Blessington lecture Flashcards by Elaina Collins

patient presents with periumbilical pain migrating to the RLQ with low-grade fever and nausea, vomiting

appendicitis

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what is the single most important sign for diagnosing appendicitis?

RLQ pain on palpation

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what 5 signs may be positive in your patient with appendicitis?

1) guarding
2) psoas
3) obturator
4) rovsings
5) dunphy’s (increased pain w/ coughing)

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in what position will a patient with appendicitis lay in for comfort?

hip flexion with knees drawn up

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diagnosis of appendicitis?

CT with contrast if stable

without contrast if unstable

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treatment of appendicitis?

NPO then appendectomy

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what meds will we give as part of our treatment for appendicitis?

flagyl (metronidazole) and unasyn?

fentanyl and zofran on PRN schedules

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a bloated, distended, “taunt” abdomen and increased pain in the LLQ should make you think what?

diverticulitis

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what other symptoms, aside from pain, may your patient with diverticulitis present with?

nausea
maybe loose stools with blood
fever

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will a patient with diverticulitis pain be improved while lying down or standing up?

improved lying down

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where is the most common area in the abdomen for diverticulitis?

left sided/sigmoid lesions

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what genetic disease increases risk for diverticulitis?

familial polyposis

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patients with diverticula and polyposis are at increased risk for what?

colon cancer

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how do we diagnose diverticulitis?

CT! will see diverticula in rectosigmoid, focal wall thickening in sigmoid colon with adjacent fat stranding

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pneumoperitoneum on CT indicates what?

perforation!

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fluid collection adjacent to the area of inflammation and diverticulitis indicates what?

abscess

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management of uncomplicated diverticulitis?

1) NPO initially, then gastric and bowel rest (clear liquids)
2) IV hydration
3) analgesic medications
4) antibiotics
5) discharge home
6) return if worsening symptoms

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what are the antibiotics of choice for managing diverticulitis?

cipro and flagyl

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when is diverticulitis considered “complicated”?

presence of perforation, bowel obstruction, abscess or fistula seen on CT, high fever, sepsis, vomiting

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if your patient with diverticulitis is vomiting, what do they need?

NG tube!

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management of complicated diverticulitis?

1) NPO
2) IV cipro + flagyl
3) IV analgesics
4) surgical intervention

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what are the two surgical procedures used for complicated, emergent diverticulitis?

primary or secondary anastomosis*

colectomy (hartman procedure) – use is limited to emergency surgery when immediate anastomosis is not possible

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what are recommendations you can give your patient with a hx of diverticulitis/diverticulosis?

increase fiber

avoid seed containing products (popcorn, tomatoes, nuts)

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following a bout of diverticulitis, when should your patient go in for a colonoscopy?

1 month

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what is the recurrent rate of diverticulitis?

30-50 percent

what is charcot's triad of cholangitis?

1) abdominal pain 2) fever 3) jaundice

what is reynold's pentad of cholangitis?

1) abdominal pain 2) fever 3) jaundice 4) confusion 5) septic shock

what may a patient with cholangitis complain of during their history intake?

diffuse itching

what is the most common cause of cholangitis?

bile duct obstruction by gallstones or cancer

imaging modality of choice for ruling out carcinoma as the cause of patient's cholangitis?

MRI

what should the first diagnostic modality of suspected cholangitis always be?

ultrasound!

what might ultrasound of cholangitis show?

dilation of the bile duct; identification of a percentage of bile duct stones relatively poor at identifying stones further down the bile duct

when do we choose ERCP in patient with suspected cholangitis?

only used first-line in critically ill patients in whom delay for diagnostic tests is not acceptable

if the index of suspicion for cholangitis is high, what do we do?

jump to the ERCP

what are the most common bacteria linked to ascending cholangitis?

1) gram neg = e. coli, klebsiella 2) gram pos = enterococcus 3) anaerobic = c. diff and bacterioides (MC in elderly)

treatment of cholangitis?

1) IV fluids 2) ABX 3) fix underlying problem (ERCP)

what should we do following ERCP if patient's cholangitis was due to gallstones?

cholecystectomy wait until all symptoms have resolved and ERCP has confirmed that bile duct is clear of gallstones!

what causes the abdominal pain associated with ectopic pregnancy?

prostaglandins are released at implantation site and free blood is in the peritoneal cavity

what causes the vaginal bleeding seen in ectopic pregnancy?

falling progesterone levels

shoulder pain is an ominous sign in the face of ectopic pregnancy, why?

often due to free blood tracking up the abdominal cavity and irritating the diaphragm

where do most ectopic pregnancies occur?

the fallopian tubes (tubal pregnancies)

true or false, an ectopic pregnancy can occur anywhere in the abdomen?

true

6 risk factors for ectopic PG?

1) PID 2) IUD 3) tubal surgery (ligation) 4) intrauterine surgery (ie D and C) 5) smoking/alcohol abuse 6) previous ectopic

sharp, lower abdominal pain and intermittent bleeding is classic of ectopic pregnancy. how else may they present?

1) bladder and rectal pressure | 2) pain radiating to loer back

when is pain the worst with ectopic pregnancy?

when walking; car ride in can be very difficult

on palpation of a patient with an ectopic pregnancy's abdomen, what will you appreciate?

1) firmness 2) diffuse rigidity 3) guarding

will a patient with an ectopic pregnancy have rebound tenderness?

yes

what other signs will be positive on abdominal/pelvic exam of an ectopic pregnancy?

positive psoas, obturator acute cervical motion tenderness, bilateral tenderness to both adnexa

what my you see on inspection of a patient's cervix with an ectopic pregnancy?

bright red blood per cervix

at what level of beta-quantitative HCG will an intrauterine pregnancy, if present, be apparent on ultrasound?

2,000 mIU

what if you don't see an intrauterine pregnancy on ultrasound in a patient with an HCG level of 2,000?

high suspicion for ectopic

if levels are around 1500 and there is no evidence of an intrauterine pregnancy, what should you do?

it may be too small to see do repeat in 2-3 days

an ultrasound showing a gestational sac with a fetal heart in the fallopian tube is what?

ectopic

if a large amount of free fluid exists throughout the abdominal cavity with pooling in the cul de sac, what should we worry about?

perforated ectopic pregnancy

you aren't sure if your patients abdominal pain and cervical motion tenderness is due to PID or an ectopic pregnancy. what should you do?

get PG test! the presence of a positive PG test virtually rules out pelvic infection as it is rare to find pregnancy with active PID

what is the most common misdiagnosis assigned to early ectopic pregnancy?

PID!

how can stable patients with an ectopic pregnancy be treated?

methotrexate injection (reduces need for surgery)

unstable patients with an ectopic pregnancy need what?

surgery

what happens if there is no intrauterine OR ectopic pregnancy found in a STABLE patient with a positive beta-HCG? what should you do?

manage expectantly with follow-up quantitative beta-HCG levels and ultrasound within 2-3 days

if left untreated, what percentage of ectopics will resolve without treatment?

half tubal abortions

shoulder pain, lower back pain, cramping on one side of the pelvis mean what?

more severe internal bleeding may have occurred

an ectopic pregnancy should be considered as the cause of ______ or ______ in EVERY woman who has a positive pregnancy test

abdominal pain or vaginal bleeding