Exam 2 PD Objectives

From Iusmicm

Revision as of 14:41, 6 March 2012 by 134.68.138.157 (Talk)
  • PD 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,


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 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

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).

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


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

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

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

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)

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

Small bowel obstruction

  • Symptoms:
    • same as LBO, except more pts have a hx of surgery
  • Signs:
    • same as LBO
  • Diagnostics:
  • 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

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

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)

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

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.
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