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Clinical Medicine 4 > Lecture 5 (GI)-Exam 2 > Flashcards

Lecture 5 (GI)-Exam 2 Flashcards

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1
Q

Types of abdominal pain: Pain from a hollow viscera
* How is the patient like?
* What are two examples? (2)

A
  • Patient move around and cannot sit still. Can wait to go to OR.
  • Gastroenteritis
  • Kidney stones
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2
Q

Types of Abdominal Pain: Pain from peritoneal irritation
* What is the patient like? What are two examples?

A

Patient lie very still, severe guarding, rebound tenderness etc.
* Surgical abdomen
* Peritonitis

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3
Q

What are examples of surgical abdomen? (6)

A
  • Ectopic pregnancy
  • Appendicitis
  • Diverticulitis
  • Ulcers rupture
  • Ruptured spleen
  • Trauma (stab, gun shot)
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4
Q

Fill for the different radiation of abdominal pain

A
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5
Q

Classic Presentations - Acute Appendicitis
* What is the first sign?
* What are the gastroenteritis signs?
* What are the appendicitis signs?
* What can McBurney’s point be tender in?

A
  • Periumbilical pain – 1st sign.
  • GE – nausea before the abd pain.
  • Appendicitis – periumbilical pain before the nausea. Patients aren’t hungry – negative hamburger sign.
  • McBurney’s point can be tender in: Meckels, UC, Crohn’s, cecal volvulus, ovarian cysts etc.
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6
Q

Classic Presentations - Acute Appendicitis
* What are all the special tests?(5)

A

Test McBurney’s, Psoas, Rovsign, obturator sign, rectal exam with pain and tenderness on the right side.

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7
Q

Classic Presentations - Acute Cholecystitis
* What are the RFs?

A

Female, fat, forty, fertile, fair, flatulent, family Hx.

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8
Q

Classic Presentations - Acute Renal Colic
* What are the sxs?(5)

A

Typically abrupt flank pain radiating to the groin, nausea, vomiting, labor pains, hematuria (gross or micro).

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9
Q

Overview
* What are the major goals of abdominal pain? (3)

A
  • Identify life-threatening situations quickly
  • Differentiate surgical from non-surgical cases
  • Narrow diagnostic possibilities with a thorough H&P

  • Abdominal pain represents ~ 5% of all Emergency Department chief complaints
  • Diagnosis is challenging
  • Approximately 50% do not have a definitive diagnosis at time of discharge.
    *
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10
Q

What are the life threatening situations that you need to ID quickly? (5) These patients are generally what?

A

Examples:
* Aortic dissection
* Ruptured viscous/Organ injury
* Ischemic bowel
* Bowel obstruction
* Peritonitis

These patients are generally SICK and usually have abnormal vital signs or physical findings

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11
Q

Differentiate surgical from non-surgical cases among these examples:
* Cholecystitis v.s. Pancreatitis
* Appendicitis v.s. mesenteric adenitis (epiploic appendagitis)
* Bowel obstruction v.s. fecal impaction
* Ectopic pregnancy v.s. ruptured ovarian cyst

A
  • Cholecystitis (surgical) v.s. Pancreatitis (no)
  • Appendicitis (surgical) v.s. mesenteric adenitis (epiploic appendagitis-> omentum fat hanging off and causing inflammation)
  • Bowel obstruction (surgical) v.s. fecal impaction (no)
  • Ectopic pregnancy (surgical) v.s. ruptured ovarian cyst
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12
Q

Surgery is necessary for some abdominal pathology and not for others-
* What will happen if you miss a surgical pathology?

A

IF YOU MISS A SURGICAL PATHOLOGY THE PATIENT WILL USUALLY GET VERY SICK VERY QUICKLY

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13
Q

What are ways to narrow diagnostic possibilities with a thorough H&P? (4)

A
  • Have patient “SHOW YOU” where pain is-
  • Acute v.s. Chronic
  • Traumatic?
  • Associated symptoms: Vaginal discharge, dysuria, fever, diarrhea etc.

Ex: Hypotensive, belly pain and just fell off a horse-> Spleen rupture

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14
Q

Abdominal Pain Types: Explain the pain for each
* Somatic:
* Visceral (colicky):

A

Somatic
* Sharp with a more specific location

Visceral (Colicky)
* dull and/or cramping, intermittent
* poorly localized

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15
Q

Abdominal Pain Types: Explain the pain for each
* Parietal:
* Referred:

A

Parietal
* Refers to surrounding wall (typically musculoskeletal)
* Sharp, dull, achy
* Typically have point tenderness, reproduced by mechanical stimulation

Referred
* pain is distant from site of involved organ

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16
Q

What do you need to get for HPI?

A
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17
Q

Abdominal Exam:
* What do you need to look for Physical examination?
* What do you need to inspect for?

A

Physical Examination
* Appearance: Does the patient look sick?
* VITAL SIGNS

Inspection
* scars, distension, discoloration, rashes, trauma, striae, caput medusa

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18
Q

Abdominal Exam
* What do you need to ausculate for?
* Percuss for what?
* Palpate for what?

A

Auscultation
* bruits, bowel sounds +/- “tinkling”, high pitched

Percussion
* organomegaly, peritonitis, dullness

Palpation
* pain location, rebound, guarding, rigidity, masses, referred pain

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19
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the RUQ?(5)

A
  • Duodenal Ulcer (right flank)
  • Hepatitis
  • Acute Cholecystitis
  • Biliary issues/colic
  • Pneumonia/effusion

PHABD

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20
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the LUQ?(6)

A
  • Ruptured Spleen
  • Gastric Ulcer
  • Aortic aneurysm
  • Splenic thrombosis/injury
  • Perforated colon
  • Pneumonia/effusion
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21
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the RLQ? (11)

A
  • Appendicitis
  • Salpingitis
  • Ovarian Cyst/torsion
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Meckel diverticulitis
  • Backwash ileitis
  • Regional Ileus
  • Perforated cecum
  • Testicular problems
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22
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain in the LLQ? (10)

A
  • Sigmoid diverticulitis
  • Salpingitis
  • Ovarian cyst
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Perforated colon
  • Regional Ileus
  • Ulcerative colitis
  • Testicular problems
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23
Q

Some Causes of Pain Perceived in Anatomic Regions
* What can be going on with pain that is periumbilical or diffuse? (9)

A
  • Intestinal obstruction/perforation/peritonitis
  • Acute pancreatitis
  • Early appendicitis
  • Mesenteric thrombosis
  • Aortic aneurysm
  • Diverticulitis
  • Enteritis/AGE
  • Ischemia/thrombosis
  • Parietal wall problems
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24
Q
A
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25
Classic Signs * What is murphy's sign? * Suggestive of what?
Murphy’s sign * Pressure applied to RUQ during inspiration causes pain and cessation of inspiratory effort * suggestive of gallbladder inflammation
26
Classic Signs * What is kehr's sign? What is it suggestive of?
* Left shoulder pain referred from diaphragm * suggestive of free intaperitoneal blood (splenic injury)
27
Classic Signs * What the mcburney's point? What is it suggestive of?
* tenderness with palpation of abdomen 2/3 of the way between the umbilicus and right iliac crest * suggestive of appendicitis
28
What is the Psoas sign? What is it suggestive of?
* patient flexes right hip against resistance and experiences RLQ pain * suggestive of appendicitis
29
What is the obturator and rovsing's sign? What is that suggestive of?
Obturator sign * internal and external rotation of patients leg while right hip flexed causing RLQ pain * suggestive of appendicitis Rovsing’s sign * Palpation into the LLQ causes RLQ pain * suggestive of appendicitis
30
What is grey turner's sign and cullen's sign? What is the suggestive of?
Grey-Turner’s sign * ecchymosis of flanks * suggests hemorrhagic pancreatitis Cullen’s sign * ecchymosis of periumbilical area * suggests hemorrhagic pancreatitis
31
What is Lloyd's sign? What does it suggest?
Lloyd’s sign (CVA tenderness) * percussion of flank elicits pain * suggests renal inflammation *
32
Explain how to do the mc burney's point? (spider senses is telling me to know this)
33
What is this?
Grey-turner's sign * Flank ecchymosis from pancreatitis or retroperitoneal bleeding
34
What is this?
Cullen’s Sign * Periumbilical ecchymosis from intraperitoneal hemorrhage
35
Bedside Exam for Peritonitis * What can you do? What is the false positive and negatives?
Rebound Tenderness * False Positive ~ 20% of the time * False Negative ~ 15% of the time
36
Complete/cursory PE * What do you need to rule out for cardiopulmonary and pelvic?
Cardiopulmonary exam * Rule out referred pain Pelvic exam * PID, ectopic pregnancy, ovarian mass, etc.
37
Complete/Cursory Physical Examination * What do you need to rule out for genital and rectal exam?
Genital exam * testicular torsion, epididymitis, hernias, etc. Rectal exam * guaiac, masses, abscess, hemorrhoids, etc.
38
The most important diagnostic study in a FEMALE with abdominal pain is what?
PREGNANCY TEST * Any female with a uterus that is not post-menopausal gets one!!!! * Some providers refer to this as “6-60”
39
Pregnant Yes/No??? * What is this is major factor in? * Must be done when? * What can be done?
* This is a major determining factor in disposition and treatment * Must be done rapidly upon patient presentation * Urine or serum testing is equivalent in most cases
40
Common Diagnostic Studies * What is the workup for abdominal pain?(6)
* Complete Blood Count * Complete Metabolic Profile (Chem 8 and Liver enzymes) * UA (with C&S as appropriate) * **Amylase and Lipase** * Guaiac * Vaginal and Cervical specimens if indicated
41
Common Diagnostic Studies * What is some imaging that needs to be done? What are they looking for?(4)
KUB (Kidney/Ureters/Bladder) or AAS (Acute Abdominal Series-Obstruction Series) * Renal calculi, free air, obstruction/ileus, air/fluid levels Ultrasound * Pregnancy (ectopic or intrauterine), gall bladder, ovarian cyst/abscess, AAA, obstructive uropathy CT of abdomen/pelvis
42
When do you need contrast and not?(3)
WITHOUT IV: Kidney Stones, Fractures, Foreign Bodies WITH IV: Obstruction, appendix, diverticulitis-(When you want to light up the plumbing or find tissue tumors) * Need oral and IV for low BMI
43
General management principles * Treat what? * Who should you involve?
* Treat the underlying process * Involve the surgical team ASAP when you believe it’s a surgical problem
44
What you need to do when discharging a patient? (3)
* Provide complete follow up instructions * Always tell patient to come back if clinical situation worsens * Involve primary doctor, specialist consultants liberally
45
Ectopic Pregnancy * What does work up usually include? * Who should be involved early? * Clinically unstable patients need to go where?
* Work up usually includes blood tests and Ultrasound * Gyn consultants should be involved early * Clinically unstable patients go directly to surgery (skip US)
46
Tubal ligation + positive HCG =
ECTOPIC
47
Aortic Aneurysm/Dissection * What is an aneurysm? * What is a dissection?
Aneurysm is enlargement Dissection is tear * Intima is just inner lining * Complete rupture = dead
48
ANY PAIN ABOVE AND BELOW THE DIAPHRAGM OR “TEARING” IN NATURE SHOULD PROMPT what?
PROMPT SUSPICION OF AORTIC ANEURYSM OR DISSECTION
49
Dissecting AAA do not always present with what?
Dissecting AAA do not always present with palpable pulsatile masses or bruits that can be auscultated
50
Appendicitis * Cecal _ * Variable what? What does that cause?
Cecal Diverticulum or fecalith: MCC Variable Anatomical Positions * Symptoms and Signs are inconsistent * Retrocecal: side pain
51
Appendicitis: MC surgical problem * what is the risk of population during their lifetime? * Common in who? * What is not common? What ages does it have a higher risk in?
* 7 - 10% of population during their lifetime * 10 - 30 year olds (3M:2F); after 30 yo ~1M:1F * Perforation - not uncommon (up to 20% of cases) * Perforation more common < 12 yo and > 65 yo
52
Appendicitis: * What are the common causes?
* Luminal obstruction: fecalith; lymphoid hyperplasia * Mucosal edema * Infarction and tissue necrosis
53
Appendicitis * Infarction and tissue necrosis which can lead to what (3)
* Abscess formation * Perforation * Peritonitis | This is considered complicated
54
Clinical Manifestations of appendicitis * What happens with pain? * Abdominal complaints? * What about temp? * WBC?
* Periumbilical-> RLQ pain (occurs in 50 – 80%) * Anorexia->Nausea->Vomiting * Low Grade Fever * Mild Leukocytosis (10 - 17.5K)
55
Clinical Manifestations of appendicitis * What are the classic findings? * What about UA?
Classic findings (present in minority of patients) * McBurney’s Point; Rovsings sign * Obturator sign; Psoas Sign Urinalysis – usually negative (although microhematuria is typically seen)
56
Appendicitis: Management * What do you need to do for surgery? * Control what? How? * Give what? * Repeat what?
* NPO * PAIN CONTROL-> morphine or fentenyl * IV Fluids and usually antibiotics * Repeat Physical Examinations
57
Appendicitis: Management * What imaging should be done? * What consult? * What is the surgery?
* Ultrasound; CT Scan-usually WITH contrast (low bmi: oral constrast too) * Surgical consult * Appendectomy
58
What is the difference between incarcerated vs strangulated hernia?
Incarcerated * A hernia that is not able to be reduced on exam * The vascular supply of the bowel is not compromised Strangulated * Ischemia and necrosis of the hernia and bowel
59
What is the groin hernia anatomy? (ex hesselbach's triangle)
* Medial border: Lateral edge of the rectus abdominis muscle (also known as the linea semilunaris). * Lateral border: Inferior epigastric vessels (artery and vein). * Inferior border: Inguinal ligament (Poupart’s ligament).
60
Hernia: * What is a Pantaloon/Sadlebag hernia? * What is a hiatal hernia? * What is a incisional/ventral hernia?
* Pantaloon/Sadlebag hernia: double hernia (direct + indirect) mc following a laprascopic procedure * Hiatal – protrusion of the stomach through the diaphragm * Incisional/Ventral – seen more commonly with vertical incisions
61
Inguinal * What is indirect hernia? * What is direct hernia? * What is femoral hernia?
* Indirect (most common) – passes through the internal inguinal ring down the inguinal canal and may pass into the scrotum * Direct – passes through the external inguinal ring at Hesselbach’s triangle, rarely enters the scrotum. * Femoral – passes through the femoral ring (least common & occur almost exclusively in females)
62
What is an umbilical hernia? What is the age cutoff for observation vs surgical repair?
Umbilical – generally congenital and appears at birth * 5 year old
63
1. Air fluid levels: NG tube suction, pain control, CAT scan, gen surgery consult, NPO, abx (bowel obstruction) 2. Sigmoid volvus (older, psych pt, emergency): labs, fluids, abx, gen surg consult 3. Emergency: Fluids, abx, labs, gen surg consult, type and screen

Clinical Medicine 4 (13 decks)

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