Q

Ask patient either to raise the head and shoulders off the table or bear down

Findings: Mass in abdominal wall remains palpable

A

Mass in abdominal wall assessment

222
Q
  • Make patient comfortable – supine position, arms at side, pillow under head, knees bent
  • Expose abdomen from xiphoid process to pubic symphysis (drape appropriately)
  • Stand at right side of exam table
A

tips for a good exam

223
Q

INSPECTION
Scars, striae, rashes, dilated veins & ecchymoses
Contour of the abdomen, peristalsis & pulsations

AUSCULTATION
Four quadrants for bowel sounds
Renal, iliac, & femoral arteries bilaterally and aorta for bruits
Liver and spleen for friction rubs

PERCUSSION
Percuss four quadrant for tympany and dullness
Percuss liver to measure its vertical span
Percuss spleen
Percuss costovertebral angle (CVA) for tenderness bilaterally (on the back)

PALPATION 
Lightly palpate 4 quadrants
Deeply palpate 4 quadrants 
Guarding, rigidity, rebound tenderness indicate peritonitis or “acute abdomen”
Palpate liver 
Palpate spleen 
Palpate kidneys bilaterally 
Palpate aorta
A

part of the exam

224
Q

Liver enzyme

which one of these is produced in bone as well and not just liver

A

AST
ALT
GGT
Alkaline phosphatase: produced in bone as well!

225
Q

Liver function

A

Albumin
bilirubin, total and direct
PT/INR

226
Q

if there is liver damage what will be elvated

A

all of thsee previous lab test

227
Q

do these values tell you much seperate like just a GGT?

A

nope

228
Q

LFT elevated could be

A

alvohol
drugs/toxins
risk factors for hepatitis

229
Q

patterns of abnormal LFTs

A

–> Hepatocellular damage (hepatitis, cirrhosis) : increased ALT/AST, increases Alkaline phosphatase

–> cholestasis: increased ALT and AST, increase alkaline phosphatase

—> Jaundice: increased total bilirubin, doesn’t differentiate between hepatocellular damage of cholestasis

—> low albumin suggest chronic process (cirrhosis, cancer)

—> prolonged PT/INR- significant hepatocellular dyfunction

230
Q

what is cholestasis

A

retention of bile in the liver

231
Q

AST to ALT ratio greater than or equal to a ratio of 2:1

A

alcoholic liver disease (with increase GGT), cirrhosis

232
Q

AST and ALT greater than 4 times normal

A

nonalcoholic fatty liver disease

233
Q

AST and ALT greater than 25 times normal

A

hepatitis/ toxin-related disease

234
Q

AST and ALT great than 50 times normal

A

Ischemic hepatopathy

235
Q

increased bilirubin production (eg hemolytic anemia) or impaired bulirubin uptake and storage

signs and symptoms: mild jaundice, stool and urine normal, splenomeagly in hemolysis

A

…

missed it… go back

236
Q

missed it go back….

A

missed it go back….

237
Q

bowel obstruction

labs?
most likely where?
most likely due to?
imaging?
2 buzz words to remember and seen more on which imaging positions
A

CBCD, electrolytes, H&H, most likely in Sm bowel, most likely due to previous surgery,

imaging: standing and supine X-ray

small bowel obstruction
BUZZ WORD!!!!!! : AIR FLUID LEVELS ON STANDING UP seen more
SUPINE YOU CAN SEE THE DILATED LOOPS OF BOWEL more

can also do CT: second step where you also see air fluid levels and dilated loops of bowel

238
Q

messenteric ischemia

symptoms

process

acute imaging… gold standard

chronic things that make it worse

WHAT IS KEY TO REMEMBER… like this will prob be part of the test question

A 
Symptoms: acute or chronic
high intensity, severe, diffuse pain.
worse one hour after eating
older then 50 y.o. 
bruit in 50% of pts
weight loss they dont want to eat ... because pain an hour after eating

Process: Blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion), or reduced from hypoperfusion

Acute: ABDOMINAL CT WITH ANGIOGRAM!!!!!!!!

chronic: squatting or lying down makes the pain better

KEY: such acute pain SEEMS OUT OF PROPORTION TO EXAM!

239
Q

acute cholescystitis

PE/ signs
what labs to get?
what imaging to get?

A

guarding in RUQ
positive Murphys sign
LABS: CBCD: leukocytosis with left shift… to check for infection

Imaging? Right upper quadrant US: gallbladder wall thickening and sometimes can see stones obstructing
you will see INCREASED COLOR FLOW on US

240
Q

cholangitis
labs (3)
and what do you do to diagnose and treat

A

Labs: CBCD: leukocytosis
LFT: specifically billirubin and Alk phosphatase
Blood cultures x 2

ERCP: diagnosis and treatment

241
Q

acute hepatitis

labs
what panel do you want to get… which part of this means you are immune

A

LFT: AST/ALT
serum glucose
hepatitis panel : lump together information for you
(core Ab) want to get surface Ag part of this!

positive surface ab means you are immune

242
Q

PUD

A

H.pylori
NSAIDS

breath test: for H. pylori
Stool Ag to follow up

upper endoscopy dx: want to know where it is! to see if in stomach or in duodenum

if gastric ulcer more worried for malignancy for get a biopsy

symptoms: epigastric pain not initially when you first eat food but 2-5 hours after and pain at night
fullness
nausea

PE: asymptomatic …. could have some burning pain

243
Q

Acute pancreatitis

onset:

vitals:

A

painful.
rapid onset

vitals: tachy may have a fever

LABS: CBC, amylase, lipase (more lipase), LFT (these will be elevated if gallbladder related)

Imaging: CT (angry pancreas) looks more heterogeneous
FAT STRANDING!!!!!

either due to alcohol association or gallstone

244
Q

Acute Appendicitis

PE
SIGNS?

IMAGING TO CONFIRM?

WHAT DO WE DO?

A

PERIUMBILICAL PAIN OR DISCOMFORT WITH RLQ PAIN
N/V

PE: rebound tenderness, ridigit, guarding
Rovsings sign
Murphys sign
psoas sign
rebound tenderness

CT scan to confirm!

TAKE IT OUT!

245
Q

Diverticulitis

symptoms:
TOC:
Labs:

A

Fever, N/V, diarrhea
LLQ
diverticula (pockets) something gets stuck in that and gets inflamed and infected

TOC: diagnosis this with CT scan

Labs: WBC
positive guiac test

Sasha: Module 9 GI (2 decks)

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