Exam 2 PD Objectives

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Revision as of 23:26, 5 March 2012 by 134.68.138.157 (Talk)

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:
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