1. A 24-year-old male presents with right lower quadrant abdominal pain radiating to the groin. On exam, he has mild guarding and tenderness in the right lower quadrant. His differential diagnosis includes appendicitis.
2. A 68-year-old female presents with left lower quadrant pain, diarrhea, fevers and nausea. On exam, she has tenderness in the left lower quadrant. Her differential diagnosis includes diverticulitis.
3. The document discusses the history, exam, differential diagnosis, diagnostic workup, and treatment of common causes of acute abdominal pain such as appendicitis and diverticulitis.
Physical exam of an acute surgical abdomen. Using detailed descriptions of pain along with onset and physical exam tests including peritoneal signs and more advanced physical exam maneuvers in order to formulate a diagnosis and severity of illness.
writes I have a good salary, am married, and have two children. My whole life I've been drawn to prescription and have always enjoyed it. However, I have a unattached in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm bearing in mind doing one of the post bac premed programs out there and going for it.
Dr. Guy Nicastri, Associate Professor of Surgery and Family Medicine at the Warren Alpert School of Medicine at Brown University takes us through some of the pearls of the Acute Abdomen Examination in the Adult
Abdominal pain is one of common problems
encountered by doctors, either in primary or
secondary health care (specialists). It may be
mild, but it may also a life-threatening sign. It
has been estimated that almost 50% adults have
experienced abdominal pain. In general, abdominal pain is categorized
based on the onset as acute or chronic pain.
Sudden onset of abdominal pain that lasts for less
than 24 hours is considered as acute abdominal
pain.
The problems of a surgeon
If 'I' operate 'and 'the' problem 'is' not 'surgical, Pt
exposed 'to' unnecessary 'risk ,'anesthetic,'etc.'
Risks 'greater' with 'concomitant 'illness,'older 'age'
If 'I' do 'not' operate 'and' problem 'is' surgical, 'patient 'at'
risk 'because' of 'wrong' therapy.'
Again 'the' older 'patient 'is' under 'greater' burden.'
Physical exam of an acute surgical abdomen. Using detailed descriptions of pain along with onset and physical exam tests including peritoneal signs and more advanced physical exam maneuvers in order to formulate a diagnosis and severity of illness.
writes I have a good salary, am married, and have two children. My whole life I've been drawn to prescription and have always enjoyed it. However, I have a unattached in English literature, so I've always put it as unattainable to become a doctor. Now, once again, I'm bearing in mind doing one of the post bac premed programs out there and going for it.
Dr. Guy Nicastri, Associate Professor of Surgery and Family Medicine at the Warren Alpert School of Medicine at Brown University takes us through some of the pearls of the Acute Abdomen Examination in the Adult
Abdominal pain is one of common problems
encountered by doctors, either in primary or
secondary health care (specialists). It may be
mild, but it may also a life-threatening sign. It
has been estimated that almost 50% adults have
experienced abdominal pain. In general, abdominal pain is categorized
based on the onset as acute or chronic pain.
Sudden onset of abdominal pain that lasts for less
than 24 hours is considered as acute abdominal
pain.
The problems of a surgeon
If 'I' operate 'and 'the' problem 'is' not 'surgical, Pt
exposed 'to' unnecessary 'risk ,'anesthetic,'etc.'
Risks 'greater' with 'concomitant 'illness,'older 'age'
If 'I' do 'not' operate 'and' problem 'is' surgical, 'patient 'at'
risk 'because' of 'wrong' therapy.'
Again 'the' older 'patient 'is' under 'greater' burden.'
Describes the concept of a surgical abdomen, acute abdominal pain, emergency intervention and approach to management, including the controversial use of analgesic and antibiotics in emergency room.
SIGMOID VOLVULUS- GENERALISED ABDOMINAL PAIN
#surgicaleducator #generalisedabdominalpain #sigmoidvolvuus #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Sigmoid Volvulus- a didactic lecture.
• It is one of the life-threatening surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology, pathology, clinical features, investigations, and treatment of Sigmoid volvulus.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Sigmoid Volvulus.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Peritonitis is usually caused by infection from bacteria or fungi
HEMORRHOIDECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #hemorrhoidectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Hemorrhoidectomy- Barron’s banding, open and closed hemorrhoidectomy, Stapler hemorrhoidectomy and THD- Transanal Hemorroidal Dearterialisation. So, it is a 4in1 video.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Femoral hernia is the third common hernia after inguinal and incisional hernias. The swelling in femoral hernia is below and lateral to pubic tubercle. It is more common in females. Strangulation is very common in this hernia.
Describes the concept of a surgical abdomen, acute abdominal pain, emergency intervention and approach to management, including the controversial use of analgesic and antibiotics in emergency room.
SIGMOID VOLVULUS- GENERALISED ABDOMINAL PAIN
#surgicaleducator #generalisedabdominalpain #sigmoidvolvuus #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Sigmoid Volvulus- a didactic lecture.
• It is one of the life-threatening surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology, pathology, clinical features, investigations, and treatment of Sigmoid volvulus.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Sigmoid Volvulus.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
Peritonitis is an inflammation of the peritoneum, the tissue that lines the inner wall of the abdomen and covers and supports most of your abdominal organs. Peritonitis is usually caused by infection from bacteria or fungi
HEMORRHOIDECTOMY- OPERATIVE SURGERY
#surgicaleducator #operativesurgery #hemorrhoidectomy #usmle #babysurgeon #surgicaltutor
Subscription Link: http://youtube.com/c/surgicaleducator...
Surgical Educator Android App link: https://play.google.com/store/apps/de...
Dear viewers,
• Greetings from “Surgical Educator”
• Because of the popular demand by viewers of the YouTube channel “Surgical Educator”, I have decided to create and upload videos on common surgeries.
• In this video today, I have discussed Hemorrhoidectomy- Barron’s banding, open and closed hemorrhoidectomy, Stapler hemorrhoidectomy and THD- Transanal Hemorroidal Dearterialisation. So, it is a 4in1 video.
• However, these videos are not real surgeries but the theoretical aspect of operative surgery like going through an atlas of operative surgery.
• Along with these videos, I recommend you watch real operative surgery videos as well and I will give a link for each surgery in the end of the video as end-cards, which I think will be very useful.
• This will give a very good opportunity for the surgical trainees to mentally rehearse various surgical steps in a sequential manner prior to actual surgery. You can watch the video in the following links:
• surgicaleducator.blogspot.com
• youtube.com/c/surgicaleducator
• Thank you for watching the videos.
Femoral hernia is the third common hernia after inguinal and incisional hernias. The swelling in femoral hernia is below and lateral to pubic tubercle. It is more common in females. Strangulation is very common in this hernia.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
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micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
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Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
2. Case #1
24 yo healthy M with one day hx of abdominal pain. Pain
was generalized at first, now worse in right lower abd &
radiates to his right groin. He has vomited twice today.
Denies any diarrhea, fevers, dysuria or other complaints.
No appetite today. ROS otherwise negative.
PMHx: negative
PSurgHx: negative
Meds: none
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory
3. Abdominal pain
What else do you want to know?
What is on your differential diagnosis so far?
(healthy male with RLQ abd pain….)
How do you approach the complaint of
abdominal pain in general?
Let’s review in this lecture:
Types of pain
History and physical examination
Labs and imaging
Abdominal pain in special populations (Elderly, HIV)
Clinical pearls to help you in the ED
4. “Tell me more about your pain….”
Location
Quality
Severity
Onset
Duration
Modifying factors
Change over time
5. What kind of pain is it?
Visceral
Involves hollow or solid organs; midline pain due to bilateral innvervation
Steady ache or vague discomfort to excruciating or colicky pain
Poorly localized
Epigastric region: stomach, duodenum, biliary tract
Periumbilical: small bowel, appendix, cecum
Suprapubic: colon, sigmoid, GU tract
Parietal
Involves parietal peritoneum
Localized pain
Causes tenderness and guarding which progress to rigidity and rebound as
peritonitis develops
Referred
Produces symptoms not signs
Based on developmental embryology
Ureteral obstruction → testicular pain
Subdiaphragmatic irritation → ipsilateral shoulder or supraclavicular pain
Gynecologic pathology → back or proximal lower extremity
Biliary disease → right infrascapular pain
MI → epigastric, neck, jaw or upper extremity pain
7. And don’t forget the history
GI
Past abdominal surgeries, h/o GB disease, ulcers; FamHx IBD
GU
Past surgeries, h/o kidney stones, pyelonephritis, UTI
Gyn
Last menses, sexual activity, contraception, h/o PID or STDs, h/o
ovarian cysts, past gynecological surgeries, pregnancies
Vascular
h/o MI, heart disease, a-fib, anticoagulation, CHF, PVD, Fam Hx of AAA
Other medical history
DM, organ transplant, HIV/AIDS, cancer
Social
Tobacco, drugs – Especially cocaine, alcohol
Medications
NSAIDs, H2 blockers, PPIs, immunosuppression, coumadin
8. Moving on to the Physical Exam
General
Pallor, diaphoresis, general appearance, level of distress or discomfort, is the patient lying
still or moving around in the bed
Vital Signs
Orthostatic VS when volume depletion is suspected
Cardiac
Arrhythmias
Lungs
Pneumonia
Abdomen
Look for distention, scars, masses
Auscultate – hyperactive or obstructive BS increase likelihood of SBO fivefold – otherwise
not very helpful
Palpate for tenderness, masses, aortic aneurysm, organomegaly, rebound, guarding, rigidity
Percuss for tympany
Look for hernias!
rectal exam
Back
CVA tenderness
Pelvic exam
CMT
Vaginal discharge – Culture
Adenexal mass or fullness
9. Abdominal Findings
Guarding
Voluntary
Contraction of abdominal musculature in anticipation of palpation
Diminish by having patient flex knees
Involuntary
Reflex spasm of abdominal muscles
aka: rigidity
Suggests peritoneal irritation
Rebound
Present in 1 of 4 patients without peritonitis
Pain referred to the point of maximum tenderness when palpating
an adjacent quadrant is suggestive of peritonitis
Rovsing’s sign in appendicitis
Rectal exam
Little evidence that tenderness adds any useful information beyond
abdominal examination
Gross blood or melena indicates a GIB
10. Differential Diagnosis
It’s Huge!
Use history and physical exam to narrow it down
Rule out life-threatening pathology
Half the time you will send the patient home with a diagnosis of nonspecific
abdominal pain (NSAP or Abdominal Pain – NOS)
90% will be better or asymptomatic at 2-3 weeks
12. Most Common Causes in the ED
Non-specific abd pain 34%
Appendicitis 28%
Biliary tract dz 10%
SBO 4%
Gyn disease 4%
Pancreatitis 3%
Renal colic 3%
Perforated ulcer 3%
Cancer 2%
Diverticular dz 2%
Other 6%
13. What kind of tests should you order?
Depends what you are looking
for!
Abdominal series
3 views: upright chest, flat view of
abdomen, upright view of abdomen
Limited utility: restrict use to
patients with suspected obstruction
or free air
Ultrasound
Good for diagnosing AAA but not
ruptured AAA
Good for pelvic pathology
CT abdomen/pelvis
Noncontrast for free air, renal colic,
ruptured AAA, (bowel obstruction)
Contrast study for abscess,
infection, inflammation, unknown
cause
MRI
Most often used when unable to
obtain CT due to contrast issue
Labs
CBC: “What’s the white count?”
Chemistries
Liver function tests, Lipase
Coagulation studies
Urinalysis, urine culture
GC/Chlamydia swabs
Lactate
14. Disposition
Depends on the source
Non-specific abdominal pain
No source is identified
Vital signs are normal
Non specific abdominal exam, no evidence of peritonitis
or severe pain
Patient improves during ED visit
Patient able to take fluids
Have patient return to ED in 12-24 hours for re-
examination if not better or if they develop new
symptoms
15. Back to Case #1….24 yo with RLQ pain
Physical exam:
T: 37.8, HR: 95, BP 118/76, R: 18, O2 sat: 100%
room air
Uncomfortable appearing, slightly pale
Abdomen: soft, non-distended, tender to
palpation in RLQ with mild guarding; hypoactive
bowel sounds
Genital exam: normal
What is your differential diagnosis and what
do you do next?
16. Appendicitis
Classic presentation
Periumbilical pain
Anorexia, nausea, vomiting
Pain localizes to RLQ
Occurs only in ½ to 2/3 of patients
26% of appendices are retrocecal
and cause pain in the flank; 4%
are in the RUQ
A pelvic appendix can cause
suprapubic pain, dysuria
Males may have pain in the
testicles
Findings
Depends on duration of symptoms
Rebound, voluntary guarding,
rigidity, tenderness on rectal exam
Psoas sign
Obturator sign
Fever (a late finding)
Urinalysis abnormal in 19-40%
CBC is not sensitive or specific
Abdominal xrays
Appendiceal fecalith or gas,
localized ileus, blurred right psoas
muscle, free air
CT scan
Pericecal inflammation, abscess,
periappendiceal phlegmon, fluid
collection, localized fat stranding
21. Appendicitis
Diagnosis
WBC
Clinical appendicitis – call
your surgeon
Maybe appendicitis - CT
scan
Not likely appendicitis –
observe for 6-12 hours or
re-examination in 12
hours
Treatment
NPO
IVFs
Preoperative antibiotics –
decrease the incidence of
postoperative wound
infections
Cover anaerobes, gram-
negative and enterococci
Zosyn 3.375 grams IV or
Unasyn 3 grams IV
Analgesia
22. Case #2
68 yo F with 2 days of LLQ abd pain,
diarrhea, fevers/chills, nausea; vomited
once at home.
PMHx: HTN, diverticulosis
PSurgHx: negative
Meds: HCTZ
NKDA
Social hx: no alcohol, tobacco or drug use
Family hx: non-contributory22
23. Case #2 Exam
T: 37.6, HR: 100, BP: 145/90, R: 19, O2sat: 99%
room air
Gen: uncomfortable appearing, slightly pale
CV/Pulmonary: normal heart and lung exam, no
LE edema, normal pulses
Abd: soft, moderately TTP LLQ
Rectal: normal tone, guiac neg brown stool
What is your differential diagnosis & what
next?
24. Diverticulitis
Risk factors
Diverticula
Increasing age
Clinical features
Steady, deep
discomfort in LLQ
Change in bowel habits
Urinary symptoms
Tenesmus
Paralytic ileus
SBO
Physical Exam
Low-grade fever
Localized tenderness
Rebound and guarding
Left-sided pain on
rectal exam
Occult blood
Peritoneal signs
Suggest perforation or
abscess rupture
25. Diverticulitis
Diagnosis
CT scan (IV and oral
contrast)
Pericolic fat stranding
Diverticula
Thickened bowel wall
Peridiverticular
abscess
Leukocytosis present in
only 36% of patients
Treatment
Fluids
Correct electrolyte
abnormalities
NPO
Abx: gentamicin AND
metronidazole OR
clindamycin OR
levaquin/flagyl
For outpatients (non-toxic)
liquid diet x 48 hours
cipro and flagyl
26. Case #3
46 yo M with hx of alcohol abuse with 3
days of severe upper abd pain, vomiting,
subjective fevers.
Med Hx: negative
Surg Hx: negative
Meds: none; Allergies: NKDA
Social hx: homeless, heavy alcohol use,
smokes 2ppd, no drug use
27. Case #3 Exam
Vital signs: T: 37.4, HR: 115, BP: 98/65, R: 22, O2sat:
95% room air
General: ill-appearing, appears in pain
CV: tachycardic, normal heart sounds, pulses normal
Lungs: clear
Abdomen: mildly distended, moderately TTP epigastric,
+voluntary guarding
Rectal: heme neg stool
What is your differential diagnosis & what next?
28. Pancreatitis
Risk Factors
Alcohol
Gallstones
Drugs
Amiodarone, antivirals,
diuretics, NSAIDs,
antibiotics, more…..
Severe hyperlipidemia
Idiopathic
Clinical Features
Epigastric pain
Constant, boring pain
Radiates to back
Severe
N/V
bloating
Physical Findings
Low-grade fevers
Tachycardia, hypotension
Respiratory symptoms
Atelectasis
Pleural effusion
Peritonitis – a late finding
Ileus
Cullen sign*
Bluish discoloration around
the umbilicus
Grey Turner sign*
Bluish discoloration of the
flanks
*Signs of hemorrhagic pancreatitis
29. Pancreatitis
Diagnosis
Lipase
Elevated more than 2
times normal
Sensitivity and specificity
>90%
Amylase
Nonspecific
Don’t bother…
RUQ US if etiology unknown
CT scan
Insensitive in early or mild
disease
NOT necessary to
diagnose pancreatitis
Useful to evaluate for
complications
Treatment
NPO
IV fluid resuscitation
Maintain urine output of
100 mL/hr
NGT if severe, persistent
nausea
No antibiotics unless severe
disease
E coli, Klebsiella,
enterococci,
staphylococci,
pseudomonas
Imipenem or cipro with
metronidazole
Mild disease, tolerating oral
fluids
Discharge on liquid diet
Follow up in 24-48 hours
All others, admit
30. Case #4
72 yo M with hx of CAD on aspirin and Plavix
with several days of dull upper abd pain and now
with worsening pain “in entire abdomen” today.
Some relief with food until today, now worse
after eating lunch.
Med Hx: CAD, HTN, CHF
Surg Hx: appendectomy
Meds: Aspirin, Plavix, Metoprolol, Lasix
Social hx: smokes 1ppd, denies alcohol or drug
use, lives alone
31. Case #4 Exam
T: 99.1, HR: 70, BP: 90/45, R: 22, O2sat: 96%
room air
General: elderly, thin male, ill-appearing
CV: normal
Lungs: clear
Abd: mildly distended and diffusely tender to
palpation, +rebound and guarding
Rectal: blood-streaked heme + brown stool
What is your differential diagnosis & what
next?
32. Peptic Ulcer Disease
Risk Factors
H. pylori
NSAIDs
Smoking
Hereditary
Clinical Features
Burning epigastric pain
Sharp, dull, achy, or “empty” or
“hungry” feeling
Relieved by milk, food, or antacids
Awakens the patient at night
Nausea, retrosternal pain and
belching are NOT related to PUD
Atypical presentations in the
elderly
Physical Findings
Epigastric tenderness
Severe, generalized pain
may indicate perforation
with peritonitis
Occult or gross blood per
rectum or NGT if bleeding
33. Peptic Ulcer Disease
Diagnosis
Rectal exam for occult blood
CBC
Anemia from chronic blood
loss
LFTs
Evaluate for GB, liver and
pancreatic disease
Definitive diagnosis is by EGD
or upper GI barium study
Treatment
Empiric treatment
Avoid tobacco, NSAIDs,
aspirin
PPI or H2 blocker
Immediate referral to GI if:
>45 years
Weight loss
Long h/o symptoms
Anemia
Persistent anorexia or
vomiting
Early satiety
GIB
35. Perforated Peptic Ulcer
Abrupt onset of severe epigastric pain
followed by peritonitis
IV, oxygen, monitor
CBC, T&C, Lipase
Acute abdominal x-ray series
Lack of free air does NOT rule out perforation
Broad-spectrum antibiotics
Surgical consultation
36. Case #5
35 yo healthy F to ED c/o nausea and vomiting
since yesterday along with generalized
abdominal pain. No fevers/chills, +anorexia. Last
stool 2 days ago.
Med Hx: negative
Surg Hx: s/p hysterectomy (for fibroids)
Meds: none, Allergies: NKDA
Social Hx: denies alcohol, tobacco or drug use
Family Hx: non-contributory
37. Case #5 Exam
T: 36.9, HR: 100, BP: 130/85, R: 22, O2 sat:
97% room air
General: mildly obese female, vomiting
CV: normal
Lungs: clear
Abd: moderately distended, mild TTP diffusely,
hypoactive bowel sounds, no rebound or
guarding
What is your differential and what next?
39. Bowel Obstruction
Mechanical or nonmechanical
causes
#1 - Adhesions from previous
surgery
#2 - Groin hernia incarceration
Clinical Features
Crampy, intermittent pain
Periumbilical or diffuse
Inability to have BM or flatus
N/V
Abdominal bloating
Sensation of fullness, anorexia
Physical Findings
Distention
Tympany
Absent, high pitched or
tinkling bowel sound or
“rushes”
Abdominal tenderness:
diffuse, localized, or
minimal
40. Bowel Obstruction
Diagnosis
CBC and electrolytes
electrolyte abnormalities
WBC >20,000 suggests bowel
necrosis, abscess or
peritonitis
Abdominal x-ray series
Flat, upright, and chest x-ray
Air-fluid levels, dilated loops of
bowel
Lack of gas in distal bowel and
rectum
CT scan
Identify cause of obstruction
Delineate partial from
complete obstruction
Treatment
Fluid resuscitation
NGT
Analgesia
Surgical consult
Hospital observation for ileus
OR for complete obstruction
Peri-operative antibiotics
• Zosyn or unasyn
41. Case #6
48 yo obese F with one day hx of upper
abd pain after eating, does not radiate, is
intermittent cramping pain, +N/V, no
diarrhea, subjective fevers. No prior
similar symptoms.
Med hx: denies
Surg hx: denies
No meds or allergies
Social hx: no alcohol, tobacco or drug use
42. Case #6 Exam
T: 100.4, HR: 96, BP: 135/76, R: 18, O2 sat:
100% room air
General: moderately obese, no acute distress
CV: normal
Lungs: clear
Abd: moderately TTP RUQ, +Murphy’s sign,
non-distended, normal bowel sounds
What is your differential and what next?
43. Cholecystitis
Clinical Features
RUQ or epigastric pain
Radiation to the back or
shoulders
Dull and achy → sharp
and localized
Pain lasting longer than
6 hours
N/V/anorexia
Fever, chills
Physical Findings
Epigastric or RUQ pain
Murphy’s sign
Patient appears ill
Peritoneal signs
suggest perforation
44. Cholecystitis
Diagnosis
CBC, LFTs, Lipase
Elevated alkaline
phosphatase
Elevated lipase suggests
gallstone pancreatitis
RUQ US
Thicken gallbladder wall
Pericholecystic fluid
Gallstones or sludge
Sonographic murphy sign
HIDA scan
more sensitive & specific
than US
H&P and laboratory findings
have a poor predictive value –
if you suspect it, get the US
Treatment
Surgical consult
IV fluids
Correct electrolyte
abnormalities
Analgesia
Antibiotics
Ceftriaxone 1 gram IV
If septic, broaden coverage
to zosyn, unasyn,
imipenem or add anaerobic
coverage to ceftriaxone
NGT if intractable vomiting
45. Case #7
34 yo healthy M with 4 hour hx of sudden onset
left flank pain, +nausea/vomiting; no prior hx of
similar symptoms; no fevers/chills. +difficulty
urinating, no hematuria. Feels like has to urinate
but cannot.
PMHx: neg
Surg Hx: neg
Meds: none, Allergies: NKDA
Social hx: occasional alcohol, denies tobacco or
drug use
Family hx: non-contributory
46. Case #7 Exam
T: 98.9, HR: 110, BP: 150/90, R: 20, O2 sat: 99% room
air
General: writhing around on stretcher in pain,
+diaphoretic
CV: tachycardic, heart sounds normal
Lungs: clear
Abd: soft; non-tender
Back: mild left CVA tenderness
Genital exam: normal
Neuro exam: normal
What is your differential diagnosis and what next?
47. Renal Colic
Clinical Features
Acute onset of severe,
dull, achy visceral pain
Flank pain
Radiates to abdomen
or groin including
testicles
N/V and sometimes
diaphoresis
Fever is unusual
Waxing and waning
symptoms
Physical Findings
non tender or mild
tenderness to palpation
Anxious, pacing,
writhing in bed – unable
to sit still
48. Renal Colic
Diagnosis
Urinalysis
RBCs
WBCs suggest infection or
other etiology for pain (ie
appendicitis)
CBC
If infection suspected
BUN/Creatinine
In older patients
If patient has single kidney
If severe obstruction is
suspected
CT scan
In older patients or patients
with comorbidities (DM,
SCD)
Not necessary in young
patients or patients with h/o
stones that pass
spontaneously
Treatment
IV fluid boluses
Analgesia
Narcotics
NSAIDS
• If no renal insufficiency
Strain all urine
Follow up with urology in 1-2
weeks
If stone > 5mm, consider
admission and urology consult
If toxic appearing or infection
found
IV antibiotics
Urologic consult
49. Just a few more to go….hang in
there
Ovarian torsion
Testicular torsion
GI bleeding
Abd pain in the Elderly
50. Ovarian Torsion
Acute onset severe pelvic pain
May wax and wane
Possible hx of ovarian cysts
Menstrual cycle: midcycle also
possibly in pregnancy
Can have variable exam:
acute, rigid abdomen,
peritonitis
Fever
Tachycardia
Decreased bowel sounds
May look just like Appendicitis
Obtain ultrasound
Labs
CBC, beta-hCG,
electrolytes, T&S
IV fluids
NPO
Pain medications
GYN consult
51. Testicular Torsion
Sudden onset of severe
testicular pain
If torsion is repaired within 6
hours of the initial insult,
salvage rates of 80-100% are
typical. These rates decline
to nearly 0% at 24 hours.
Approximately 5-10% of torsed
testes spontaneously detorse,
but the risk of retorsion at a
later date remains high.
Most occur in males less than
20yrs old but 10% of affected
patients are older than 30
years.
Detorsion
Emergent urology consult
Ultrasound with doppler
52. Abdominal Pain in the Elderly
Mortality rate for
abdominal pain in the
elderly is 11-14%
Perception of pain is
altered
Altered reporting of pain:
stoicism, fear,
communication problems
Most common causes:
Cholecystitis
Appendicitis
Bowel obstruction
Diverticulitis
Perforated peptic ulcer
Don’t miss these:
AAA, ruptured AAA
Mesenteric ischemia
Myocardial ischemia
Aortic dissection
53. Appendicitis – do not exclude it because of prolonged
symptoms. Only 20% will have fever, N/V, RLQ pain and
↑WBC
Acute cholecystitis – most common surgical emergency
in the elderly.
Perforated peptic ulcer – only 50% report a sudden
onset of pain. In one series, missed diagnosis of PPU
was leading cause of death.
Mesenteric ischemia – we make the diagnosis only 25%
of the time. Early diagnosis improves chances of
survival. Overall survival is 30%.
Increased frequency of abdominal aortic aneurysms
AAA may look like renal colic in elderly patients
Abdominal Pain in the Elderly
54. Mesenteric Ischemia
Consider this diagnosis in all elderly patients with risk factors
Atrial fibrillation, recent MI
Atherosclerosis, CHF, digoxin therapy
Hypercoagulability, prior DVT, liver disease
Severe pain, often refractory to analgesics
Relatively normal abdominal exam
Embolic source: sudden onset (more gradual if thrombosis)
Nausea, vomiting and anorexia are common
50% will have diarrhea
Eventually stools will be guiaic-positive
Metabolic acidosis and extreme leukocytosis when advanced
disease is present (bowel necrosis)
Diagnosis requires mesenteric angiography or CT angiography
55. Abdominal Aortic Aneurysm
Risk increases with age, women >70, men >55
Abdominal pain in 70-80% (not back pain!)
Back pain in 50%
Sudden onset of significant pain
Atypical locations of pain: hips, inguinal area, external genitalia
Syncope can occur
Hypotension may be present
Palpation of a tender, enlarged aorta on exam is an important finding
May present with hematuria
Suspect it in any older patient with back, flank or abdominal pain especially
with a renal colic presentation
Ultrasound can reveal the presence of a AAA but is not helpful for rupture.
CT abd/pelvis without contrast for stable patients. High suspicion in an
unstable patient requires surgical consult and emergent surgery.
56. GI Bleeding
Upper
Proximal to Ligament of Treitz
Peptic ulcer disease most common
Erosive gastritis
Esophagitis
Esophageal and gastric varices
Mallory-Weiss tear
Lower
Hemorrhoids most common
Diverticulosis
Angiodysplasia
57. Medical History
Common Presentation:
Hematemesis (source proximal to right colon)
Coffee-ground emesis
Melena
Hematochezia (distal colorectal source)
High level of suspicion with
Hypotension
Tachycardia
Angina
Syncope
Weakness
Confusion
Cardiac arrest
58. Labs and Imaging
Type and crossmatch: Most important!
Other studies: CBC, BUN, creatinine, electrolyte, coagulation studies,
LFTs
Initial Hct often will not reflect the actual amount of blood
loss
Abdominal and chest x-rays of limited value for source of
bleed
Nasogastric (NG) tube
Gastric lavage
Angiography
Bleeding scan
Endoscopy/colonoscopy
59. Management in the ED
ABCs of Resuscitation
AIRWAY:
Consider definitive airway to prevent aspiration
of blood
BREATHING
Supplemental Oxygen
Continuous pulse oximetry
60. Management in ED
Circulation
Cardiac monitoring
Volume replacement
Crystalloids
2 large-bore intravenous lines (18g or larger)
Blood Products
General guidelines for transfusion
• Active bleeding
• Failure to improve perfusion and vital signs after the infusion of
2 L of crystalloid
• Lower threshold in the elderly
NOT BASED ON INITIAL HEMATOCRIT ALONE
Coagulation factors replaced as needed
Urinary catheter with hypotension to monitor output
61. Management
Early GI consult for severe bleeds
Therapeutic Endoscopy: band ligation or
injection sclerotherapy
Also….electrocoagulation, heater probes, and lasers
Drug Therapy: somatostatin, octreotide,
vasopressin, PPIs
Balloon tamponade: adjunct or
temporizing measure
Surgery: if all else fails
62. Disposition
ADMIT
Certain patients with lower GI bleeding may be discharged for
Outpatient work-up
Patients are risk stratified by clinical and endoscopic
criteria
Independent predictors of adverse outcomes in upper GI
bleeding (Corley and colleagues):
Initial hematocrit < 30 %
Initial SBP < 100 mm Hg
Red blood in the NG lavage
History of cirrhosis or ascites on examination
History of vomiting red blood
63. Abdominal Pain Clinical Pearls
Significant abdominal tenderness should never be attributed to
gastroenteritis
Incidence of gastroenteritis in the elderly is very low
Always perform genital examinations when lower abdominal pain is present
– in males and females, in young and old
In older patients with renal colic symptoms, exclude AAA
Severe pain should be taken as an indicator of serious disease
Pain awakening the patient from sleep should always be considered
signficant
Sudden, severe pain suggests serious disease
Pain almost always precedes vomiting in surgical causes; converse is true
for most gastroenteritis and NSAP
Acute cholecystitis is the most common surgical emergency in the elderly
A lack of free air on a chest xray does NOT rule out perforation
Signs and symptoms of PUD, gastritis, reflux and nonspecific dyspepsia
have significant overlap
If the pain of biliary colic lasts more than 6 hours, suspect early cholecystitis
Editor's Notes
Basic cases to go through the most common abd pain complaints we see in the ED
Orthostatic VS are less reliable in the diabetic, elderly, those on beta-blocker. Pulse increase of 30 or presyncope on standing are highly sensitive for loss of 1 L of blood or 3L of fluid. BP changes are less reliable. Patient must be standing at least one minute before measurements are taken.
Heme positive stool – 10% of people over the age of 50 sent home with diagnosis of NSAP and heme positive stools were found to have cancer within a year.
Heme positive stool in the setting of suspected PUD should elicit more urgent referral for further evaluation
First: r/o upper GI bleed
Lower GI bleed: most common hemorrhoids
Diverticulosis has potential for massive bleeding
NG tube for all significant bleeds: in 14% of bright red blood or maroon per rectum from upper GI source
Negative NG aspirate does not r/o upper source
Use room temp water for lavage and lavage until clear
Octreotide is 50 µg IV bolus, followed by 50 µg 8–24h
Somatostatin is 250–500 µg IV bolus followed by 250–500 µg per h
Protonix 80mg IV bolus x 1; then 8mg/hr for 72 hours
For free air – instill 500cc of air into stomach via NGT and repeat xray or do noncontrast CT scan