Exam 2 PD Objectives

From Iusmicm

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.

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

• 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: