Editing Exam 2 PD Objectives

*PD covers the following chapters:
**SWARTZ Textbook, Chapter 21 – Neurological Exam, pages 641-695, 
**SWARTZ Textbook, Chapter 13 – Pulmonary/The Chest, pages 362-390,
**LANGE Textbook, Chapter 18 – Headache, pages 287-304, 
**LANGE Textbook, Chapter 14 – Dyspnea, pages 229-247.
**SWARTZ Textbook, Chapter 17 – Abdominal, pages 477-514, 
**LANGE Textbook, Chapter 3 – Abdominal Pain, pages 26-48, 


==Chapter 3 (Lange): Abdominal pain==

===List the differential diagnosis of abdominal pain according to location in the abdomen===
*Right upper: renal colic, diverticulitis, biliary disease, hepatitis
*Right lower: appendicitis, PID (pelvic inflammatory disease), ovarian disease, ruptured extopic pregnancy
*Middle upper: MI, PUD (peptic ulcer disease), pancreatitis, biliary disease
*Middle lower: IBD (irritable bowel disease), bowel obstruction / ischemia, appendicitis, AAA, IBS, DKA (diabetic ketoacidosis), gastroenteritis
*Left upper: renal colic, splenic injury, diverticulitis
*Left lower: PID, ovarian disease, ruptured ectopic pregnancy

http://www.ashwini.org/asknk/images/subjects/Abdominalpain.jpg
http://learnpediatrics.com/files/2011/02/abdo.jpg


===Define the descriptors of pain and how they relate to the underlying diagnosis.===
*Location, character, and acuity are three important descriptors of pain.
*The location of pain can help narrow the differential (see the above division of diagnoses via quadrant of the abdomen).
*The character and acuity help prioritize within the ddx.


===Know the key factors in the history and on physical examination and initial diagnostic evaluation that accompany each of the following diagnoses===

====Appendicitis====
*Symptoms:
**diffuse pain that migrates to (focuses into) the RLQ (McBurney's point)
**octogenarians less likely to report diffuse->RLQ pain, symptoms persist longer
*Signs:
**PE: guarding, rebound
*Diagnostics:
**CBC: elevated white count: WBC > 7000/mcl (high sensitivity, low specificity); WBC > 17000/mcl (low sensitivity, high specificity)
**Urinalysis: can be confusing, may show pyuria or hematuria (from infection adjacent to bladder)
**Xray: to identify SBO
**CT: confirms dx; CT > US; '''results in lower overall costs'''
**US: use to confirm dx in pregos
*Tx:
**Observe
**Monitor urinary output and vitals
**IV fluids
**Broad antibiotics
**Urgent appy


====Biliary Colic====
*Symptoms:
**discrete episodes of pain (intense, RUQ / MUQ, radiating to back / r. scapula / r. flank / chest) that last > 30 min (< 4 hours) and begin 1 hour after eating
**pain associated with n/v
*Signs:
*Diagnostics:
**Liver function tests, lipase, and urinalysis are ''normal'' in uncomplicated cases.
**US: (sens: 89%, spec:97%); US > CT (opposite as with appendicitis)
**ETUS (endotracheal ulstrasound): 100% sensitive, use when transabdominal US is negative but biliary colic is suspected
*Tx:
**Cholecystecomy
**Lithotripsy is not advised
**Dissolution therapies (like ursodiol) are reserved for surgical non-candidates


====Irritable bowel syndrome====
*Symptoms:
**intermittent abdominal pain with d/c (diarrhea / constipation) for ''years''
**diarrhea with cramping, alleviated by defecation
**weight loss or anemia should '''point away from IBS'''
**''new'', ''persistent'' bowel habits should not be assumed to be IBS but should be evaluated for colon cancer and IBD.
*Signs:
**IBS dx requires the lack of a alarming signs: fecal occult blood, anemia, weight loss > 10 lbs, fever, persistent diarrhea causing dehydration, severe constipation / fecal impaction, family hx of colon cancer, onset of symptoms at > 50yo, major changes in symptoms, nocturnal symptoms, recent antibiotic use
**Rome criteria for IBS: recurrent abdominal pain or discomfort (of > 6 months duration) at least 3 days per month for the past 3 months, associated with two or more of the following:
***Improvement with defecation
***Onset associated with change in frequency of stool
***Onset associated with change in form (appearance) of stool
*Diagnostics:
**Note: No known structural or biochemical markers
**CBC
**Test for occult fecal blood
**Serology for celiac sprue for pts with diarrhea as primary symptom
**Routine chemistries
**For pts with alarm symptoms: Colonoscopy with biopsy, TSH levels, basic chemistries, stool culture for C. diff
*Tx:
**reduce offending dietary entities
**pharma: anticholinergics, nitrates, low does tri-cyclic antidepressants, smooth muscle relaxants
**CBT (cognitive behavioral therapy): as effective as pharma
*Miscellaneous:
**2:1::male:female
**etiology a combination of motility, visceral hypersensitivity, autonomic function, and psychological factors

====Chronic mesenteric ischemia====
*Symptoms:
**recurrent, postprandial pain (0-120 min), ''food fear'', and '''weight loss'''
**often a hx of tobacco use, peripheral vascular disease, or CAD
*Signs:
**Weight loss
*Diagnostics:
**documented stenosis ''does not'' confirm the diagnosis, 
**'''duplex ultrasonography''' (sens >90%) is first choice tool
**CT and angiogram can also be used given difficult ultrasound results
*Tx:
**revascularization: aanglioplasty with stent

====Acute mesenteric ischemia====
*Symptoms:
**abrupt onset, severe pain
**n/v (56%/38%), diarrhea
*Signs:
**'''pain out of proportion to physical exam'''
*Diagnostics:
**elevated lactate level, specific > sensitive (3.3 mmol/L, norml: <2.0)
**xray: may show thickened loops
**CT is insensitive (64%)
**'''direct angiography''' is the gold standard
*Tx:
**emergent revascularization, surgical resection of necrotic bowel
***less than 12 hours of onset is the goal
**broad-spectrum abx
**volume resuscitation
**preop and postop anticoag


*NOMI: non-occlusive mesenteric infarct
**Tx: improve perfusion via '''intra-arterial papaverine''' (a drug dropped directly into the arteries).

====Ischemic colitis====
*Symptoms:
**left sided abdominal pain (sens: 84%); 
**bloody / maroon stools (spec: 90%, sens: 46%),
**diarrhea (sens: 40%)
**''profuse bleeding is abnormal for ischemic colitis''
**''rebound tenderness is abnormal'' (sens: 15%)
**risk factors: age > 60, hemodialysis, HTN, diabetes, hypoalbuminemia
*Signs:
*Diagnostics:
**'''Colonoscopy'''
**xray: demonstrates free air, perforation
**CT
**angiography is usually normal (except in the rare case of right-sided ischemic colitis)
*Tx:
**'''support with bowel rest, IV hydration, and broad-spectrum antibiotics'''
**segmental resection for the few with infarction
**sx if: peritonitis, sepsis, free air on xray, strictures, clinical deterioration (fever, leukocytosis, lactic acidosis)


{|border="1"
!Parameter
!Ischemic Colitis
!Acute Mesenteric Ischmia
|-
!Etiology
|non-occlusive
|occlusion of SMA or celiac
|-
!precipitating event
|not usually identified
|MI, afib, etc.
|-
!Patient Gestalt
|non-ill
|ill
|-
!Pain severity
|mild
|severe
|-
!Tenderness
|mild-moderate
|not present early on
|-
!Hematochezia
|common
|uncommon until very late
|-
!Dx of choice
|colonoscopy
|angiography
|}



====Choledocholithiasis====
*Symptoms:
**RUQ pain, fever, jaundice
**cholangitis, 
*Signs:
*Diagnostics:
**Elevated alkphos
**Elevated bilirubin
**Elevated amylase
**US: dilated CBD (''not sensitive'' as it is with cholelithiasis)
**'''ERCP (endoscopic retrograde cholangiopancreatography), MRCP (magnetic resonance cholangiopancreatography), EUS (endoscopic ultrasound)''': gold standards with sens and spec 90-100%
***ERCP is best choice b/c it can also act as tx
***MRCP is non-invasive (unlike ERCP which requires sedation and contrast)
***EUS can be converted to an ERCP upon dx
*Tx:
**'''broad spectrum abx via IV'''
**decompression of the biliary system via '''ERCP'''
**cholecystectomy

====Ascending cholangitis====
*Symptoms:
**'''Charcot triad''': jaundice, elevated temp (>= 38.0C), RUQ pain
*Signs:
*Diagnostics:
**Leukocytosis
**Elevated alkphos (sens: 91%)
**Elevated bilirubin (sens: 87%)
**Bacteremia (sens: 74%)
*Tx:
**'''broad spectrum abx via IV'''
**cholecystectomy

====Acute cholecystitis====
*Symptoms:
**'''''persistent'' RUQ / epigastric pain''', fever, n/v
*Signs: (''no sign is sensitive enough to rule out cholecystitis'')
**fever (35%)
**Murphy sign (sens: 65%, spec: 87%)
*Diagnostics:
**Leukocytosis (sens: 63%)
**''does not usually alter lipase or LFTs''
**US: gallbladder wall thickening, pericholecystic fluid, gallbladder enlargement (sens: 88%, spec: 80%)
***'''US = gold standard''': less expensive, faster, avoids radx, can image adjacent organs
**HIDA scan (cholescintigraphy): absence of dye collection in gallbladder suggests obstruction
***Used when US is equivocal.
*Tx:
**'''admit'''
**parenteral antibiotics
**cholecystectom

====Acute pancreatitis====
*Symptoms:
**''constant and boring'', mod-severe pain, beginning epigastrically and radiating to the back
**n/v (75%)
*Signs:
**low grade fever, abdominal distension
**pain exacerbated in sitting position (50%), guarding (50%)
**''rare: rebound, periumbilical brusing (Cullen), flank brusing (Turner)''
*Diagnostics:
**elevated lipase (sens: 94%, spec: 96%); really high suggests pancreatitis 2-2 (secondary to) gallstones
***amylase is less sens, less spec, and returns to normal earlier so ''should not be ordered routinely''
**LFTs (bilirubin, alk phos, ALT, AST): elevated when pancreatitis is 2-2 obstruction of CBD (common bile duct)
**xray: rule out free air or SBO (small bowel obstruction)
**US: demonstrates pancreatitis and can also show complicating cholelithiasis
**CT: can be used if US is not clear but ''is not good at determining if gallstones are involved'' (see ERCP)
***Requires contrast which is bad for the kidneys
**ERCP / MRCP: use when US doesn't clearly determine if gallstones are involved
**FNA (fine needle aspiration) if infection is suspected
**Cultures of aspirate
*Tx:
**carefully monitor vitals
**IV fluids
**NPO (none per oral)
**parenteral pain medication
**NG tube (if recurrent vomiting)
**''prophylactic antibiotics'' for pts with pancreatic necrosis (controversal)
**ERCP and sphincterotomy
**Cholecystectomy
**alcohol abstinence
**enteral feeding via NJ tube (for complicated pts)

====Large bowel obstruction====
*Symptoms:
**severe, '''crampy''', incapacitating pain that initially '''comes in waves''' and eventually becomes constant
**vomiting is common (75%)
**bowel movements initially occur but eventually cease, to the point that even gas isn't passed
*Signs:
**'''bowel distension'''
**'''bowel sounds''' proceed from hyperactive to '''absent'''
**peritoneal signs may develop upon infection
*Diagnostics:
**CBC, electrolytes: '''Leukocytosis, left shift, or anion gap acidosis''' are ''late findings'' that '''suggest bowel infarction 2-2 obstruction'''
**xray: demonstrates air-fluid levels and distension
**barium enema / colonoscopy: ''highly sensitive and specific'', can be tx, too, for pseudoobstructions
**CT: used if colonoscopy is unclear
*Tx:
**aggressive rehydration, urine output monitoring
**broad spectrum abx
**sx

====Small bowel obstruction====
*Symptoms:
**same as LBO, except '''more pts have a hx of surgery'''
*Signs:
**same as LBO
*Diagnostics:
**same as LBO, plus...
**xray: shows >= 2 fluid air levels, unlikely to show the actual obstruction
**US: may be useful in pregos
**'''CT: gold standard''', used more than in LBO b/c SB is not accessible by colonoscopy
**'''must rule out ischemia / infarction'''
*Tx:

====Nephrolithiasis====
*Symptoms:
*Signs:
*Diagnostics:
*Tx:

====Abdominal Aortic aneurysm====
*Symptoms:
*Signs:
*Diagnostics:
*Tx:

====Diverticulitis====
*Symptoms:
*Signs:
*Diagnostics:
*Tx:

====PID====
*Symptoms: history of PID, vaginal discharge, 
*Signs: cervical motion tenderness on pelvic exam
*Diagnostics:
*Tx: