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1

What should you always ask?

1. eating/defecating make it better or worst
2. last menstrual cycle
3. what were you doing (trigger)

2

Most common surgical emergency of the abdomen**

acute appendicitis
r/o 1st!

3

acute appendicitis Sx

often inconsistent
only 50% class RLQ pain, N/V
Abdominal pain most common* (could be periumbilical/epigastric migrating to RLQ)
Sx usu <48hrs
N/V/D, constipation, anorexia
vomit AFTER onset of pain*

4

what should you worry about if vomiting precedes abdominal pain?

intestinal obstruction

5

McBurney's point

RLQ tenderness 96% in acute appendicitis
2/3 of way from umbilicus to ASIS

6

Physical exam special tests for acute appendicitis

McBurney's point
Rebound tenderness (Blumberg sign)
Rovsing sign: RLQ pain w/LLQ palpation
Obturator sign: RLQ pain w/int/ext rot of flexed R. hip
Psoas sign: RLQ pain w/extension of R. hip or flex of R. hip against resistance

7

Acute appendicitis labs

leukocytosis w/left shift 80-85% (unreliable in infants/elderly/preg)
elevated CRP

8

imaging study to eval for acute appendicitis

CT Abd/Pel w/oral contrast

9

Acute appendicitis Tx

NPO, IVF, Pain control, Antibiotics, consult surgery

10

what should you worry w/"pain out of proportion to exam***

mesenteric infarction
bowel is dying, surgical emergency! need to re-vascularize
often w/A.fib/CHF
CTA, MRA

11

imaging of choice for suspected rupture abdominal aortic aneurysm

U/S standard (pt unstable)
CT/CTA confirm if pt stable
high pre-hospital mortality

12

Classic triad for ectopic pregnancy*

abdominal pain
amenorrhea
vaginal bleeding

13

Imaging/labs for suspected ectopic pregnancy

hCG
U/S

14

when do MIs most often occur?

early in the morning, may only present w/indigestion

15

most common Sx of GERD/Esophagitis

Burning pain, worse w/lying down

16

abrupt onset of abdominal pain in PUD is worrisome of?**

ulcer perforation
Sx: gnawing/burning epigastric pain

17

Test of choice to Dx PUD*

EGD (esophagogastroduodenoscopy)

18

Biggest causes of acute appendicitis**

alcohol
gallstones
(constant boring pain)

19

Acute pancreatitis signs

Cullen sign
Grey-Turner sign

20

what can acute pancreatitis be caused by in the elderly?

pancreatic tumor

21

Biliary colic

sudden constant pain, 1-5hrs, may radiate to R scapula
gallstone temp block cystic duct
N/V
can develop into acute cholecystitis if untreated

22

acute cholecystitis

inflammation of GB wall
RUQ pain, radiate to R. scapula
N/V, anorexia, fever
Labs: leukocytosis, mild LFT elevation
U/S Dx, May need surgery

23

Charcot's Triad (Ascending Cholangitis)

Fever
RUQ pain
Jaundice

24

biliary dyskinesia

recurrent RUQ pain in absence of gallstones
pain typically 30-60min after eating (spicy, greasy), last 1-4hours

25

most common cause of small bowel obstruction

intra-abdominal adhesions

26

acute gastroenteritis

self limiting
eval for dehydration
typically fever, vomiting first then diarrhea, anorexia
supportive care, no abiotic

27

C. diff colitis Tx

metronidazole (PO, IV)
vancomycin (PO only! IV doesn't penetrate gut)*

28

most common type of peritonitis

secondary, identify source

29

Late complication of PID

Tubo-ovarian abscess
can be fatal if ruptures --> endotoxic shock

30

PID Dx criteria

lower abd tenderness
cervical motion tenderness
adnexal tenderness
often vaginal discharge