Evaluation of Abdominal Pain in PC (final) Flashcards by Cody Prentice

The most common GI complaint in PC is _________

Constipation

How well did you know this?

Not at all

Perfectly

Almost 50% of GI referrals eventually get diagnosed with ________

IBS

How well did you know this?

Not at all

Perfectly

The most common cause of acute abdominal pain presenting to PC is _________________

Appendicitis

How well did you know this?

Not at all

Perfectly

T/F: Hardly any differences in dx b/w pts who had complaints <1 wk vs >1 wk before presenting

True

How well did you know this?

Not at all

Perfectly

Upwards of ___% of abdominal complaints can be managed in primary care.

80%

How well did you know this?

Not at all

Perfectly

Can you name 11 DDx for acute abd pain?

Appendicitis
Cholecystitis
Pancreatitis
Diverticulitis
Perforation
Obstruction
Acute ischemia
AAA
Ectopic
PID
Nephrolithiasis

How well did you know this?

Not at all

Perfectly

Can you name 8 DDx for chronic (>6 months) abdominal pain?

PUD
Esophagitis
IBD (CD & UC)
Chronic pancreatitis
Diabetes - gastroparesis
IBS
Abdominal wall
Functional

How well did you know this?

Not at all

Perfectly

Your history in a RUQ pain pt should focus on differentiating b/w _____________, ______________, and ______________ pain.

Pulmonary, urinary, hepatobiliary

How well did you know this?

Not at all

Perfectly

Test of choice for evaluating RUQ pain?

How well did you know this?

Not at all

Perfectly

If a pt has colicky RUQ pain, you should consider a ____________ cause or ____________.

Hepatobiliary; nephrolithiasis

How well did you know this?

Not at all

Perfectly

RUQ US is + for stones, but labs are WNL. Next step?

Watch and wait.

Up to 50% of pts with gallstones will not require a cholecystectomy.

How well did you know this?

Not at all

Perfectly

RUQ is + for gallstones and CBC, CMP are abnl. Next step?

ER or general surgery
- Cholecystectomy within 72 hours ideal
Pain control

How well did you know this?

Not at all

Perfectly

Describe the timing/durationg of pain in cholecystitis

Pain persists beyond 5-6 hrs and often reoccurs.

How well did you know this?

Not at all

Perfectly

What percentage of cholecystitis pts will have a fever?

35%

How well did you know this?

Not at all

Perfectly

Roughly 40% of dyspepsia cases are caused by _______ and _______

GERD and PUD

How well did you know this?

Not at all

Perfectly

If ____________ and ______________ are the dominant sx, then GERD is the likely diagnosis.

Heartburn and regurgitation

How well did you know this?

Not at all

Perfectly

With the exception of _________________, PEx is usually unremarkable in pts with uncomplicated dyspepsia.

Epigastric TTP

How well did you know this?

Not at all

Perfectly

T/F: an association b/w dental erosions and GERD has been found

True

How well did you know this?

Not at all

Perfectly

Aside from DM, acanthosis nigricans can be a sign of _____________

Gastric cancer

How well did you know this?

Not at all

Perfectly

Dyspepsia + melena should make you think of…..

PUD

How well did you know this?

Not at all

Perfectly

What is the gold standard test to exclude gastroduodenal ulcers, reflux esophagitism, and upper GI cancers?

Endoscopy

How well did you know this?

Not at all

Perfectly

T/F: Empiric tx of dyspepsia with acid suppression will not mask the sx of malignancy.

False. Acid suppression may mask the sx of malignancy.

How well did you know this?

Not at all

Perfectly

Gold standard test for H pylori?

Urea breath test

How well did you know this?

Not at all

Perfectly

Sensitivity and specificity of fecal H pylori test?

Sensitivity: 94%
Specificity: 98%

How well did you know this?

Not at all

Perfectly

T/F: In general, once pts are positive serologically for H pylori, they will remain positive for the rest of their lives.

True

T/F: Most evidence widely favors empiric eradication of H. pylori

False.

What is the best, EBM-supported, approach to treating H pylori?

Test for H. pylori and treat if test is positive (as opposed to treating empirically prior to testing, or testing and then endoscopy)

If confirmed H pylori, you should treat with H2 blocker or PPI?

PPI

If not H pylori, your go-to empiric dyspepsia med should be H2 blocker or PPI?

H2 blocker - tend to be helpful in 50-70% of pts, cheaper, and fewer interactions than PPI.

Which meds are H2 blockers?

* Ranitidine (Zantac) * Cimetidine (Tagamet) * Famotidine (Pepcid)

Which meds are PPIs?

* Omeprazole (Prilosec) * Esomeprazole (Nexium)

MCC of PUD?

* Occurs in 5-10% of pts w/ long-term NSAID use * H. pylori - 90% of duodenal ulcers and 70-90% of gastric ulcers

\_\_\_% of pts with PUD will have a GIB

25%

T/F: H. pylori resistance to abx is surprisingly not a problem

False. It is.

H. pylori triple therapy consists of....

* PPI * Clarithromycin 500 mg BID x 14d * Amoxicillin 1 g BID x14d (or Flagyl 500 mg)

H. pylori quadruple therapy consists of....

* Bismuth * Tetracycline 500 mg QID * Flagyl 500 mg TID * Prilosec 20 mg BID

Most gastric ulcers heal within ___ wks, whereas most duodenal ulcers heal within ___ wks.

Gastric: 8 wks Duodenal: 4 wks

What lipase and amylase values are diagnostic for pancreatitis?

* Lipase \>540 (3x nl) * returns to nl in 1-2 wks * Amylase \>360 (3x nl) * returns to nl in 48-72 hrs

If you are concerned for complications or first episode of pancreatitis, which imaging should you order?

CT abd/pelv w/ contrast

If someone with known chronic/recurrent pancreatitis comes into your PC office with an exacerbation, what 3 things would make you comfortble sending them home?

* Stable VS * Tolerating PO * Pain controlled

You send your chronic pancreatitis pt home because their VS are stable, their pain is under control, and they are tolerating PO. What is your outpatient treatment?

* Clear liquid diet * Pain control * Anticipate improvement in 3-7 days in 90% of cases

Imaging of choice to evaluate RLQ pain?

* CT with contrast * Abdominal or transvaginal US for females

If your RLQ pt's H&P is not consistent with appendicitis, what else should you consider on your DDx?

* Urinary * UTI * Pyelonephritis * Nephrolithiasis * Females: * Ovarian cyst * Torsion * Tubo-ovarian abscess * Ectopic * Colon: * Colitis * Obstruction * IBD

With appendicitis, does vomiting typically occur before or after onset of pain?

After (100% sensitivity)

Diverticulitis should be at the top of your DDx in pts with LLQ pain. But what if the H&P isn't consistent with diverticulitis? What else should be on your DDx?

* Urinary * UTI * Pyelo * Nephrolithiasis * Females: * Ovarian cyst * Torsion * TOA * Ectopic * Colon: * Colitis * Obstruction * IBD

You are unsure if your pt has diverticulitis. What imaging should you get?

CT w/ IV contrast

\_\_\_% of diverticulitis pts will present with LLQ pain

92% \*Approx 68% willl have leukocytosis

When is outpatient tx for diverticulitis indicated?

* Stable VS * Tolerating PO * Pain controlled

Tx for diverticulitis includes....

* Clear liquid diet → high fiber diet * Flagyl 500 TID 7-10 days PLUS * Cipro 500 BID 7-10 days * Levaquin 750 QD 7-10 days * Bactrim BID 7-10 days * Pain control * Anticipate improvement in 48-72 hrs

What are some common sx seen with IBD?

* Bowel alterations * Mucous stools (40%) * Sensation of incomplete emptying, aka tenesmus (70%)

What are the names of the 2 diagnostic scoring criteria for IBS?

* Rome III * Manning \*If meet criteria, go ahead and treat

What are some red flag sx to look out for with IBD?

* Stool incontinence * Nighttime awakenings (pain or BMs) * Wt loss, fever, night sweats * Heme + * Family h/o colon cancer * Lab anormalities (leukocytosis, anemia, +ESR)

How do you tx IBD?

* Diet * Stress reduction * Sx directed

\_\_\_% of nephrolithiasis cases have hematuria

90%

Gold standard imaging for first time or uncertain dx of nephrolithiasis?

CT abd/pelv without contrast

Imaging of choice for hydronephrosis?

Renal US

A pt with h/o CKD comes in with acute L flank pain and you confirm it is a stone. Their VS are stable, they are tolerating PO, and you have controlled their pain in the clinic. Can this pt be treated outpatient?

No, because they have a h/o CKD.

Pharmacologic tx for uncomplicated nephrolithiasis without infection?

* Push fluids * Pain control * NSAIDs (Toradol IM) * Narcotics * Alpha blocker x 14 days (Flomax 0.4 mg QD)

Your pt has a kidney stone. At what point should you consult Urology?

* Stone not passed in a few days * Stone \>7mm with hydro * All pts with stones \>10 mm

Calculi \<5 mm will pass spontaneously in \_\_\_% of pts

90%

Calculi 5 mm will pass spontaneously in \_\_\_% of cases

50%

Calculi 7 mm will pass spontaneously in \_\_\_% of pts

10%

Calculi 10 mm will pass spontaneously in \_\_\_% of cases

10 mm won't pass

Postoperative adhesions account for 50-60% of cases of \_\_\_\_\_\_\_\_\_\_\_\_\_\_

Small bowel obstruction

MC sx of SBO?

Constipation (LR 8.8)

Colicky abdominal pain with distension and tympany on percussion makes you think of....

SBO

You are concerned for SBO. Which labs do you want to order?

* CBC * CMP * Lactate

What is/are your imaging of choice for SBO?

* Mild/stable start with KUB * 60% sensitivity * False negative early in process * High suspicion → CT abd/pelv w/ contrast * 90% sensitive

Tx options for SBO?

* Imaging → send to ER * NPO * NG tube for decompression * Surgery

Sx of ectopic pregnancy typically start around ___ wks of gestation

What percentage of ectopic pts will have vaginal bleeding?

70%

Imaging of choice to r/o ectopic?

Transvaginal US should be performed regardless of bHCG level when ectopic pregnancy is considered * 40% of US-diagnosed ectopics had bHCG \<1000

In PC, what is your tx for ectopic?

Send to ER/OBGYN

T/F: Elderly pts (\>65 y/o) with abdominal pain are twice as likely than younger pts to require surgery

True

Why are you supposed to knock on the fridge door before opening it?

In case there's a salad dressing