Exam 2 PD Objectives

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(→Chapter 3 (Lange): Abdominal pain)
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==Chapter 3 (Lange): Abdominal pain==
==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
 
 +
===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
-
*Define the descriptors of pain and how they relate to the underlying diagnosis.
+
http://www.ashwini.org/asknk/images/subjects/Abdominalpain.jpg
-
**Location, character, and acuity are three important descriptors of pain.
+
http://learnpediatrics.com/files/2011/02/abdo.jpg
-
**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:
+
===Define the descriptors of pain and how they relate to the underlying diagnosis.===
-
*Appendicitis:
+
*Location, character, and acuity are three important descriptors of pain.
-
**Symptoms:
+
*The location of pain can help narrow the differential (see the above division of diagnoses via quadrant of the abdomen).
-
***diffuse pain that migrates to (focuses into) the RLQ (McBurney's point)
+
*The character and acuity help prioritize within the ddx.
-
***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
+
===Know the key factors in the history and on physical examination and initial diagnostic evaluation that accompany each of the following diagnoses===
-
**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
+
 +
====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
-
*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 and Acute mesenteric ischemia
+
====Biliary Colic====
-
**Symptoms:
+
*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
-
**Signs:
 
-
**Diagnostics:
 
-
**Tx:
 
-
*Acute pancreatitis
+
====Irritable bowel syndrome====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
**intermittent abdominal pain with d/c (diarrhea / constipation) for ''years''
-
**Diagnostics:
+
**diarrhea with cramping, alleviated by defecation
-
**Tx:
+
**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
-
*Ischemic colitis
+
====Chronic and Acute mesenteric ischemia====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Choledocholithiasis
+
====Acute pancreatitis====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Ascending cholangitis
+
====Ischemic colitis====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Acute cholecystitis
+
====Choledocholithiasis====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Small and large bowel obstruction
+
====Ascending cholangitis====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Nephrolithiasis
+
====Acute cholecystitis====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Abdominal Aortic aneurysm
+
====Small and large bowel obstruction====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*Diverticulitis
+
====Nephrolithiasis====
-
**Symptoms:
+
*Symptoms:
-
**Signs:
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
-
*PID:
+
====Abdominal Aortic aneurysm====
-
**Symptoms: history of PID, vaginal discharge,  
+
*Symptoms:
-
**Signs: cervical motion tenderness on pelvic exam
+
*Signs:
-
**Diagnostics:
+
*Diagnostics:
-
**Tx:
+
*Tx:
 +
 
 +
====Diverticulitis====
 +
*Symptoms:
 +
*Signs:
 +
*Diagnostics:
 +
*Tx:
 +
 
 +
====PID====
 +
*Symptoms: history of PID, vaginal discharge,  
 +
*Signs: cervical motion tenderness on pelvic exam
 +
*Diagnostics:
 +
*Tx:

Revision as of 12:34, 6 March 2012

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


Contents

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

Abdominalpain.jpg 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 and Acute mesenteric ischemia

  • Symptoms:
  • Signs:
  • Diagnostics:
  • Tx:

Acute pancreatitis

  • Symptoms:
  • Signs:
  • Diagnostics:
  • Tx:

Ischemic colitis

  • Symptoms:
  • Signs:
  • Diagnostics:
  • Tx:

Choledocholithiasis

  • Symptoms:
  • Signs:
  • Diagnostics:
  • Tx:

Ascending cholangitis

  • Symptoms:
  • Signs:
  • Diagnostics:
  • Tx:

Acute cholecystitis

  • Symptoms:
  • Signs:
  • Diagnostics:
  • Tx:

Small and large bowel obstruction

  • Symptoms:
  • Signs:
  • Diagnostics:
  • 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:
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