incorrect cards (0)
correct cards (0)
remaining cards (0)
retry
restart
shuffle
help
0:01
Embed Code - If you would like this activity on your web page, copy the script below and paste it into your web page.
Normal Size Small Size show me how
Normal Size Small Size show me how
SURGERY
Acute Abdomen
| Question | Answer |
|---|---|
| What is an acute abdomen? | acute abdomen refers to a sudden, severe abdominal pain that is less than 24 hours in duration in previously well pts |
| Most common causes of acute abdomen (13) | AABCDE, GIM NPPP: Abscess (tubo-ovarian), Append, Bowel Obst, Bil colic, Cholecys, Divert (inc Meckel's), Ectopic preg, Gastroent, IBD, Mes ischemia, Nephrolith/Uterolith, Ov torsion, rupture/cyst, Pancr, Peritonitis, Perf (gastr/duod ulcer), Salpingitis |
| DDx for RUQ pain (17) | Abscess (subphrenic/perinephric most common), Cholangitis, Cholecystitis, Choledocholithiasis, Congestive Hepatopathy, Diverticulitis, Hepatitis, Herpes Zoster, IBD, Muscular strain, Neoplasm, Nephrolithiasis, PUD, PNA, Pneumothorax, PE, Pyelonephritis |
| DDx for RLQ pain (12) | Abscess (subphrenic/perinephric most common), Cholangitis, Cholecystitis, Choledocholithiasis, Congestive Hepatopathy, Diverticulitis, Hepatitis, Herpes Zoster, IBD, Muscular strain, Neoplasm, Nephrolithiasis, PUD, PNA, Pneumothorax, PE, Pyelonephritis |
| DDx for LLQ pain (10) | Abscess, Diverticulitis, Ectopic pregnancy, Gastroenteritis, Hernia, IBD, Neoplasm, Ovarian torsion/cyst, PID, Pyelonephritis |
| DDx for LUQ pain (10) | Abscess (subphrenic/perinephric most common), Neoplasm (pancreatic, splenic, renal), Nephrolithiasis, Pancreatitis, PUD, PNA, Pneumothorax, PE, Pyelonephritis, Splenic infarct/rupture |
| What should you expect on physical exam of pt with acute abdomen? | 1. peritoneal signs (irritation/pain with even slight jarring), 2. lie very still (to keep from irritation peritoneum), 3. Ask them to point to pain with one finger (helps in ddx) |
| Pain from stomach refers to where? | epigastric region/substernal |
| Pain from pancreas refers to where? | epigastric region |
| Pain from small intestine refers to where? | periumbilical |
| Pain from colon refers to where? | lower abdomen/suprapubic |
| Pain from gallbladder felt where? | RUQ |
| Characterization of pain - things you want to ask about when investigating acute abdomen | CLaSP: character, location, severity, pattern |
| Temporal sequence of pain - things you want to ask about when investigating acute abdomen | onset, frequency, progression, duration (ProDuFreOn) |
| alleviating/exacerbating factors - things you want to ask about when investigating acute abdomen | position, food, activity, medications |
| associated signs/symptoms - things you want to ask about when investigating acute abdomen | nausea vomiting, fever, chills, anorexia, wt. loss, cough, dysphagia, dysuria/frequency altered bowel function (diarrhea, constipation, obstipation, hematochezia, melena |
| PMH | prior surgery or illness, associated conditions (pregnancy, menstrual cycle, diabetes, atrial fibrillation or cardiovascular disease, immunosuppression) |
| Meds | anticoagulation, steroids |
| Visceral Pain: characterize, location, types of nerve fibers, nerve system, describe pt | diffuse, ill-defined, usually colicky; typically midline, frequently referred; carried on visceral efferent fibers; may cause para/sympathetic response, typically colicky or ischemic pain; pt writhing in pain |
| Parietal Pain: etiology, types of nerve fibers, Characterize, describe pts | secondary to peritoneal irritation, typically from inflammatory causes; carried on segmental somatic fibers; usually dull, steady ache though better localized; pts do not move or want to be moved |
| Peritoneal signs | 1. extreme tenderness, 2. Rebound tenderness 3. Motion pain 4. Voluntary guarding 5. Involuntary guarding & rigidity |
| Places Where Fluid, Blood, or Pus can Collect | 1. Pelvis 2. Paracolic gutters 3. Morrison’s pouch (subhepatic) 4. Interloop (between loops of bowel) 5. Subphrenic |
| Signs of Appendicitis | 1. iliopsoas, 2. Rovsing’s, 3. Obturator, 4. McBurney's |
| Iliopsoas Sign | pain on passive extension of hip (retrocecal appendix) |
| Rovsing’s Sign | pain in RLQ when press on LLQ |
| Obturator Sign | pain on flexion & internal rotation of hip |
| McBurney’s Sign | pain at McBurney’s Point |
| Murphy’s Sign | inspiratory arrest when palpating under R costal margin (acute cholecystitis) |
| Boas’s Sign | referred R subscapular pain of biliary colic (cholelithiasis) |
| Signs of peritoneal irritation | a. Cough Tenderness b. Heel Tap: pain transmitted up muscles beneath peritoneal cavity |
| Cervical Motion Tenderness | classic sign of PID |
| Signs of Hemorrhagic Pancreatitis | a. Cullen’s Sign: bluish discoloration of periumbilical area b. Fox’s Sign: ecchymosis of inguinal ligament c. Grey Turner’s Sign: flank ecchymosis |
| Cullen’s Sign | bluish discoloration of periumbilical area, Sign of Hemorrhagic Pancreatitis |
| Fox’s Sign | ecchymosis of inguinal ligament, Sign of Hemorrhagic Pancreatitis |
| Grey Turner’s Sign | flank ecchymosis, Sign of Hemorrhagic Pancreatitis |
| Charcot’s Triad | fever, jaundice, RUQ pain (cholangitis) |
| Raynaud's pentad | fever, jaundice, RUQ pain + AMS and hypotension/sepsis/shock; harbinger of worsening, ascending cholangitis |
| Signs of Splenic Injury & Rupture | a. Kehr’s Sign: pain referred to tip of L shoulder b. Ballance’s Sign: dullness to percussion over the flanks (coag blood on L, fluid blood on R) |
| Kehr’s Sign | pain referred to tip of L shoulder |
| Ballance’s Sign | dullness to percussion in the left flank LUQ and shifting dullness to percussion in the right flank seen with splenic rupture/hematoma. The dullness in the left flank is due to coagulated blood, the shifting dullness on the right due to fluid blood. |
| Pt who is slightly febrile, with anorexia, N/V (pain before vomiting), pain is periumbilical then RLQ. What is the diagnosis? What do you diagnose with? What is the initial tx? | Acute Appendicitis, diagnose w CT, IVF rehydration, pre-op Abx (cefoxitin) |
| Pt with post-prandial biliary colic; N/V, fever, Murphy’s Sign; pain in RUQ, with referred pain to R subscapular area. What is the diagnosis? What do you diagnose with? What is the initial tx? | Gallbladder dz; diagnose w U/S; IVF, cholecystectomy. Abx, ERCP to decompress |
| Pt w N/V, absent bowel sounds, +/-fever, dehydration, shock; pain is epigastric/LUQ, radiates to back. What is the diagnosis? What do you diagnose with? What is the initial tx? | Pancreatitis; ddx w Amylase & lipase levels; AXR (sentinel loops), CT (fat stranding); NPO, NGT, IVF, TPN, H2 blocker, analgesia |
| what is the purpose of Ranson's criteria | 11 prognostic Sx to identify high risk in pts w. pancreatitis |
| Ranson's criteria on admission | GA LAW: Glucose > 200 mg/dL, Age>55yr, LDH > 350 IU/dL, AST > 250 IU/dL, WBC > 16,000 cell/mm3 |
| Ranson's criteria after 48h | C HOBBS: Ca++ < 8 mg/dL, Hematocrit decrease > 10%, arterial pO2 < 60 mmHg, BUN increase > 5 mg/dL, Base deficit > 4 mEq/L, fluid Sequestration > 6 L |
| Ranson's criteria mortality | 1. If<3 signs, 1%; 2. 3-4 signs, 15%; 3. 5-6 signs, 50%; 4. 7+ signs, approximately 100% |
| Pt w Epigastric tenderness radiating to back, diffuse abd pain, N/V, dec bowel sounds, shock/dehydration, +/-fever | pancreatitis |
| Causes of pancreatitis | I GET SMASHED: Idiopathic, Gallstone, EtOH, Trauma, Steroids, Mumps and other viruses (EBV/CMV), Autoimmune (SLE, PAN), scorpion/snake, Hyper -ca -lipid Hypo-thermia, ERCP, Duod ulcer & Drugs (SAND - steroids/sulfonamides, azathioprine, NSAIDs, diuretics) |
| Pt w N/V, anorexia, blood in stool; Epigastric, radiates to back; What is the diagnosis? What do you diagnose with? What is the initial tx? | PUD; Guaiac+, EGD, UGI series; Abx vs. H. pylori, H2 blocker, antacids, sucralfate, omeprazole |
| Pt w dec Bowel sounds, tympany over liver; pain epigastric, radiates to back. What is the diagnosis? What do you diagnose with? What is the initial tx? | Perforated Ulcer; dx with CXR (free air); NGT, IVF, Foley, Abx, surgery |
| Pt w Heartburn, resp Sx from aspiration, regurgitation; epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | GERD; dx with EGD, UGI contrast study, pH probe, manometry; H2 blockers, omeprazole, cisapride, elevate while sleeping |
| Pt with NGT blood; painless, or with epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Gastritis/Duodenitis, dx with EGD, initial tx with H2 blockers, antacids, sucralfate |
| pt with Fever, diarrhea, anorexia, mass, N/V, dysuria, LLQ or RLQ pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Diverticulitis; ddx with Abd CT, colonoscopy; tx w IVF, NPO, Abx, NG suction |
| Pt with Bloody Diarrhea, fever, weight loss; pain in hypogastric area. What is the diagnosis? What do you diagnose with? What is the initial tx? | Ulcerative colitis; Colonoscopy w. biopsy, barium enema, UGI, stool cultures; Sulfasalazine, steroids, metronidazole |
| Pt with Diarrhea, fever, weight loss; pain in hypogastric area; has anal disease. What is the diagnosis? What do you diagnose with? What is the initial tx? | Crohn's; Colonoscopy w. biopsy, barium enema, UGI, stool cultures; Sulfasalazine, steroids, metronidazole |
| N/V/D; pain after vomiting; diffuse abd pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Enterocolitis, Use hx to diagnose, abx and ivf to tx |
| Frequent vomiting, abd distention, high-pitched bowel sounds; pain is Hypogastric, Periumbilical. What is the diagnosis? What do you diagnose with? What is the initial tx? | SBO; AXR (air-fluid levels), CT; NGT, IVF, Foley |
| Abd distention, anorexia, obstipation, N/V, hypogastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Colon Obstruction; AXR, sigmoidoscopy, gastrografin enema; Colonoscopic reduction, enema, colonic tube |
| Hemoperitoneum, LUQ mass, pain in LUQ, referred to tip of L shoulder. What is the diagnosis? What do you diagnose with? What is the initial tx? | Splenic disease; Abd CT, DPL; Ex lap |
| Diffuse abd pain out of proportion to exam; N/V, hyperdefecation +/-heme stools, h/o AFib or heart dz. What is the diagnosis? What do you diagnose with? What is the initial tx? | Mesenteric Ischemia; Mesenteric A- gram, plain film shows “thumb- printing” ; Embolectomy, papaverine vasodilator; resect necrotic tissue |
| Hypotension w. pulsatile abd mass, diffuse epigastric pain. What is the diagnosis? What do you diagnose with? What is the initial tx? | Ruptured AAA; If not ruptured, U/S & CT; OR immediately |
| pain from any quadrant radiates from flank to testicles; What is the diagnosis? What do you diagnose with? | Nephrolithiasis; KUB, U/A, U/S. |
| What could thrombocytopenia indicate? | Sepsis |
| ABG showing metabolic acidosis | ischemia - possible bowel ischemia |
| Sentinel loop on KUB. What is it and what does it indicate? | pancreatitis; dilation of a segment of large or small intestine, indicative of localized ileus from nearby inflammation. |
| What study do you do for nonacute GI bleed or nonacute epigastric pain? | EGD |
| Describe acute appendicitis in elderly. What happens to the mortality rate? | more subtle Sx (less abd pain, fever & CBC unreliable); high rate of rupture --> high rate of mortality; |
| Describe acute appendicitis in infants. | high rate of rupture, faster progression of illness, inability to complain or give Hx, bowel wall inefficient at walling off perforation␣infection spreads |
| Describe acute appendicitis in pregnant women. Does it occur with increased frequency? What trimesters? | most common extrauterine surgical emergency in pregnant women – but occurs w. same frequency as nonpregnant women; usually in 1st 2 trimesters |
| Acute appendicitis in pregnant women. What about it makes the diagnosis more difficult? | appendix laterally & superiorly displaced - Dx more difficult; also “Sx of pregnancy” like N/V confused for appendicitis Sx; may compromise fetus |
Created by:
Christina Pham
on 2009-11-06