Exam 2 PD Objectives

From Iusmicm

Current revision as of 01:45, 7 March 2012

• Exam 2 covers 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,

[edit] Chapter 3 (Lange): Abdominal pain

[edit] 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

[edit] 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.

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

[edit] 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

[edit] 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

[edit] 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::female:male
  • etiology a combination of motility, visceral hypersensitivity, autonomic function, and psychological factors

[edit] 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

[edit] 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).

[edit] 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)

[edit] 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

[edit] 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

[edit] 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

[edit] 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)

[edit] 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

[edit] 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
  • Exam 2 PD Objectives#Acute_mesenteric_ischemia must rule out ischemia / infarction
• Tx:
  • fluid resuscitation, monitor urine output
    • vomiting + decreased oral intake + third spacing of fluid in gut = bad dehydration
  • NG suction (after the CT scan)
  • broad spectrum antibiotics
  • frequent plain films
  • frequent CBC
  • sx: signs of ischemia, CT showing infarct, SBO 2-2 hernia, SBO NOT 2-2 adhesions

[edit] Abdominal Aortic aneurysm

• Symptoms:
  • male, hx of HTN
  • Triad: severe abdominal pain, pulsatile abdominal mass, hypotension
• Signs:
  • PE sucks at detecting AAA
  • Bruits do not confirm the dx
  • palpable mass is unusual in pt with ruptured AAA
• Diagnostics:
  • US: bedside, emergent; sens: 96-100%, spec: 98-100%; also used for routine screening
  • CT: w/ or w/o angiography or aortography for pre-op evaluation
• Tx:
  • ruptured: do not pass Go, do not collect $200, go directly to ER.
  • asymptomatic:
    • screen men age 65-76 w/ one time US
    • repair when aneurysm >= 5.5 cm or is tender or increased by >1 cm in >= 1y
    • screen AAA 4.0-5.4 cm every 6 mo
  • Sx options:
    • open versus endovascular stent
    • 30 d mortality lower with stent but may require reintervention
  • Medical management: stop smoking, statins, blood pressure control

[edit] Nephrolithiasis

• Symptoms:
  • rapid onset, excrutiating back and flank pain that radiates to the abdomen or groin
  • intensity of pain is dramatic leading to writhing and moving about to find a comfortable position (which is not to be found)
• Signs:
  • n/v, dysuria
• Diagnostics:
  • Hematuria (80%)
  • Urinalysis and culture
  • Serum chemistries: including multiple measurements of Ca
    • Pts with recurrent stones should have a more extensive 24h urine analysis including calcium, oxalate, uric acid, sodium, creatinine, and citrate; additionally, the stones themselves should be submitted for analysis.
  • xray (kidneys, ureters, bladder = KUB): not sufficient to r/o nephrolithiasis (rule out)
  • US: not sufficient to r/o nephrolithiasis
  • Noncontrast helical renal CT: gold standard, sens: 95%, spec: 98%
• Tx:
  • Pain control: NSAIDs (diminish spasms, avoid 3 days before lithotripsy), opioids
  • Hydration
  • Sepsis: broad spectrum IV abx for gram negative and eneteroccocus
  • Renal failure: if present, get the stone out ASAP via percutaneous nephrostomy tube or ureteral stent
  • Stone passage: nifedipine and tamsulosin help passage, lithotripsy and ureterosocpy can manually remove stones.
    • Collect the stone for analysis
  • Prevention: increase fluids, moderate Na and protein intake, thiazides (decrease Ca excretion), allopurinol (for nephrolithiasis concomitant with hyperuricosuria)

[edit] Diverticulitis

• Symptoms:
  • constant, gradually increasing, LLQ pain, present for days.
  • diarrhea
  • guarding or rebound may be seen
• Signs:
  • Fever (insensitive)
• Diagnostics:
  • Leukocytosis (insensitive)
  • xray: may demonstrate free air or obstruction
  • CT is the test of choice: sens: 93-97%
    • may demonstrate diverticula, thickened bowel wall, pericolonic fat stranding, or abscess formation
  • Acute colonsocopy not advised due to potential for perforation.
• Tx:
  • Mild attacks = Outpt medicine:
    • for mild attacks (no fever, no leukocytoiss, mild pain, oral intake +)
    • ciprofloxacin, metronidazole (7-10 d)
    • liquid diet
    • high-fiber diet (after attack ends)
    • follow-up colonoscopy
  • Mod-Severe attacks:
    • broad spectrum IV antibiotics
    • NPO
    • CT guided drainage of any abscesses
    • Emergent sx if: peritonitis, uncontrolled sepsis, clinical deterioration, obstruction / abscess that cannot be aspirated
    • Maintain a low threshold for sx in immune compromised pts
    • Post attack, high fiber diet
    • Follow up colonoscopy

[edit] PID

• PID represents a spectrum of clinical disease, from endometritis to fatal intraabdominal sepsis.
• Symptoms:
  • bilateral abdominal pain, worse with coitus or with jarring movements, onset after menses
  • abnormal uterine bleeding
  • new vaginal discharge, urethritis, proctitis (insensitive)
  • fever, chills (insensitive)
• Signs:
  • Cervical motion tenderness on pelvic exam
• Diagnostics:
  • There are multiple gold standards in use to establish the diagnosis, because no one among them is adequate alone.
  • CBC: for inflammatory signs
  • Microscopy, culture, and gram stain: cervical / vaginal secretions
  • Pregnancy test
  • HIV test
  • Urinalysis
  • Occult stool test
  • amplification tests for chlamydia and gonococcus
  • US: thickened, fluid-filled oviducts, increased cul-de-sac fluid (insensitive, nonspecific)
• Tx:
  • Antimicrobials: beta-lactams, fluorquinolones, aminoglycoside, lincosamide, and macrolides.
  • Doxycycline for C. trachomatis and clindamycin + gentamicin for N. gonorrhoeae and C. trach
  • Fluoroquinolones are no longer recommended in US for gonorrhea b/c of increasing resistance.