E Med

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leaman7155
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8533
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E Med
Updated:
2010-02-28 21:50:26
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E Med
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Acute Abdominal Pain
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  1. What is Visceral Pain?
    • Deep, dull, aching pain
    • poorly localized
    • epigatric or periumbilical
  2. What is somatic pain?
    • sensation conducted via peripheral nerves
    • sharp, more intense pain
    • moving or coughing aggravates
  3. What is referred pain?
    Pain felt at a distance from its source
  4. What vital signs are indications of shock?
    • Tachycardia
    • hypotension
    • tachypnea
  5. What ancillary tests should be ordered for acute abdominal pain?
    • UA and HCG(males testicular CA)
    • CBC
    • LFT - no amylase
    • Plain films
    • Helical CT
    • Ultrasound
  6. What is Cholelithiasis?
    stone which can be found in the hepatic bile canliculi, intra/extrahepatic bile ducts, CBD, and gallbladder
  7. What is Bile needed for?
    • absorption of fats and fat soluble nutrients
    • It is produced in the canaliculi
  8. Things causing enhanced risk of cholesterol stone formation
    increased age, female gender, massive obesity, rapid weight loss, cystic fibrosis, parity, drugs, familial tendancies
  9. Explain BLACK gallstones
    • form in the GB
    • more common in elderly
    • made up of calcium
    • associated with disease causing intravascular hemolysis
  10. Explain BROWN stones
    • associated with infection
    • form in intra/extrahepatic bile duct
    • contains Ca+
    • can be seen on Xray
  11. Clinical features of Cholecystitis
    • RUQ pain - referred to right scapula
    • N/V
    • Prior history of something similar but less severe
  12. Physical findings of Cholecystitis
    • Increased Temp
    • tachycardia
    • RUQ tenderness/epigastric
    • guarding/rebound tenderness
    • + Murphys Sign
  13. Diagnostic stuff for Cholecystitis
    • Increased WBC
    • LFTs CAN BE elevated (but not always)
    • ULTRASOUND * Most usefull
    • HIDA scan - most specific
  14. Aclculous cholecystitis
    • Inflammation of the gallbladder without the prescence of stones
    • usually elderly
    • complication of HIV with infection from CMV
    • usually high mortality rate
  15. What is a porcelain gallbladder?
    • Linear/punctuate calcifications within the GB wall
    • found in females in their 50s
    • high carcinoma rate - most common malignancy
  16. What is the courvosier sign?
    palpable gallbladder
  17. Acute Pancreatitis - some facts
    • Divided in severity based on organ failue or local complications
    • Gallstones are most common obstructive cause - 45%
    • Chronic ETOH abuse is 2nd common cause
    • More common in men, after heavy drinking
  18. Clinical features of pancreatitis
    • epigastric, LUQ, RUQ pain
    • rapid onset - minutes
    • Pain is constant and severe
    • Pain radiates to mid back
    • N/V
    • Little relief with position change
  19. Physical exam findings for pancreatitis
    • Moderate distress
    • rales - pleural effusion possible
    • jaundice
    • Cullens or Turners sign
  20. Lab tests for Pancreatitis
    • Amylase 70% specific but 100% specific if 3-5x normal
    • Lipase 60% specific but 100% specific if 5x normal
    • Xray - exclude other things, may show effusions or atelectasis
    • CT/US - oral contrast
  21. Symptoms of Appendicitis
    • vague, epigastric pain
    • RLQ at McBurneys point
    • Pain before vomitting
    • no history
    • Pt. feels constipated
  22. Rebound Tenderness
    • sign for appendicitis
    • Push in at point of pain, pull away after 30 seconds
    • Pt. should be in pain
  23. Rovsings Sign
    • push deeply in LLQ
    • pull away, pain should be felt in RLQ
  24. Psoas sign, Obturator sign
    • Test for appendicitis
    • Psoas-patient supine, pull leg up upon resistance
    • Obturator - flexing knee and internal rotate
    • *Both cause psoas muscle to rub inflamed appendix
  25. Inflammatory Markers for appendicitis
    • WBC count
    • C-Reative Protein
    • Interleukin - 6
  26. Imagine for Appendicitis
    • Abdominal plain films
    • Barium enema
    • Ultrasound
    • CT scan
    • MRI
    • Laproscopy
  27. Advantages of US
    • no radiation, or contrast
    • low cost
    • widely available
    • may find other diagnosis
  28. Disadvantages of US
    • Confounding findings
    • Nonvisualization of perforated appendix
    • limited view in obese patients
    • operator-dependent
  29. Advantages of CT
    • Finds alternative diagnoses
    • not-operator dependent
    • useful in obese patients
    • widely available
  30. Disadvantages of CT
    • Radiation, contrast
    • increased cost
    • potential false negatives
  31. Etiology of diverticulitis
    fecal matter sequestered in a sac and becomes hard forming a fecolith which compromises the blood supply
  32. Symptoms of Diverticulitis
    • depends on amount of decontamination resulting from perforation
    • LLQ
    • low grade fever, change in bowel habits
    • malaise
    • Urinary sx - secondary
  33. Exam findings of diverticulitis
    • LLQ tenderness
    • Distention is common
    • Rectal bleeding may be seen - more common diverticulosis
  34. What is the test of choice for Diverticulitis, and what test is used after diagnosis?
    • CT scan* test of choice
    • Barium enema-excludes other colonic pathology and check for complications
  35. What will labs show in diverticulitis?
    Elevated WBC with bands
  36. Managagement of diverticulitis
    • Most resolve with meds
    • Tx of peritonitis, perforation or gas in bowel wall = surgery
    • abseccess larger then 5cm = surgery
  37. What is a simple SBO?
    lumen is partially or completely occluded at one or more points, producing distention but no compromise of the blood supply
  38. What is a Closed Loop SBO?
    • bowel obstructed at two sequential sites, usually twisted on an adhesion or hernia opening
    • high change of compromising blood flow - strangulation obstruction
  39. Most common causes for SBO
    • ADHESIONS #1
    • inflammatory, neoplasm, trauma
    • foreign body, gallstones, barium
  40. What are clinical features of SBO?
    • Crampy pain
    • recurrent bouts of poorly localized pain
  41. Explain proximal SBO
    • several hours of severe colicky pain
    • vomitting
    • mild distention
  42. Explain distal SBO
    • A day or two of progressively worsening pain
    • more prominent abdominal distention
  43. What are the 6 clinical indications for high sensitivity of a SBO?
    • Age >50
    • Previous surgery
    • Abdominal distention
    • Increased Bowel sounds
    • History of Constipation
    • Vomitting
  44. What is the worst things that can happen in relation to SBO?
    • Peritoneal signs - pain with cough, shaking or moving
    • Tachycardia
    • Hypotension
    • fever
  45. Diagnostic tests for SBO
    • Plain films - supine and upright
    • CT - high accuracy
  46. Causes of LBO
    • Usually elderly
    • Carcinoma
    • diverticulitis
    • volvulus

    LBO is less common then SBO
  47. Clinical features of LBO
    • high pitched bowel sounds
    • fever
    • abdominal tenderness
    • possibly peritonitis
  48. Diagnostic tests for LBO
    • Plain films - supine and upright - see dilated bowel
    • CT - less helpful in LBO
  49. AAA epidemiology
    • Most below renal arteries
    • Most ruptured AAA's have diametes of >5cm
    • Most of true aneurysms - involve all three layers
    • Men > Women
  50. Sx of Unruptured AAA
    • pain in abdomen, back, or flank
    • abdominal mass or fullness
    • vague dull, quality, gradual onset of pain
    • Most Pt. are Asymptomatic
  51. Clinical features of RUPTURE AAA
    • Pain, Hypotension, Mass
    • pain in abdomen, back, flank
  52. Diagnostic tools for AAA
    • plain films, will be seen if large enough
    • Cross-table lateral of lumber spine
    • *Ultrasound - 100% sensitive
    • *CT-100% acurate for diagnosis for stable pt. only
    • Pt. with ruptured AAA need to be cross clamped before stable

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