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RRCCPA Clinical Decision Making II > Evaluation of Abdominal Pain in PC (final) > Flashcards

Evaluation of Abdominal Pain in PC (final) Flashcards

1
Q

The most common GI complaint in PC is _________

A

Constipation

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2
Q

Almost 50% of GI referrals eventually get diagnosed with ________

A

IBS

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3
Q

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

A

Appendicitis

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4
Q

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

A

True

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5
Q

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

A

80%

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6
Q

Can you name 11 DDx for acute abd pain?

A
  • Appendicitis
  • Cholecystitis
  • Pancreatitis
  • Diverticulitis
  • Perforation
  • Obstruction
  • Acute ischemia
  • AAA
  • Ectopic
  • PID
  • Nephrolithiasis
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7
Q

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

A
  • PUD
  • Esophagitis
  • IBD (CD & UC)
  • Chronic pancreatitis
  • Diabetes - gastroparesis
  • IBS
  • Abdominal wall
  • Functional
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8
Q

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

A

Pulmonary, urinary, hepatobiliary

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9
Q

Test of choice for evaluating RUQ pain?

A

US

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10
Q

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

A

Hepatobiliary; nephrolithiasis

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11
Q

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

A

Watch and wait.

  • Up to 50% of pts with gallstones will not require a cholecystectomy.
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12
Q

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

A
  • ER or general surgery
    • Cholecystectomy within 72 hours ideal
  • Pain control
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13
Q

Describe the timing/durationg of pain in cholecystitis

A

Pain persists beyond 5-6 hrs and often reoccurs.

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14
Q

What percentage of cholecystitis pts will have a fever?

A

35%

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15
Q

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

A

GERD and PUD

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16
Q

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

A

Heartburn and regurgitation

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17
Q

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

A

Epigastric TTP

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18
Q

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

A

True

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19
Q

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

A

Gastric cancer

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20
Q

Dyspepsia + melena should make you think of…..

A

PUD

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21
Q

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

A

Endoscopy

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22
Q

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

A

False. Acid suppression may mask the sx of malignancy.

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23
Q

Gold standard test for H pylori?

A

Urea breath test

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24
Q

Sensitivity and specificity of fecal H pylori test?

A
  • Sensitivity: 94%
  • Specificity: 98%
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25
Q

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

A

True

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26
Q

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

A

False.

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27
Q

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

A

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

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28
Q

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

A

PPI

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29
Q

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

A

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

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30
Q

Which meds are H2 blockers?

A
  • Ranitidine (Zantac)
  • Cimetidine (Tagamet)
  • Famotidine (Pepcid)
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31
Q

Which meds are PPIs?

A
  • Omeprazole (Prilosec)
  • Esomeprazole (Nexium)
32
Q

MCC of PUD?

A
  • Occurs in 5-10% of pts w/ long-term NSAID use
  • H. pylori - 90% of duodenal ulcers and 70-90% of gastric ulcers
33
Q

___% of pts with PUD will have a GIB

A

25%

34
Q

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

A

False. It is.

35
Q

H. pylori triple therapy consists of….

A
  • PPI
  • Clarithromycin 500 mg BID x 14d
  • Amoxicillin 1 g BID x14d (or Flagyl 500 mg)
36
Q

H. pylori quadruple therapy consists of….

A
  • Bismuth
  • Tetracycline 500 mg QID
  • Flagyl 500 mg TID
  • Prilosec 20 mg BID
37
Q

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

A

Gastric: 8 wks

Duodenal: 4 wks

38
Q

What lipase and amylase values are diagnostic for pancreatitis?

A
  • Lipase >540 (3x nl)
    • returns to nl in 1-2 wks
  • Amylase >360 (3x nl)
    • returns to nl in 48-72 hrs
39
Q

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

A

CT abd/pelv w/ contrast

40
Q

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?

A
  • Stable VS
  • Tolerating PO
  • Pain controlled
41
Q

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?

A
  • Clear liquid diet
  • Pain control
  • Anticipate improvement in 3-7 days in 90% of cases
42
Q

Imaging of choice to evaluate RLQ pain?

A
  • CT with contrast
  • Abdominal or transvaginal US for females
43
Q

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

A
  • Urinary
    • UTI
    • Pyelonephritis
    • Nephrolithiasis
  • Females:
    • Ovarian cyst
    • Torsion
    • Tubo-ovarian abscess
    • Ectopic
  • Colon:
    • Colitis
    • Obstruction
    • IBD
44
Q

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

A

After (100% sensitivity)

45
Q

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?

A
  • Urinary
    • UTI
    • Pyelo
    • Nephrolithiasis
  • Females:
    • Ovarian cyst
    • Torsion
    • TOA
    • Ectopic
  • Colon:
    • Colitis
    • Obstruction
    • IBD
46
Q

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

A

CT w/ IV contrast

47
Q

___% of diverticulitis pts will present with LLQ pain

A

92%

*Approx 68% willl have leukocytosis

48
Q

When is outpatient tx for diverticulitis indicated?

A
  • Stable VS
  • Tolerating PO
  • Pain controlled
49
Q

Tx for diverticulitis includes….

A
  • 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
50
Q

What are some common sx seen with IBD?

A
  • Bowel alterations
  • Mucous stools (40%)
  • Sensation of incomplete emptying, aka tenesmus (70%)
51
Q

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

A
  • Rome III
  • Manning

*If meet criteria, go ahead and treat

52
Q
A
53
Q

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

A
  • Stool incontinence
  • Nighttime awakenings (pain or BMs)
  • Wt loss, fever, night sweats
  • Heme +
  • Family h/o colon cancer
  • Lab anormalities (leukocytosis, anemia, +ESR)
54
Q

How do you tx IBD?

A
  • Diet
  • Stress reduction
  • Sx directed
55
Q

___% of nephrolithiasis cases have hematuria

A

90%

56
Q

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

A

CT abd/pelv without contrast

57
Q

Imaging of choice for hydronephrosis?

A

Renal US

58
Q

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?

A

No, because they have a h/o CKD.

59
Q

Pharmacologic tx for uncomplicated nephrolithiasis without infection?

A
  • Push fluids
  • Pain control
    • NSAIDs (Toradol IM)
    • Narcotics
  • Alpha blocker x 14 days (Flomax 0.4 mg QD)
60
Q

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

A
  • Stone not passed in a few days
  • Stone >7mm with hydro
  • All pts with stones >10 mm
61
Q

Calculi <5 mm will pass spontaneously in ___% of pts

A

90%

62
Q

Calculi 5 mm will pass spontaneously in ___% of cases

A

50%

63
Q

Calculi 7 mm will pass spontaneously in ___% of pts

A

10%

64
Q

Calculi 10 mm will pass spontaneously in ___% of cases

A

10 mm won’t pass

65
Q

Postoperative adhesions account for 50-60% of cases of ______________

A

Small bowel obstruction

66
Q

MC sx of SBO?

A

Constipation (LR 8.8)

67
Q

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

A

SBO

68
Q

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

A
  • CBC
  • CMP
  • Lactate
69
Q

What is/are your imaging of choice for SBO?

A
  • Mild/stable start with KUB
    • 60% sensitivity
    • False negative early in process
  • High suspicion → CT abd/pelv w/ contrast
    • 90% sensitive
70
Q

Tx options for SBO?

A
  • Imaging → send to ER
  • NPO
  • NG tube for decompression
  • Surgery
71
Q

Sx of ectopic pregnancy typically start around ___ wks of gestation

A

7

72
Q

What percentage of ectopic pts will have vaginal bleeding?

A

70%

73
Q

Imaging of choice to r/o ectopic?

A

Transvaginal US should be performed regardless of bHCG level when ectopic pregnancy is considered

  • 40% of US-diagnosed ectopics had bHCG <1000
74
Q

In PC, what is your tx for ectopic?

A

Send to ER/OBGYN

75
Q

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

A

True

76
Q

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

A

In case there’s a salad dressing

RRCCPA Clinical Decision Making II (10 decks)

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