Flashcards in Critical Care Deck (136)
What are the characteristics of renal pain?
-CC: colicky right-sided flank pain, nausea, vomiting, hematuria, CVA tenderness
-Workup: UA, BUN/Cr, CT abdomen, renal US, KUB, blood cultures
-Ddx: nephrolithiasis, renal cell carcinoma, pyelonephritis, GI etiology, glomerulonephritis, splenic rupture
What are the characteristics of pancreas pain?
-CC: dull epigastric pain that radiates to the back
-Workup: CT abdomen, CBC, electrolytes, amylase, lipase, AST, ALT, bilirubin, alkaline phosphatase, U/S abdomen
-Ddx: pancreatitis, pancreatic cancer, peptic ulcer disease, cholecystitis/choledocholithiasis
What are the characteristics of gallbladder pain?
-CC: RUQ pain
-Workup: RUQUS, CBC, CMP, HIDA scan, MRCP/ERCP, amylase, lipase, alkaline phosphatase, bilirubin
-Ddx: cholecystitis, choledocholithiasis, hepatitis, ascending cholangitis, Fitz-Hugh-Curtis syndrome, acute sub hepatic appendicitis
What are the characteristics of liver pain?
-CC: RUQ pain, fever, anorexia, nausea, vomiting, dark urine, clay stool
-Workup: CBC, amylase, lipase, liver enzymes, viral hepatitis serologies, UA, U/S abdomen, ERCP, MRCP
-Ddx: acute hepatitis, acute cholecystitis, ascending cholangitis, choledocholithiasis, pancreatitis, primary sclerosis cholangitis, primary biliary cirrhosis, glomerulonephritis
What are the characteristics of spleen pain?
-CC: severe LUQ pain that radiates to left scapula w hx of infectious mono
-Workup: CBC, CXR, CT/US of the abdomen
-Ddx: splenic rupture, splenic infarct, kidney stone, rib fracture, pneumonia, perforated peptic ulcer
What are the characteristics of stomach pain?
-CC: burning epigastric pain after meals
-Workup: rectal exam (occult blood in stool), amylase, lipase, lactase, AST, ALT, bilirubin, alkaline phosphatase, upper endoscopy (H. pylori biopsie), upper GI series
-Ddx: peptic ulcer disease, perforated peptic ulcer disease, gastritis, GERD, cholecystitis, mesenteric ischemia, chronic pancreatitis
What are the characteristics of pipes pain?
-CC: cramps abdominal pain, vomiting, abdominal distention, inability to pass flatus
-Workup: rectal exam, CBC, electrolytes, CT abdomen/pelvis, colonoscopy
-Ddx: intestinal obstruction, small bowel/colon cancer, volvulus, gastroenteritis, food poisoning, illness, hernia mesenteric ischemia/infarction, diverticulitis, with alternating diarrhea, constipation, diverticulitis, Crohn's disease, ulcerative colitis, abscess, IBS, celiac disease, GI parasitic infection (amebiasis, giardiasis)
What are the characteristics of pelvis pain?
-CC: RLQ pain, nausea, vomiting, dysuria, hematuria
-Workup: pelvic exam, urine hCG, doppler U/S, rectal exam, UA, CBC, CT abdomen, laparoscopy, chlamydia, and gonorrhea testing
-Ddx: ovarian torsion, appendicitis, ectopic pregnancy, ruptured ovarian cyst, pelvic inflammatory disease, bowel infarction/perforation, endometriosis, vaginitis, cysts, pyelonephritis
What are the characteristics of primary (Addison's disease)?
autoimmune, infectious, disease of adrenal gland = decrease in cortisol secretion
-adren gland destruction causing lack of cortisol and aldosterone secretion (usually autoimmune)
-autoimmune (70%), infectious (tuberculosis), vascular (thrombosis/hemorrhage), metastatic, medications (rifampin, barbiturates, phenytoin, ketoconazole)
-dx: increased ATCH, decreased cortisol, decreased aldosterone
What are the characteristics of secondary adrenal insufficiency?
pituitary adenoma or discontinuation of steroid - pituitary failure
-exogenous steroid use (most common); hypopituitarism
-dx: decreased ACTH, decreased cortisol, normal aldosterone
-adrenal crisis = acute adrenal insufficiency
How is adrenal insufficiency dx?
-8 am serum cortisol and plasma ACTH alone with ACTH stimulation test
-high ACTH, low cortisol = primary
-low ACTH, low cortisol = secondary
-CRH stimulation test: differentiates between causes of adrenal insufficiency
-primary/Addison's (adrenal): high ACTH, low cortisol
-secondary (pituitary): low ACTH, low cortisol
-adrenal autoantibodies can be assessed; CXR for TB (CT of adrenals)
-autoimmune: atrophied adrenals
-TB/granulomas: enlarged adrenals + calcification
-bilateral adrenal hyperplasia = genetic enzyme defect
What is the tx of adrenal insufficiency?
-Addison's cortisol replacement therapy + androgen replacement
-glucocorticoid + mineralocorticoid = hydrocortisone = 1st line, fludrocortisone for primary Addison's disease only
-Secondary: cause = focus of treatment (pituitary adenoma resection, wean steroid therapy slowly)
What are the characteristics of an upper GI bleed?
bleeding that originates proximal to the ligament of Treitz
-hematemesis: vomiting of blood or coffee-ground emesis
-melena: black tarry stool
-orthostatic hypertension, tachycardia, abdominal tenderness - causes include:
-peptic ulcer: upper abdominal pain
-esophageal ulcer: odynophagia, gastroesophageal reflux, dysphagia
-Mallory-Weiss tear: emesis, retching, or coughing prior to hematemesis
-Esophageal varies with hemorrhage or portal hypertension: jaundice, abdominal distention (ascites)
-Malignancy (gastric cancer and right-sided colon cancer): dysphagia, early satiety, involuntary weight loss, cachexia
-Severe erosive esophagitis: odynophagia (painful swallowing), dysphagia and retrosternal chest pain
What is the tx of an upper GI bleed?
-supportive care: NPO, IV access, oxygen, IV fluids of isotonic crystalloid
-transufse for hemodynamic instability despite fluis, Hgb < 9 in high-risk patients (elderly, CAD), Hgb < 7 in low-risk patients
-Treat with IV PPI until confiramtion of cause of bleeding - treat the underlyin cause
-surgery - duodenotomy or gastroduodenostomy, ligation of bleeding
What are the characteristics of lower GI bleed?
-Hematochezia (BRBPR): the passage of maroon or right red blood or clots per rectum
-orthostatic hypotension or shock - causes include:
-hemorrhoids: painless bleeding with wiping
-anal fissures: severe rectal pain with defecation
-proctitis: rectal bleeding and abdominal pain
-polyps: painless rectal bleeding, no red flag signs
-colorectal cancer: painless rectal bleeding and a change in bowel habits in a patient 50-80 years of age
-diverticulosis is generally an incidental finding since diverticular bleeding is usually of greater volume
What is acute glaucoma?
increased IOP with optic nerve damage; an impediment to the flow of aqueous humor through trabecular meshwork; canal of Schlemm's with increasing pressure in the anterior chamber
-open-angle = more common = > 40 yo, African Americans + family history
What is acute angle-closure glaucoma?
ophthalmic emergency - complete closure of the angle
-classic triad: injected conjunctiva, steamy cornea, and fixed dilated pupil
-painful eye/loss of vision, tearing, nausea, vomiting, diaphoresis
-IOP acutely elevated
What is the tx of acute angle-closure glaucoma?
immediately refer to ophthalmology - start IV carbonic anhydrase inhibitor (acetazolamide), topical b-blocker (timolol), osmotic diuresis; laser/surgical iridotomy
-mydriatics (to dilate pupils) should NOT BE ADMINISTERED
What is open-angle glaucoma?
chronic, asymptomatic, potentially blinding disease
-increased IOP, defects in the peripheral visual field, increased cup to disc ratio
-asymptomatic until late in the disease, loss of peripheral vision = main symptoms
How is open-angle glaucoma dx?
can have elevated IOP without optic disc damage or optic nerve damage without increased IOP
What is the tx of open-angle glaucoma?
should be referred to an ophthalmologist for close monitoring
-prostaglandin analogs are the 1'st line (ex. latanoprost), beta-blocker (timolol), alpha-agonist, a carbonic anhydrase inhibitor to decrease production
-laser or surgical treatment
What is acute respiratory syndrome?
a type of respiratory failure characterized by fluid collecting in the lungs depriving organs of oxygen
-increased permeability of alveolar-capillary membranes = development of protein-rich pulmonary edema (non-cariogenic pulmonary edema)
-ARDS can occur in those who are critically ill or who have significant injuries = sepsis (most common), severe trauma, aspiration of gastric contents, near-drowning
What are the characteristics of ARDS?
People with ARDS have severe shortness of breath and often are unable to breathe on their own without support from a ventilator
-rapid onset of profound dyspnea occurring 12-24 hours after the precipitating event
-tachypnea, pink frothy sputum, crackles
-chest radiograph shows air bronchograms and bilaterally fluffy infiltrate
-normal BNP, pulmonary wedge pressure, left ventricule function and echocardiogram
What is the tx of ARDS?
identifying and managing underlying precipitation and secondary conditions
-tracheal intubation with the lowest level PEEP to maintain PaO2 > 60 mmHG or SaO2 > 90
-ARDS is often fatal, the risk increases with age and severity of illness
What is angina pectoris?
chest pain or discomfort, heaviness, pressure, squeezing, tightness is increased with exertion or emotion
What is stable angina?
predictable, relieved by rest and/or nitroglycerine
-stress test demonstrates reversible wall motion abnormalities/ST depression > 1 mm
-angiography provides a definitive diagnosis
What is the tx of stable angina?
-beta-blockers and nitroglycerin
-severe: angioplasty and bypass
What is unstable angina?
previously stable and predictable symptoms of angina that are now more frequent, increasing or present at rest
-chronic angina - increasing in frequency, duration, or intensity of pain
-new-onset angina - sever and worsening
-angina at rest
What is the tx of unstable angina?
-admit to the unit with continuous cardiac monitoring, establish IV access, O2
-pain control with NTG and morphine
-ASA, clopidogrel, beta-blockers (first line), LMWH
-if the patient responds to medical therapy - stress test to determine if catheterization/revascularization necessary
-reduce risk factors: stop smoking, weight loss, treat DM/HTN