CLINICAL PROBLEM SOLVING WHEN

YOU ARE ON CALL

Speaker: Jon Tomada, MD

CLINICAL PROBLEM SOLVING WHEN

YOU ARE ON CALL

How to work-up and manageABDOMINAL PAIN

Acute “Surgical” abdominal

• an acute intra-abdominal condition

• abrupt onset

• usually requires emergency surgical intervention

• inflammation

• perforation, rupture of abdominal organs

• obstruction

• infarction

Phone Call

•severity?

• localized or generalized?

•vital signs?

•new or recurrent?

•reason for admission?

•steroids?

Acute Surgical Abdomen

•anxious, in severe pain, pale

•signs of shock (tachycardia, hypotension, diaphoresis, confusion, oliguria)

•signs of peritonitis (rigid, involuntary guarding, rebound tenderness)

•abdominal distention

•tender pulsatile mass (AAA)

•vaginal bleeding (ectopic pregnancy)

Travel Time

Travel TimeLiver

Gallbladder Hepatic Flexure

Right lower lung

Travel TimeHeartAAA

StomachPancreasKidney(L)

Travel Time

SpleenSplenic flexure

Travel Time

AppendixTerminal ileum

Ovary(R)

Travel Time

Kidney(R)Intestines

OvaryFallopian tubes

Bladder

Travel Time

Left ColonOvary(L)

Travel Time

InfectionObstruction

Inflammatory bowel diseaseAppendicitisPeritonitis

DKA

Travel Time

ruptured viscus shock, peritonitis

ascending cholangitis

charcot’s triad

necrosis of viscusshock, lactic

acidosisintra-abdominal

hemorrhageruptured AAA

Bedside

•rapid visual assessment

•deceptive if on steroids or narcotics

•ABCs and vital signs (check orthostatics)

•start resuscitation if with shock

•consider acute surgical abdomen diagnoses if with shock

Bedside

•Precipitating/alleviating factors

•Quality

•Region/Radiation/Referred pain

•associated Symptoms

•Time

PQRST

Bedside

•Physical exam

•rectal and pelvic exam!

•Selective chart review

Acute Surgical Abdomen

A quick review

Acute Surgical Abdomen

ruptured viscus shock, peritonitis

ascending cholangitis

charcot’s triad

necrosis of viscusshock, lactic

acidosisintra-abdominal

hemorrhageruptured AAA

Acute Surgical Abdomen

•anxious, in severe pain, pale

•signs of shock (tachycardia, hypotension, diaphoresis, confusion, oliguria)

•signs of peritonitis (rigid, involuntary guarding, rebound tenderness)

•abdominal distention

•tender pulsatile mass (AAA)

•vaginal bleeding (ectopic pregnancy)

Acute Surgical Abdomen

• resuscitate if in shock; IVF and pRBC

• keep patient NPO, NGT if vomiting

• lab: CBC, BMP, amylase, lactic acid, PT/PTT, type and x-match, 2 sets of blood cultures

• stat CXR, KUB, lateral decub film

• stat ICU and Surgery consult

Common causes of Acute Non-surgical

Abdomen

A quick review

Acute Pancreatitis

•epigastric pain radiating to the back

•History of EtOH, gallstone, recent ERCP, hypertriglyceridemia

•elevated amylase and lipase, AXR

•IV fluids (0.9% NS 200-300cc/hr)

•NPO, pain control

Peptic Ulcer Disease/GERD

•burning pain from epigastric radiating to the neck, worse when supine

•trial of grasshopper

•H2 blockers versus PPI

•rule out GI bleed

•rule out Helicobacter pylori infection

Acute Pyelonephritis

•fever, nausea, vomiting, intermittent urination +/- dysuria

•flank tenderness, suprapubic tenderness

•blood cultures, urine culture, CT abdomen

•empiric IV antibiotics, anti-emetics

Nephrolithiasis

•colicky abdominal pain radiating to inguinal area, blood tinged urine

•IV fluids, pain management

•rule out urinary tract infection

Infectious Gastroenteritis

•fever, nausea, vomiting, diarrhea

•viral: IV fluids, anti-emetics

•bacterial: stool studies, empiric IV antibiotics

•C. difficile infection: isolation precautions, metronidazole versus PO vancomycin

Acute Cholecystitis

•female, fat, forty; nausea, vomiting

•history of GB stones

•RUQ tenderness

•empiric IV antibiotics, RUQ UTZ, HIDA scan

•rule out ascending cholangitis

Always remember...

•Call your senior resident if you need some assistance.

•Perform proper hand-offs and sign-out

CLINICAL PROBLEM SOLVING WHEN

YOU ARE ON CALL

How to work-up and manageABDOMINAL PAIN