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EM quiz readings > Lecture 11: Abdominal Pain Readings > Flashcards

Lecture 11: Abdominal Pain Readings Flashcards

1
Q

When does an AAA require repair?

A
  • Symptomatic
  • >= 5.0cm
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2
Q

Classic presentation of ruptured AAA

A
  1. Older male smoker
  2. hx of atherosclerosis
  3. Sudden back/abd pain, hypotension, pulsatile abd mass
  4. Onset of pain is both severe and abrupt.
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3
Q

What hx might predispose aortoenteric fistulas?

A

Prior aortic grafting

Duodenum MC location

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4
Q

When do you really start monitoring an AAA?

A

Once it hits 3cm, refer to vascular to monitor

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5
Q

What is the MC initial misdiagnosis for an AAA?

A

Renal colic

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6
Q

What bedside study is helpful in identifying unclear AAA?

A

Bedside abdominal US

Measures diameter only!

You really need a CTA

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7
Q

Goal SBP for ruptured AAA

A

90 SBP

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8
Q

What two layers is blood pouring between for an aortic dissection?

A

Between the intima and adventitia

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9
Q

Classic demographic of Aortic Dissection

A
  • Older male (>50y) using cocaine
  • Hx of HTN
  • CT disorders (EDS, Marfan’s, or CHD)
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10
Q

Stanford classification and Debakey of aortic dissections

A
  • Stanford is just Type A = Ascending, B = descending
  • DeBakey is type 1 = both, type 2 = ascending, type 3 = descending.
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11
Q

What kind of murmur can be heard during aortic dissection?

A

Diastolic murmur of aortic insufficiency

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12
Q

MC XR findings for aortic dissection

A
  1. Abnormal aortic contour + widening of mediastinum
  2. Tracheal deviation
  3. Displacement of aortic intimal calcifications
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13
Q

Imaging modality of choice for aortic dissection

A

CT Scan with IV contrast (altho im pretty sure its CTA)

Alternate is TEE

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14
Q

How do we manage HTN initially in aortic dissection?

A
  • Esmolol
  • Labetolol

Goals: 100-120 SBP, 60-70 HR

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15
Q

If SBP of 100-120 is not met after BB usage in aortic dissection, what can we use?

A
  • Nitroprusside
  • Nicardipine
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16
Q

In elderly patients, what hx is important besides the abdominal pain hx?

A
  • Hx of MI
  • Dysrhythmias
  • Coagulopathies
  • Vasculopathies
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17
Q

What is the most important part in the physical exam for abdominal pain?

A

Palpation

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18
Q

What combination is pretty confirmatory for peritonitis?

A
  1. Rigidity
  2. Referred tenderness
  3. Cough pain

Also use a Carnett test!

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19
Q

Who gets a pelvic exam in evaluation for abdominal pain?

A

Any post-pubertal female

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20
Q

In a patient older than 50 showing pain out of proportion to the PE, what is an important DDx to consider?

A

Mesenteric ischemia

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21
Q

Generally, what does plain XR look for in abdominal pain?

A
  • Obstruction
  • Perforation
  • Free air
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22
Q

Generally, what does US look for in abdominal pain?

A
  • Stones
  • Fluid build-up
  • AAA
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23
Q

What is the MC need for abdominal pain that needs resuscitation?

A

IV fluids (NS/LR)

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24
Q

If we accidentaly give too much morphine, how can we undo it?

A

Naloxone

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25
Generally, what is considered an "acute/surgical abdomen"?
1. Pain 2. Guarding (involuntary) 3. Rebound
26
Overall, what is the purpose of analgesics and antiemetics for abdominal pain?
Making it easier to workup/evaluate the patient | So you can get their PE findings more accurately.
27
Top 2 RFs for PUD
1. H. Pylori infection 2. NSAIDs (chronic)
28
Classic description of PUD
* **Burning** epigastric pain * **Relieved by ingestion of food/milk/anatacids** * **Recurrent pain that awakens patient up at NIGHT**
29
What change in someone with PUD suggests perforation?
Abrupt onset of severe pain
30
What epigastric pain description is most indicative of GERD?
* Radiating into chest * Belching
31
In what population is epigastric pain more suspicious and what condition?
**Elderly**; it could be an atypical MI
32
Gold standard for diagnosis of PUD
EGD showing an ulcer | Definitive diagnosis of PUD
33
What are the **alarm features for possible cancer** with upper GI bleeding?
* **Older than 55** * Unexplained Wt loss * Early satiety/anorexia * Persistent vomiting * Dysphagia * Anemia * Abd Mass * Jaundice
34
Main 3 drugs used to aid in acid decrease for PUD?
* PPIs (-prazoles) * H2RAs (-tidines) * Liquid Antacids
35
Triple therapy H. pylori eradication
1. Omeprazole 20mg BID 2. Amoxicillin 1g BID 3. Clarithomycin 500mg BID
36
Quadruple eradication therapy H. pylori
1. PPI BID 2. Metronidazole QID 3. Tetracycline QID 4. Bismuth QID
37
How long is eradication therapy for H. pylori?
14 days
38
How do you definitively diagnose PUD?
Endoscopy | Anyone with a presumptive dx or alarm features
39
Mainstay of tx for stable, uncomplicated PUD?
**PPI or H2RA** w/ liquid antacid for breakthrough.
40
2 MCC of Acute pancreatitis
* **Cholelithiasis** * Alcohol Abuse
41
What condition can result in secondary pancreatitis?
Severe hyperlipidemia
42
Classic acute pancreatitis
* Mid-epigastric pain that is **constant** * Radiates to the **back** * **Worse when supine**
43
What 3 features of the H&P make acute pancreatitis highly likely? | 2 out of 3 is very sus
1. H&P consistent with acute pancreatitis 2. **Lipase** or amylase 2-3x ULN 3. Imaging showing pancreatic inflammation
44
Preferred lab test for acute pancreatitis
Lipase
45
What CBC findings are seen in acute pancreatitis?
Leukocytosis or anemia
46
What lab findings suggest complicated pancreatitis?
* Persistent **hypocalcemia** < 7 * Hypoxia * Increasing BUN * **Metabolic acidosis**
47
Preferred imaging modality for acute pancreatitis
Abdominal CT
48
Initial tx of pancreatitis
Fluids
49
When are ABX used for pancreatitis and what are they?
Infected pseudocyst, abscess, infected fluid * Imipenem-cilastatin * Meropenem * **Cipro + metro**
50
What procedure is used for **Gallstone pancreatitis**?
ERCP + Sphincterotomy
51
4 MC biliary tract emergencies caused by gallstones
1. Biliary colic 2. Cholecystitis 3. Gallstone pancreatitis 4. Ascending cholangitis
52
Top RFs for gallstones
1. Old 2. Female 3. Obese 4. Rapid wt loss/fasting 5. Asians 6. Sickle cell disease
53
Classic description of biliary colic
* RUQ * Colicky to constant pain * N/V * Episodic * Referred pain to R shoulder or left upper back
54
If biliary colic pain persists **longer than 5 hours**, what is it probably?
Acute cholecystitis
55
Most sensitive physical test for cholecystitis
Murphy's sign
56
Which version of cholecystitis has the worst prognosis?
Acalculous cholecystitis | DM, elderly, trauma, post-sx
57
What is ascending cholangitis?
* Complete biliary obstruction * Bacterial superinfection * **Charcot triad may be present: Fever, Jaundice, RUQ Pain** | Emergency!!!
58
Elevation of what 2 labs may suggest **choledocholithiasis or ascending cholangitis**?
* Serum bilirubin * ALP (stasis)
59
Initial imaging modality for **suspected biliary colic or cholecystitis?**
**US** of the hepatobiliary tract | Can also do sonographic Murphy's ## Footnote Chole = murphy's and murphy's has a sonographic version so US is preferred imaging
60
What US finding suggests choledocholithiasis?
Bile duct diameter > 5cm
61
If US seems inconclusive for suspected cholecystitis, what is the 2nd imaging modality we should consider?
Radionuclide scan (**HIDA scan**)
62
First step in managing cholecystitis
Fluids
63
What is the empiric ABX for uncomplicated cholecystitis? | Anyone with suspected chole gets this
Cefotaxime/ceftriaxone + Metronidazole
64
What is the empiric ABX for Complicated cholecystitis or ascending cholangitis?
1. Ampicillin 2. Gentamicin 3. Clindamycin | Triple coverage ## Footnote Clint the gentle amp
65
Which chole conditions require ERCP + Sphincterotomy?
1. Choledocholithiasis 2. Gallstone pancreatitis 3. Ascending Cholangitis | Other conditions need surgery
66
When can you discharge someone with uncomplicated biliary colic?
* Symptoms abate with tx in **4-6 hrs** * PO tolerable
67
Most reliable symptom of appendicitis
Abdominal pain (Classically in the RLQ at Mcburney's)
68
Where exactly is McBurney's point?
2/3 Between Umbilicus and ASIS | More laterally
69
What 3 physical exam tests can be done to check for appendicitis?
1. Rovsing's (roving from LLQ to RLQ) 2. Psoas (Left lateral decubitus, Stretch SOAS) 3. Obturator (Flex R Hip + Knee + Internal rotation)
70
Why does appendicitis pain location vary?
Your appendix can move around (pelvic, retrocecal, etc)
71
Although a late finding, what is the most useful sign suggestive of appendicitis?
Fever | Rebound tenderness, then pain localizing to RLQ.
72
Highest sensitivity S/S for appendicitis
1. Fever 2. RLQ pain 3. Pain before vomiting 4. Absence of prior similar pain
73
What transition in pain is considered highly predictive of appendicitis?
Migration to the RLQ | Starts more diffusely
74
What is the imaging study of choice for establishing the diagnosis of appendicitis?
CT (non-con is pretty accurate) | **DO NOT USE RADIOGRAPHS** ## Footnote Thin patients might be false negative
75
In children and pregnant patient, we prefer a different imaging modality over CT for acute appendicitis. What is it?
Graded compression US
76
Which imaging modality works for **appendicitis** and is not reliant on operator skill?
MRI | No ionizing radiation, no contrast needed
77
What is the MC surgical emergency in pregnant patients?
Acute appendicitis
78
Mainstay of tx for acute appendicitis
Appendectomy
79
Empiric abx prior to appendectomy
* Pipta**Z**o (**Z**osyn) * Amp**S**ul (Una**S**yn)
80
What populations are you probably not sure of acute appendicitis in?
* Pediatric * Geriatric * Pregnant * Immunocompromised | Admit for serial exams + monitoring
81
Classic diverticulitis
* LLQ pain (Steady & deep) * Fever * Leukocytosis
82
What RFs cause diverticulitis to present in the R quadrant?
* **Redundant sigmoid** * Asian * Right-sided disease
83
How is diverticulitis diagnosed?
Clinically/Imaging | Only need imaging if fail conservative tx or unclear or SUS ## Footnote Generally, only a person with hx of diverticulitis does not need imaging if presentation is similar to previous. Any systemic S/S or inability to undergo conservative tx = CT abd pelvis w/ IV con
84
Preferred imaging modality to evaluate diverticulitis (r/o ddx)
CT w/ con (extremely high spec and sens)
85
ABX of uncomplicated diverticulitis (oral, outpatient)
* Metronidazole plus * Cipro or levofloxacin or Bactrim | Augmentin or Moxifloxacin alternate ## Footnote Cipro + Metro
86
ABX of moderate diverticulitis (**i**npatient, **I**V)
* Metro plus * Cipro or levofloxacin or aztreonam or rocephin ## Footnote Cipro + metro, just switch to IV for Inpatient
87
ABX for severe diverticulitis
* Ampicillin plus * Metronidazole plus * Cipro or amikacin/gentamicin/tobramycin ## Footnote Cipro + Metro + Amp because you need to **amplify** the regimen for severe from inpatient.
88
How soon do you f/u with GI if you're being treated for diverticulitis OP?
6 weeks if you show improvement | I think for a colonoscopy
89
Top RFs for SBO
1. Previous bowel surgery 2. Incarcerated hernias 3. Inflammatory diseases
90
Who is sigmoid volvulus MC in?
Elderly taking an anticholinergic | Think benadryl, hydroxyzine, oxybutynin
91
Who is cecal volvulvus MC in?
Gravid patient
92
Who is **Ogilvie syndrome**/intestinal pseudo-obstruction MC in?
**Bedridden elderly** on anticholinergics or TCAs | Mimics large bowel obstruction
93
What does bilious vomiting suggest?
Proximal obstruction
94
What does feculent vomiting suggest?
Distal obstruction
95
In mechanical SBO, when are high-pitched bowel sounds heard?
Early
96
How is ileus treated vs SBO?
* Ileus: Observe and hydrate * SBO: NG tube +/- surgery
97
Diagnostic imaging modality of choice in the ED for bowel obstruction
CT scan (w/ contrast when possible) | Helps differentiate partial vs complete vs ileus vs strangulated.
98
If **leukocytosis > 20k** is noted with bowel obstruction, what are we concerned about?
* Abscess * Gangrene * Peritonitis
99
What does elevated hematocrit suggest for bowel obstruction?
Dehydration
100
Initial tx for managing bowel obstruction
NG tube
101
Pre-op abx for mechanical SBO requiring surgery?
* **Zosyn** * Tircarcillin-clavulanate (discontinued in the US in 2015) * **Unasyn** * Cefotaxmine/rocephin + clinda/metro/carbapenem
102
In patients with Ogilvie/pseudo-obstruction, what is the dx and tx?
Colonoscopy
103
For an unclear bowel obstruction that is non-surgical, what is the mainstay of tx?
* NG Tube * IV fluids * Observation

EM quiz readings (43 decks)

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