Exam 2 PD Objectives
From Iusmicm
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**CBT (cognitive behavioral therapy): as effective as pharma | **CBT (cognitive behavioral therapy): as effective as pharma | ||
*Miscellaneous: | *Miscellaneous: | ||
- | **2:1: | + | **2:1::female:male |
**etiology a combination of motility, visceral hypersensitivity, autonomic function, and psychological factors | **etiology a combination of motility, visceral hypersensitivity, autonomic function, and psychological factors | ||
- | |||
====Chronic mesenteric ischemia==== | ====Chronic mesenteric ischemia==== |
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
- emergent revascularization, surgical resection of necrotic bowel
- 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)
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 |
[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
- elevated lipase (sens: 94%, spec: 96%); really high suggests pancreatitis 2-2 (secondary to) gallstones
- 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
- fluid resuscitation, monitor urine output
[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
- Mild attacks = Outpt medicine:
[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.