setting the stage for diagnosis of the acute abdomen jennifer rodgers, msn, arnp, acnp wichita state...

SETTING THE STAGE FOR SETTING THE STAGE FOR DIAGNOSIS OF THE ACUTE DIAGNOSIS OF THE ACUTE

ABDOMENABDOMEN

JENNIFER RODGERS, MSN, JENNIFER RODGERS, MSN, ARNP, ACNPARNP, ACNP

WICHITA STATE UNIVERSITYWICHITA STATE UNIVERSITY

ACUTE ABDOMENACUTE ABDOMEN

By definition: Sudden, severe By definition: Sudden, severe abdominal painabdominal pain that is less than 24 that is less than 24 hours in duration. It is in many cases hours in duration. It is in many cases a medical emergency.a medical emergency.

Don’tDon’t want to miss the Acute Surgical want to miss the Acute Surgical Abdomen!! Abdomen!!

ACUTE ABDOMENACUTE ABDOMEN

Based on Natl. Hospital Ambulatory Based on Natl. Hospital Ambulatory Medical Care Survey:Medical Care Survey:

Abdominal Pain #3 most common Abdominal Pain #3 most common presenting symptom to the ER for presenting symptom to the ER for both men and women age 45-64 both men and women age 45-64

#1 most common presenting #1 most common presenting symptom for women age 15-44 symptom for women age 15-44

Represents >5% of ED visits annuallyRepresents >5% of ED visits annually

FINDINGS SUGGESTIVE OF FINDINGS SUGGESTIVE OF SURGICAL ABDOMENSURGICAL ABDOMEN

Severe, sudden onset pain under 1 hourSevere, sudden onset pain under 1 hour

Think about Ruptured AAA (often Think about Ruptured AAA (often accompanying back pain), Mesenteric accompanying back pain), Mesenteric Ischemia (often accompanying AFIB) , AMI Ischemia (often accompanying AFIB) , AMI (dyspnea/chest pain), Perforated Viscous, (dyspnea/chest pain), Perforated Viscous, Nephrolithiasis (radiating to groin or back)Nephrolithiasis (radiating to groin or back)

Pain precedes vomiting (Appendicitis, Pain precedes vomiting (Appendicitis, Cholecystitis, Small Bowel Obstruction)Cholecystitis, Small Bowel Obstruction)

Graff, L.G 4Graff, L.G 4thth & Robinson D. (2001). & Robinson D. (2001). Abdominal Pain and Emergency Department Abdominal Pain and Emergency Department Evaluation. Evaluation. Emerg. Med Clinic North Am. 19(1):123-126.Emerg. Med Clinic North Am. 19(1):123-126.

FINDINGS SUGGESTIVE OF FINDINGS SUGGESTIVE OF SURGICAL ABDOMENSURGICAL ABDOMEN

Fever > 101 (with accompanying sx) Fever > 101 (with accompanying sx) *Fever lags behind sx in the elderly*Fever lags behind sx in the elderly

TachycardiaTachycardiaLeukocytosis with Left ShiftLeukocytosis with Left ShiftPeritoneal SignsPeritoneal SignsAge > 65 yrsAge > 65 yrs

Graff, L.G 4Graff, L.G 4thth & Robinson D. (2001). & Robinson D. (2001). Abdominal Pain and Emergency Abdominal Pain and Emergency Department EvaluationDepartment Evaluation. Emerg. Med Clinic North Am. 19(1):123-126.. Emerg. Med Clinic North Am. 19(1):123-126.

ABDOMINAL ASSESSMENTABDOMINAL ASSESSMENT

Have a systematic approachHave a systematic approachTake a thorough history-the patient Take a thorough history-the patient

will tell you their story if you take time will tell you their story if you take time to listento listen

Always think about the cost & reason Always think about the cost & reason for a test and implications (i.e. IV for a test and implications (i.e. IV contrast)contrast)

Thorough physical exam (review your Thorough physical exam (review your abdominal assessment)abdominal assessment)

ABDOMINAL ASSESSMENTABDOMINAL ASSESSMENT

Think about age, gender of patient Think about age, gender of patient when considering differentialwhen considering differential

Think about where the pain is (i.e. Think about where the pain is (i.e. RUQ versus Diffuse) and P.E. tests RUQ versus Diffuse) and P.E. tests (i.e. Murphy’s sign)(i.e. Murphy’s sign)

Don’t miss the surgical abdomen Don’t miss the surgical abdomen (quiet & rigid is never good!!)(quiet & rigid is never good!!)

WHAT DO YOU THINK?WHAT DO YOU THINK?

WHAT ARE THE TWO MOST WHAT ARE THE TWO MOST COMMONLY MISSED SURGICAL COMMONLY MISSED SURGICAL DIAGNOSIS?DIAGNOSIS?

APPENDICITISAPPENDICITIS

SMALL BOWEL OBSTRUCTIONSMALL BOWEL OBSTRUCTION

LET’S GET STARTED!!LET’S GET STARTED!!

76 YEAR OLD MALE76 YEAR OLD MALE

““Unable to void for the past 36 hours”Unable to void for the past 36 hours”+constipation, no fever +constipation, no fever No associated/aggravating factorsNo associated/aggravating factorsPMH: HTN, CKD (baseline Cr 1.5), mild PMH: HTN, CKD (baseline Cr 1.5), mild

Dementia, Hyperlipidemia, DM IIDementia, Hyperlipidemia, DM IIMEDS: HCTZ 25 mg Q day, Norvasc 5 MEDS: HCTZ 25 mg Q day, Norvasc 5

mg Q day, Zocor 40 mg Q evening, mg Q day, Zocor 40 mg Q evening, Glipizide 5mg Q day, Aricept 10 mg Q Glipizide 5mg Q day, Aricept 10 mg Q dayday

76 YEAR OLD MALE76 YEAR OLD MALE

VS 99.4 110 128/76VS 99.4 110 128/76PE: + RLQ pain no rebound or PE: + RLQ pain no rebound or

guardingguarding

Lab: Cr 8.6 K 5.0 WBC 13,000 Bands Lab: Cr 8.6 K 5.0 WBC 13,000 Bands 12% Lymphs 34% Monos 4% Hgb 1212% Lymphs 34% Monos 4% Hgb 12

UA +bloodUA +blood

76 YEAR OLD MALE76 YEAR OLD MALEWhat do you think?What do you think?

WHAT IS YOUR DIFFERENTIAL?WHAT IS YOUR DIFFERENTIAL?

Acute Renal Failure, Pyleonephritis, Acute Renal Failure, Pyleonephritis, Neprolithiasis, Diverticulitis, SBONeprolithiasis, Diverticulitis, SBO

WHAT OTHER TESTS WOULD YOU WHAT OTHER TESTS WOULD YOU LIKE?LIKE?

Urine C & S, CRP, Renal CT Scan, CXRUrine C & S, CRP, Renal CT Scan, CXR

76 YEAR OLD MALE76 YEAR OLD MALE

Renal CT: Multiple Renal Calculi as Renal CT: Multiple Renal Calculi as well as stones in the bladder, diffuse well as stones in the bladder, diffuse constipationconstipation

CRP 8.0 (Elevated)CRP 8.0 (Elevated)CXR-negative for infiltrateCXR-negative for infiltrateUrine-negative for growthUrine-negative for growth

76 YEAR OLD MALE76 YEAR OLD MALE

Dx: Acute Renal Failure (post renal), Dx: Acute Renal Failure (post renal), Multiple Renal Calculi & Bladder Multiple Renal Calculi & Bladder Calculi, Hyperkalemia, ConstipationCalculi, Hyperkalemia, Constipation

Tx: NPO, Consult Urolology & Renal, Tx: NPO, Consult Urolology & Renal, Crystalloid Fluids, Foley to DD, Crystalloid Fluids, Foley to DD, Kayexelate, IV antibiotics (renal Kayexelate, IV antibiotics (renal dose), frequent monitoring of dose), frequent monitoring of Chemistry & U.O.Chemistry & U.O.

76 YEAR OLD MALE76 YEAR OLD MALE

36 hours later….36 hours later….Lab Cr 2.3 K 4.0 WBC 9,000 Bands Lab Cr 2.3 K 4.0 WBC 9,000 Bands

7% +BM, eating and ambulating 7% +BM, eating and ambulating Post Lithotripsy and Right Renal Post Lithotripsy and Right Renal

Stent PlacementStent PlacementAlways think about cause Renal Always think about cause Renal

Failure Pre-Intra-Post>drives your Failure Pre-Intra-Post>drives your Treatment PlanTreatment Plan

RLQ DifferentialRLQ Differential

Think about age & sex of patient & Think about age & sex of patient & organs in the regionorgans in the region

Appendix-Appendicitis Appendix-Appendicitis Large Bowel-Diverticulitis, Abscess, Large Bowel-Diverticulitis, Abscess,

PerforationPerforationSmall Bowel-SBO, Enteritis, Meckel’s Small Bowel-SBO, Enteritis, Meckel’s

DiverticulitisDiverticulitisPelvic Organs-Ectopic Pregnancy, Pelvic Organs-Ectopic Pregnancy,

Ovarian cyst, PID, Ovarian TorsionOvarian cyst, PID, Ovarian Torsion

RLQ DifferentialRLQ Differential

Gallbladder-cholelithiasis, Gallbladder-cholelithiasis, cholecystitischolecystitis

Bladder-Prostatitis, Bladder stones, Bladder-Prostatitis, Bladder stones, TorsionTorsion

Rectal Area-Hemorrhoids, prostatitis, Rectal Area-Hemorrhoids, prostatitis, perirectal abscess, STDperirectal abscess, STD

Aorta/illiac vessels-aneurysmsAorta/illiac vessels-aneurysms

LLQ PAIN DIFFERENTIALLLQ PAIN DIFFERENTIAL

Same as RLQSame as RLQ

Appendicitis low probabilityAppendicitis low probabilityDescending colon-Diverticulitis, Descending colon-Diverticulitis,

perforation, constipation, volvulusperforation, constipation, volvulus

ABDOMINAL IMAGINGABDOMINAL IMAGING

CT Scans-superior to MRI in abdominal CT Scans-superior to MRI in abdominal area b/c looking at organ structuresarea b/c looking at organ structures

Renal CT-no dye looks specifically for Renal CT-no dye looks specifically for Renal Calculi & hydronephrosisRenal Calculi & hydronephrosis

CT Appendix-Sensitivity near 100%, CT Appendix-Sensitivity near 100%, smaller bolus of contrastsmaller bolus of contrast

CT Angiogram of Chest-R/O PE-gold CT Angiogram of Chest-R/O PE-gold standard *lots of contrast watch Cr!standard *lots of contrast watch Cr!

ABDOMINAL IMAGINGABDOMINAL IMAGING

Ultrasound-not good for appendix, low Ultrasound-not good for appendix, low yield, negative means didn’t visualizeyield, negative means didn’t visualize

Ultrasound-best first look for: gallbladder, Ultrasound-best first look for: gallbladder, pancreas, testicles, ovaries & adnexal pancreas, testicles, ovaries & adnexal structures, vascular structures (if bedside structures, vascular structures (if bedside capabilities & patient stable)capabilities & patient stable)

Plain Films (Obstructive Series)-Flat/ Plain Films (Obstructive Series)-Flat/ upright abdomen + CXR- will show upright abdomen + CXR- will show obstruction, constipation (FOS), free air obstruction, constipation (FOS), free air under diaphragmunder diaphragm

56 YEAR OLD MALE56 YEAR OLD MALE

CC: nausea “abdominal cramping, CC: nausea “abdominal cramping, points to RUQ” x 3 days, intermittent points to RUQ” x 3 days, intermittent chest painchest pain

Worse after eatingWorse after eatingPMH: CAD S/P CABG 3 weeks ago, ESRD PMH: CAD S/P CABG 3 weeks ago, ESRD

on Dialysis, COPD, OSA, DMII, PVDon Dialysis, COPD, OSA, DMII, PVDMeds: Cardizem CD 240 mg q day, Meds: Cardizem CD 240 mg q day,

Lantus/Humolog, Advair 50/250 BID, Lantus/Humolog, Advair 50/250 BID, Renal Cap q day, Protonix 40 mg q am, Renal Cap q day, Protonix 40 mg q am, Zocor 40 mg q dayZocor 40 mg q day

56 YEAR OLD MALE56 YEAR OLD MALE

VS: 97.6 120/70 80 SpO2 94%-3LVS: 97.6 120/70 80 SpO2 94%-3L

PE: +RUQ tenderness, no chest wall PE: +RUQ tenderness, no chest wall tenderness, no CVA tendernesstenderness, no CVA tenderness

Labs: Cr 5.6 (pre-dialysis) LFT’s-Labs: Cr 5.6 (pre-dialysis) LFT’s-normal WBC 12,000 Bands 7% normal WBC 12,000 Bands 7%

56 YEAR OLD MALE 56 YEAR OLD MALE WHAT DO YOU THINK?WHAT DO YOU THINK?

WHAT IS YOUR DIFFERENTIAL?WHAT IS YOUR DIFFERENTIAL?

Cholelithiasis, Renal Stone, Pancreatitis, Cholelithiasis, Renal Stone, Pancreatitis, Pneumonia (RLL), PE, MI, PUDPneumonia (RLL), PE, MI, PUD

WHAT OTHER TESTS DO YOU WANT?WHAT OTHER TESTS DO YOU WANT?

CXR, GB Ultrasound, Troponin, 12-Lead CXR, GB Ultrasound, Troponin, 12-Lead EKG, Amylase, Lipase, CRPEKG, Amylase, Lipase, CRP

56 YEAR OLD MALE56 YEAR OLD MALE

WHAT OTHER PHYSICAL EXAM FINDING WHAT OTHER PHYSICAL EXAM FINDING SHOULD YOU CHECK FOR IN RUQ PAIN?SHOULD YOU CHECK FOR IN RUQ PAIN?

MURPHY’S SIGN-Slide finger tips up MURPHY’S SIGN-Slide finger tips up under right rib margin during under right rib margin during exhalation. Then have pt take a deep exhalation. Then have pt take a deep breath.breath.POSITIVE=any inspiratory arrest/painPOSITIVE=any inspiratory arrest/pain

56 year old male has +Murphy’s!!56 year old male has +Murphy’s!!

56 YEAR OLD MALE56 YEAR OLD MALERESULTSRESULTS

CXR-COPD, S/P CABG no acute infiltrateCXR-COPD, S/P CABG no acute infiltrateGB Ultrasound-Sludge & GB thickening GB Ultrasound-Sludge & GB thickening

+ stones+ stonesTroponin <0.04 (which is negative)Troponin <0.04 (which is negative)12-Lead EKG-unchanged from previous12-Lead EKG-unchanged from previousAmylase, Lipase WNLAmylase, Lipase WNLCRP 4.2 (Elevated)CRP 4.2 (Elevated)

56 YEAR OLD MALE56 YEAR OLD MALE

HAS YOUR DIFFERENTIAL CHANGED?HAS YOUR DIFFERENTIAL CHANGED?

WHAT DO WE DO FROM HERE?WHAT DO WE DO FROM HERE?

HIDA SCAN-Nuclear Med scan that HIDA SCAN-Nuclear Med scan that evaluates function of Gallbladder, after evaluates function of Gallbladder, after T99 injected, should see GB within 1 T99 injected, should see GB within 1 hr. If GB not visualized within 4 hrs hr. If GB not visualized within 4 hrs >cholecystitis OR cystic duct >cholecystitis OR cystic duct obstruction obstruction

56 YEAR OLD MALE56 YEAR OLD MALE

HIDA Results-> 4 hrs GB not HIDA Results-> 4 hrs GB not visualizedvisualized

DX: Acute CholecystitisDX: Acute CholecystitisTX: NPO, Consult Surgery, Gentle IV TX: NPO, Consult Surgery, Gentle IV

Fluids, Pre-op AntiobioticsFluids, Pre-op Antiobiotics

56 YEAR OLD MALE56 YEAR OLD MALE

36 hours later….S/P Open 36 hours later….S/P Open Chole>necrosed Gallbladder stable Chole>necrosed Gallbladder stable post oppost op

Emergency cholecystectomy Emergency cholecystectomy mortality rates 8-15% in the elderlymortality rates 8-15% in the elderly

RUQ DIFFERENTIALRUQ DIFFERENTIALThink about organs in that areaThink about organs in that area

Gallbladder-Cholecystitis, Gallbladder-Cholecystitis, cholelithiasis, biliary coliccholelithiasis, biliary colic

Renal-pyleonephritis, stone, Renal-pyleonephritis, stone, hydronephrosishydronephrosis

Liver-Hepatitis, cirrhosis, CHFLiver-Hepatitis, cirrhosis, CHFPancreas-pancreatitisPancreas-pancreatitis

RUQ DIFFERENTIALRUQ DIFFERENTIALThink about organs in that areaThink about organs in that area

Lung-Pneumonia, PELung-Pneumonia, PEHeart-MI, PericarditisHeart-MI, PericarditisDuodenum-PUDDuodenum-PUD

LUQ DIFFERENTIALLUQ DIFFERENTIALThink about the organs in that Think about the organs in that

areaareaStomach-Gastritis, Gastric UlcerStomach-Gastritis, Gastric UlcerPancreas-PancreatitisPancreas-PancreatitisKidney-Hydronephrosis, Calculi, Kidney-Hydronephrosis, Calculi,

pyleonephritispyleonephritisSpleen-Trauma, Mono, occult ruptureSpleen-Trauma, Mono, occult ruptureLarge bowel-DiverticulitisLarge bowel-DiverticulitisHeart-MI, pericarditisHeart-MI, pericarditisLung-Pneumonia, PELung-Pneumonia, PE

Location of abdominal pain & Location of abdominal pain & possible causes.possible causes.

Go to this link, scroll down to figure Go to this link, scroll down to figure one.one.

http://www.merck.com/mmpe/sec02/http://www.merck.com/mmpe/sec02/ch011/ch011b.htmlch011/ch011b.html

This is an excellent diagram which This is an excellent diagram which can be printed off for future can be printed off for future reference.reference.

66 YEAR OLD MALE66 YEAR OLD MALE

CC: Two day onset of “back pain” has CC: Two day onset of “back pain” has gradually worsened, thought maybe gradually worsened, thought maybe he strained his back initially, this he strained his back initially, this a.m. awakened with chest pain, a.m. awakened with chest pain, diaphoresis, “feel weak”diaphoresis, “feel weak”

PMH: HTN, Tobacco Addiction, PMH: HTN, Tobacco Addiction, Hyperlipidemia, PUDHyperlipidemia, PUD

Meds: Lisinopril/HCTZ 10/25 mg q Meds: Lisinopril/HCTZ 10/25 mg q day, Lipitor 40 mg q day, Zantac 150 day, Lipitor 40 mg q day, Zantac 150 mg BIDmg BID

66 YEAR OLD MALE66 YEAR OLD MALE

VS 98.2 90/56 52 SpO2 88%-Room AirVS 98.2 90/56 52 SpO2 88%-Room Air

P.E. Pulse-weak, thready, pale P.E. Pulse-weak, thready, pale appearingappearing

Labs: Cr 1.2 WBC 6,000 normal diff. Labs: Cr 1.2 WBC 6,000 normal diff.

Hgb 12 INR 1.0Hgb 12 INR 1.0

66 YEAR OLD MALE66 YEAR OLD MALEWHAT DO YOU THINK?WHAT DO YOU THINK?

WHAT IS YOUR DIFFERENTIAL?WHAT IS YOUR DIFFERENTIAL?Aneursym Dissection, AMI, Bowel Aneursym Dissection, AMI, Bowel PerforationPerforation

WHAT OTHER TESTS DO YOU WANT?WHAT OTHER TESTS DO YOU WANT?STAT CT ABDOMEN R/O ANEURSYM STAT CT ABDOMEN R/O ANEURSYM OR STAT BEDSIDE ULTRASOUND IF U OR STAT BEDSIDE ULTRASOUND IF U HAVE AVAILABLEHAVE AVAILABLE12-Lead EKG, Troponin12-Lead EKG, Troponin

66 YEAR OLD MALE 66 YEAR OLD MALE RESULTSRESULTS

Abdominal CT-Dissecting AAA Abdominal CT-Dissecting AAA Other results don’t matter at this Other results don’t matter at this

pointpointSTAT Surgery Consult, Fluids Wide STAT Surgery Consult, Fluids Wide

Open, Type & Cross Open, Type & Cross You can’t get this patient to the OR You can’t get this patient to the OR

fast enough!!!fast enough!!!

66 YEAR OLD MALE66 YEAR OLD MALE

Review AAA photos on this site, also Review AAA photos on this site, also read Pearls/Pitfalls at bottom page of read Pearls/Pitfalls at bottom page of this sitethis site

http://www.erpocketbooks.com/er-ulthttp://www.erpocketbooks.com/er-ultrasounds/aortic-ed-ultrasounds/rasounds/aortic-ed-ultrasounds/

66 YEAR OLD MALE66 YEAR OLD MALE

Ruptured AAA 13Ruptured AAA 13thth leading cause of death leading cause of death in U.S.in U.S.

7 times more common in men than women7 times more common in men than women Most commonly occurs between ages 65-Most commonly occurs between ages 65-

75, most common in male smokers75, most common in male smokers Presence of pulsatile mass present in < Presence of pulsatile mass present in <

30-50% of cases30-50% of cases Leading misdiagnosis is renal colic, as Leading misdiagnosis is renal colic, as

dissection of the renal artery may produce dissection of the renal artery may produce flank pain & hematuria flank pain & hematuria

Retrieved: Retrieved: http://emedicine.medscape.com/article/756735-overviewhttp://emedicine.medscape.com/article/756735-overview 05/04/2010 05/04/2010

67 YEAR OLD FEMALE67 YEAR OLD FEMALE

CC: Abdominal Pain and vomiting X CC: Abdominal Pain and vomiting X 48 hours, nearly “passed out” on the 48 hours, nearly “passed out” on the way to the ERway to the ER

PMH: Recently Diagnosed Lung PMH: Recently Diagnosed Lung Cancer, COPD, Tobacco Addition, Cancer, COPD, Tobacco Addition, HTNHTN

MEDS: Chemotherapy, DuoNeb Via MEDS: Chemotherapy, DuoNeb Via nebulizer TID, Lisinopril 10 mg Q Daynebulizer TID, Lisinopril 10 mg Q Day

67 YEAR OLD FEMALE67 YEAR OLD FEMALE

VS: 101.4 80/54 120 Spo2 92%-5 VS: 101.4 80/54 120 Spo2 92%-5 litersliters

P.E. Ill appearing, abdomen rigid with P.E. Ill appearing, abdomen rigid with absence of bowel sounds, diffuse absence of bowel sounds, diffuse abdominal pain with rebound & abdominal pain with rebound & guardingguarding

LABS: WBC 5.9 Bands 62%, Hgb 12.5LABS: WBC 5.9 Bands 62%, Hgb 12.5 Cr 1.6 Amylase 1112, Lipase 53Cr 1.6 Amylase 1112, Lipase 53

67 YEAR OLD FEMALE67 YEAR OLD FEMALEWHAT DO YOU THINK?WHAT DO YOU THINK?

WHAT IS YOUR DIFFERENTIAL?WHAT IS YOUR DIFFERENTIAL?

Bowel Perforation, Ruptured/dissecting Bowel Perforation, Ruptured/dissecting AAA, Small Bowel Obstruction, Esophageal AAA, Small Bowel Obstruction, Esophageal rupture, perforated or ruptured abscess, rupture, perforated or ruptured abscess, Peptic ulcer perforation, Mesenteric Peptic ulcer perforation, Mesenteric Infarct, Pancreatitis, Splenic Infarct, Infarct, Pancreatitis, Splenic Infarct, Ischemic ColitisIschemic Colitis

WHAT TESTS DO YOU WANT?WHAT TESTS DO YOU WANT?

STAT ABDOMINAL CTSTAT ABDOMINAL CT

67 YEAR OLD FEMALE67 YEAR OLD FEMALETEST RESULTSTEST RESULTS

CT reveals Multiple distal enlarged CT reveals Multiple distal enlarged bowel segments with distal bowel segments with distal decompression decompression

Other results don’t matter at this pointOther results don’t matter at this pointSTAT Surgery Consult, Fluids Wide STAT Surgery Consult, Fluids Wide

Open, Type & Cross Open, Type & Cross You can’t get this patient to the OR fast You can’t get this patient to the OR fast

enough!!!enough!!!

67 YEAR OLD FEMALE67 YEAR OLD FEMALE

S/P Extensive Ischemic colitis with S/P Extensive Ischemic colitis with subtotal colectomy/ileostomy subtotal colectomy/ileostomy

Post operatively patient developed Post operatively patient developed severe sepsis syndrome and severe sepsis syndrome and persistent Resp. Failure requiring persistent Resp. Failure requiring vent. supportvent. support

1 week later…extubated, TPN in 1 week later…extubated, TPN in place, up in chair Cr 0.6 Hgb 10.3 place, up in chair Cr 0.6 Hgb 10.3 WBC 1.0 Bands 10%WBC 1.0 Bands 10%

24 YEAR OLD FEMALE24 YEAR OLD FEMALE

CC: “Increased pain with intercourse CC: “Increased pain with intercourse over past several weeks” over past 2 over past several weeks” over past 2 days onset of abdominal pain LLQ days onset of abdominal pain LLQ worsening, now rates as “9” Temp worsening, now rates as “9” Temp 102.8102.8

PMH: TonsillectomyPMH: TonsillectomyMeds: NoneMeds: None

24 YEAR OLD FEMALE24 YEAR OLD FEMALE

What else do you want to know?What else do you want to know?

History of STD’s? History of STD’s? Number of sexual partners? Number of sexual partners? IUD? IUD? Sexual orientation? Sexual orientation? Date of last menses? Date of last menses? Vaginal discharge?Vaginal discharge?

24 YEAR OLD FEMALE24 YEAR OLD FEMALE

WHAT IS YOUR DIFFERENTIAL?WHAT IS YOUR DIFFERENTIAL?

Ruptured Uterine Cyst, Ecoptic Pregnancy, Ruptured Uterine Cyst, Ecoptic Pregnancy, PID, Appendicitis (usually RLQ pain), UTI, PID, Appendicitis (usually RLQ pain), UTI, Ovarian TorsionOvarian Torsion

WHAT TEST DO YOU WANT TO ORDER?WHAT TEST DO YOU WANT TO ORDER?

Urine Pregnancy Test, CBC, CRP, Wet Urine Pregnancy Test, CBC, CRP, Wet mount & DNA probe for Gonorrhea mount & DNA probe for Gonorrhea &Chlamydia, Blood Cultures, Transvaginal &Chlamydia, Blood Cultures, Transvaginal pelvic ultrasoundpelvic ultrasound

24 YEAR OLD FEMALE24 YEAR OLD FEMALERESULTSRESULTS

WBC 13,000 with 9% BandsWBC 13,000 with 9% BandsCRP 5.3 (elevated)CRP 5.3 (elevated)Cr 1.0Cr 1.0Urine Preg. NegativeUrine Preg. NegativeBlood cultures NegativeBlood cultures NegativeVaginal Ultrasound- Positive for tubo-Vaginal Ultrasound- Positive for tubo-

ovarian abscess ovarian abscess

24 YEAR OLD FEMALE24 YEAR OLD FEMALE

Treatment: Hospitalize for IV Treatment: Hospitalize for IV antibiotics, gentle hydration, pain antibiotics, gentle hydration, pain management, consult OB/GYN may management, consult OB/GYN may need surgical intervention to drain need surgical intervention to drain abscess, remove IUDabscess, remove IUD

PID affects 1 million women annually PID affects 1 million women annually with ¼ requiring hospitalizationwith ¼ requiring hospitalization

Women under the age of 25 & sexually Women under the age of 25 & sexually active teens are at highest riskactive teens are at highest risk

24 YEAR OLD FEMALE24 YEAR OLD FEMALE

What are the two most common What are the two most common bacteria that cause PID?bacteria that cause PID?

Chlamydia trachomatis & Niesseria Chlamydia trachomatis & Niesseria gonorrhoeaegonorrhoeae

24 YEAR OLD FEMALE24 YEAR OLD FEMALE

36 hours later….36 hours later….

Afebrile with WBC 6,000 Bands 4% Afebrile with WBC 6,000 Bands 4% being discharged on PO antibioticsbeing discharged on PO antibiotics

85 YEAR OLD FEMALE85 YEAR OLD FEMALE

CC: 2 to 3 day onset of increased CC: 2 to 3 day onset of increased abdominal distention, increasing abdominal distention, increasing pain, & no BM, this a.m. onset of pain, & no BM, this a.m. onset of severe pain rates as “10” severe pain rates as “10”

PMH: CAD, Asthma, HTN, PMH: CAD, Asthma, HTN, Hyperlipidemia, OsteoarthritisHyperlipidemia, Osteoarthritis

Meds: ASA 81 mg Q Day, Lisinopril 10 Meds: ASA 81 mg Q Day, Lisinopril 10 mg Q Day, Advair 50/250 1 puff BID, mg Q Day, Advair 50/250 1 puff BID, Zocor 40 mg Q Day Zocor 40 mg Q Day

85 YEAR OLD FEMALE85 YEAR OLD FEMALE

VS 97.6 180/90 84 SpO2 91% (Room VS 97.6 180/90 84 SpO2 91% (Room Air)Air)

PE: Diaphoretic, ill appearing elderly PE: Diaphoretic, ill appearing elderly female, diffuse abdominal female, diffuse abdominal tenderness with palpable inguinal tenderness with palpable inguinal hernia, guarding with examhernia, guarding with exam

Lab: Cr 1.8 Hgb 11.6 WBC 13,000 Lab: Cr 1.8 Hgb 11.6 WBC 13,000

Bands 24% Bands 24%

85 YEAR OLD FEMALE85 YEAR OLD FEMALE

WHAT IS YOUR DIFFERENTIAL?WHAT IS YOUR DIFFERENTIAL?Small Bowel Obstruction, IschemicSmall Bowel Obstruction, IschemicBowel, AAA, Renal Calculi, Bowel, AAA, Renal Calculi, Diverticulitis, Pancreatitis, Diverticulitis, Pancreatitis, AppendicitisAppendicitisWHAT OTHER TESTS DO YOU WANT?WHAT OTHER TESTS DO YOU WANT?CT Abdomen/Pelvis, Amylase, Lipase, CT Abdomen/Pelvis, Amylase, Lipase, Coag. Panel Coag. Panel

85 YEAR OLD FEMALE85 YEAR OLD FEMALERESULTSRESULTS

Amylase/Lipase WNLAmylase/Lipase WNLCoag. Panel WNLCoag. Panel WNLCT Abd/Pelvis=Incarcerated Hernia CT Abd/Pelvis=Incarcerated Hernia

with SBOwith SBO

85 YEAR OLD FEMALE85 YEAR OLD FEMALE

Underwent partial colectomy with Underwent partial colectomy with repair of incarcerated herniarepair of incarcerated hernia

Post op she initially was hypovolemic, Post op she initially was hypovolemic, CVP was 3, received crystalloids, CVP was 3, received crystalloids, colloidscolloids

72 hours later….transferred to 72 hours later….transferred to med/surg floor, aggressive pulm. toiletmed/surg floor, aggressive pulm. toilet

Labs Cr 1.3 Hgb 10.6 WBC 6,000 Labs Cr 1.3 Hgb 10.6 WBC 6,000

Bands 6% Bands 6%

OTHER ABDOMINAL “PEARLS”OTHER ABDOMINAL “PEARLS”

Be open in your differential, think about age Be open in your differential, think about age & gender, as well as what organs are in the & gender, as well as what organs are in the region of painregion of pain

Thorough History and Review of SystemsThorough History and Review of Systems Don’t be afraid to touch an acute abdomenDon’t be afraid to touch an acute abdomen Rule out pregnancy in women of Rule out pregnancy in women of

childbearing agechildbearing age The appendix is the great masqueraderThe appendix is the great masquerader Don’t miss a surgical abdomen!!!Don’t miss a surgical abdomen!!!