clinical problem solving when you are on call
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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 manage ABDOMINAL PAIN. Acute “Surgical” abdominal. an acute intra-abdominal condition abrupt onset usually requires emergency surgical intervention. - PowerPoint PPT PresentationTRANSCRIPT
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