COMAT Emergency Medicine
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TABLE OF CONTENTS Preface........................................................................................................ 1 Introduction: About the COMAT Examinations ........................................... 5 Chapter One: Abdominal and Gastrointestinal Complaints ......................... 7 General Assessment of Abdominal Pain ......................................................................... 7 Aortic aneurysm .............................................................................................................. 11 Ruptured Abdominal Aortic Aneurysm......................................................................... 14 Appendicitis ................................................................................................................... 14 Bowel Obstruction ......................................................................................................... 16 Cholecystitis/Cholelithiasis ........................................................................................... 18 Diverticulitis................................................................................................................... 19 Gastroenteritis ............................................................................................................... 21 Acute Pancreatitis .......................................................................................................... 25 Key Takeaways ............................................................................................................... 27 Quiz ................................................................................................................................ 28 Chapter Two: Chest Pain and Related Disorders ....................................... 32 Evaluation of Chest Pain ................................................................................................ 32 Esophageal Spasm ......................................................................................................... 34 Acute Coronary Syndromes ........................................................................................... 34 Pericarditis ..................................................................................................................... 38 Pneumothorax................................................................................................................ 41 Pulmonary Embolism .................................................................................................... 43 Key Takeaways ............................................................................................................... 46
Quiz ................................................................................................................................ 47 Chapter Three: Environmental/Travel Disorders ...................................... 51 Chemical and Thermal Burns ........................................................................................ 51 Electrical Injuries ........................................................................................................... 54 Snakebites ...................................................................................................................... 56 Insect Stings ................................................................................................................... 58 Spider Bites .................................................................................................................... 60 Hypothermia .................................................................................................................. 62 Heat Cramps .................................................................................................................. 63 Heat Exhaustion ............................................................................................................ 64 Heatstroke ...................................................................................................................... 64 Key Takeaways ............................................................................................................... 66 Quiz ................................................................................................................................ 67 Chapter Four: Gastrointestinal Bleeding and Hemorrhage Control........... 72 External Bleeding ........................................................................................................... 72 Internal Bleeding ........................................................................................................... 74 Excessive Bleeding ......................................................................................................... 75 Gastrointestinal Bleeding .............................................................................................. 77 Upper GI Bleeding ......................................................................................................... 78 Lower GI Bleeding .........................................................................................................80 Variceal Bleeding ........................................................................................................... 81 Hemorrhoids .................................................................................................................. 82 Key Takeaways ............................................................................................................... 83 Quiz ................................................................................................................................ 84
Chapter Five: HEENT Disorders................................................................ 89 Acute Otitis Media ......................................................................................................... 89 Conjunctivitis ................................................................................................................. 90 Corneal Abrasion ........................................................................................................... 92 Blunt Eye Trauma .......................................................................................................... 94 Sore Throat..................................................................................................................... 96 Sinusitis .......................................................................................................................... 97 Headache........................................................................................................................ 99 Glaucoma ..................................................................................................................... 100 Epistaxis ....................................................................................................................... 102 Trauma to the Nasal Bones .......................................................................................... 103 Key Takeaways ............................................................................................................. 104 Quiz .............................................................................................................................. 105 Chapter Six: Mental Status Changes and Weakness ................................. 109 Delirium ....................................................................................................................... 109 Stroke ............................................................................................................................ 111 Hemorrhagic Stroke...................................................................................................... 114 Hypoglycemia ............................................................................................................... 115 Meningitis ..................................................................................................................... 116 Encephalitis................................................................................................................... 116 Seizure ........................................................................................................................... 118 Syncope ........................................................................................................................ 120 Weakness ...................................................................................................................... 121 Key Takeaways ............................................................................................................. 123
Quiz .............................................................................................................................. 124 Chapter Seven: OB/GYN Disorders ......................................................... 129 Spontaneous Abortion ................................................................................................. 129 Ectopic Pregnancy........................................................................................................ 130 Placenta Previa .............................................................................................................. 131 Placental Abruption ..................................................................................................... 133 Preeclampsia/Eclampsia ............................................................................................. 134 Pelvic Inflammatory Disease ....................................................................................... 135 Sexual transmitted infections ...................................................................................... 136 Key Takeaways ............................................................................................................. 139 Quiz .............................................................................................................................. 140 Chapter Eight: Poisoning/Overdose ........................................................ 145 Anion Gap Acidosis ...................................................................................................... 145 Poisoning...................................................................................................................... 146 Toxic Alcohol Overdoses .............................................................................................. 148 Salicylate Overdoses .................................................................................................... 150 Carbon Monoxide Poisoning ........................................................................................ 151 Overdoses of Opioids ................................................................................................... 152 Acetaminophen Overdoses .......................................................................................... 153 Key Takeaways ............................................................................................................. 154 Quiz ...............................................................................................................................155 Chapter Nine: Psychiatric Emergencies .................................................. 159 Psychiatric Evaluation ................................................................................................. 159 Managing Agitation ..................................................................................................... 162
Alcohol Withdrawal Management ............................................................................... 164 Psychosis ...................................................................................................................... 165 Suicidal Ideation or Attempt ....................................................................................... 166 Key Takeaways ............................................................................................................. 167 Quiz .............................................................................................................................. 168 Chapter Ten: Shock and Resuscitation ..................................................... 172 Basic airway management ............................................................................................172 Endotracheal Tube Insertion ........................................................................................175 Cardiopulmonary Resuscitation .................................................................................. 176 Dysrhythmia Identification and Management in a Code ............................................ 178 Types of Shock ............................................................................................................. 183 Treatment of Shock ...................................................................................................... 184 Key Takeaways ............................................................................................................. 186 Quiz .............................................................................................................................. 187 Chapter Eleven: Shortness of Breath ....................................................... 192 Evaluation of Dyspnea ................................................................................................. 192 Community-acquired Pneumonia ............................................................................... 195 Asthma Exacerbation ................................................................................................... 199 COPD Exacerbation ..................................................................................................... 199 Pulmonary Edema ...................................................................................................... 200 Epiglottitis ....................................................................................................................202 Key Takeaways ............................................................................................................. 203 Quiz ..............................................................................................................................204 Chapter Twelve: Traumatic Injuries ........................................................ 209
Abdominal Trauma ......................................................................................................209 Chest Trauma ............................................................................................................... 210 Fracture Care ................................................................................................................ 211 Spinal Trauma .............................................................................................................. 213 Head Trauma ............................................................................................................... 215 Pediatric Child Abuse....................................................................................................217 Domestic Violence ....................................................................................................... 219 Key Takeaways .............................................................................................................220 Quiz .............................................................................................................................. 221 Chapter Thirteen: Wounds and Laceration Care ..................................... 226 Puncture Wounds ........................................................................................................ 226 Animal Bites ................................................................................................................. 227 Laceration Care ............................................................................................................ 229 Tetanus Prophylaxis..................................................................................................... 232 Key Takeaways ............................................................................................................. 233 Quiz .............................................................................................................................. 234 Summary ................................................................................................ 238 Course Questions .................................................................................... 242 Answers to Course Questions .................................................................. 301
PREFACE The purpose of this audio course is to prepare the osteopathic student for the clinical series of COMAT examinations, which are sponsored by and provided to students by the National Board of Osteopathic Medical Examiners. This is actually a series of shorter examinations on eight core clinical areas of practice by the doctor of osteopathy. The world of osteopathy is a large one, encompassing all the different areas of medicine plus specialized care given by the general osteopathist. The area of study in this course is emergency medicine. You will take the COMAT examination in emergency medicine after your emergency medicine rotation. In the introduction to the course, we will talk about the COMAT examination itself as well as how you can prepare for it. Upon finishing the course, you should have a solid basis of understanding of the practice of osteopathy in emergency medicine and will have reviewed each of the topics represented in the COMAT exam. The introduction to the course will teach you specifically about the examination itself. As you will see, each of the tests have a specific format and rules you will need to follow when you take the examination. The COMAT examinations are standardized to give everyone a reliable way to demonstrate their knowledge and skills on the different exams. Chapter one in the course represents the abdominal and gastrointestinal complaints you will most likely encounter in an emergency medicine practice and reflects the content on the COMAT emergency medicine examination. Areas covered include abdominal pain, gastrointestinal bleeding, bowel obstruction, certain infectious processes, gallbladder disease, and hepatitis. As will be asked of you in all areas of the clinical COMAT examination, you will focus on patient presentation, differential diagnosis, and management of the patient in an emergency situation. Chest pain is a common complaint in the emergency department; this is the main topic of discussion in chapter two. While each case must be treated as though it represents a serious process, most cases seen do not represent serious pathology but are secondary to
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anxiety or chest wall pain. What follows in this chapter is a discussion of the emergency medicine approach to chest pain and information on some known causes of chest pain and related symptoms seen in the emergency setting. Chapter three in the course covers environmental and travel disorders, including the different types of burns, snakebites, other envenomation’s, hypothermia, and heatrelated injuries, including heatstroke. These are problems that bring patients into the emergency department for treatment every day, although you will need to familiarize yourself with those things that are most likely to affect your patients in your community and in different weather situations. The purpose of chapter four is to discuss the control of hemorrhaging, including gastrointestinal hemorrhaging. Hemorrhage itself takes on a relatively high priority, after airway and breathing. You need to recognize both internal and external bleeding and treat the patient accordingly. GI bleeding can come from many different sources in the GI tract. Depending on the severity of the bleeding, your treatment may be an urgent matter. Chapter five in the course includes the different head, eye, ear, nose, and throat disorders seen in emergency medicine. There is a variety of infectious processes linked to the ear, nose, and throat that are covered in this chapter. In addition, headaches, eye diseases, and facial trauma fall in this category as part of what you will encounter in the emergency department. Chapter six talks about issues related to the central nervous system and related phenomena. The patient with weakness or a mental status change can have a variety of different underlying etiologies, which range from metabolic diseases to actual central nervous system diseases. This chapter will focus on these types of conditions and how they are managed in the emergency department setting. Chapter seven in the course refers to the different gynecological and obstetric conditions encountered in emergency medicine. The pregnant woman can present with a variety of emergency conditions, some of which are true obstetrical emergencies. Women who are not pregnant can still present with complaints that are seen and
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evaluated in the emergency department; these kinds of things are discussed as part of this chapter. Chapter eight talks about the different conditions you will be asked to manage in the emergency department that are related to the use of substances that lead to poisoning, overdose, or withdrawal symptoms. Some of these patients come with a clear history, while others present with symptoms suggestive of toxicity and a medical puzzle as to what might be the causative agent. The different toxic ingestions are covered in this chapter. Chapter nine in the course discusses psychiatric emergencies in the emergency medical setting. There are a great number of emergency department visits related to psychiatric problems. For this reason, the emergency department physician should know how to handle these types of emergencies. Discussed in this chapter are the psychiatric examination, handling the agitated patient, the identification and management of psychosis, and the management of suicidal behavior. Chapter ten deals with shock and the resuscitation of the patient. These are critical care issues that come up all the time in the emergency department. You will need to refresh yourself on airway management, cardiopulmonary resuscitation, identification and management of arrhythmias, and the treatment of shock in an emergency setting. Each of these is dealt with as part of this chapter. The focus of chapter eleven in the course is the different manifestations of dyspnea or shortness of breath. The patient with a variety of diseases can have shortness of breath as their primary complaint in the emergency department. The evaluation of dyspnea is covered in this chapter because the approach to this can involve a great many differential diagnoses. Primary lung diseases leading to dyspnea include asthma and COPD. Infections like pneumonia can be causes of dyspnea. Heart failure and epiglottitis can also lead to shortness of breath in the emergency department. Chapter twelve is about the management of traumatic injuries. Traumatic injuries generally present to the emergency department for evaluation and early management. These injuries can come from automobile accidents, falls, sporting injuries, and violent
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acts. The different types of traumatic injuries you can encounter are discussed in this chapter. The topics in chapter thirteen in the course are traumatic wounds, the management of lacerations, and tetanus prophylaxis in wound care. Not every wound need suturing, depending on the nature of the injury. Animal bites represent special wounds requiring advanced care measures. The management of lacerations is covered in this chapter as well as guidelines for how you can prevent the complication of tetanus after the patient has sustained a wound.
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INTRODUCTION: ABOUT THE COMAT EXAMINATIONS The Clinical COMAT examinations cover eight different areas of osteopathic medicine. Each examination covers one clinical area. The tests are administered by various colleges of osteopathic medicine (COMs) and the term COMAT means Comprehensive Osteopathic Medical Achievement Test. The examinations are given by computer and are each 125 questions in length. You, the test taker, are given two hours and thirty minutes to take the examination. The COMAT examination you take will not be the same examination each time you take it; they are given and proctored by the individual COMs. You will not be allowed access to books, a cell phone, or another computerized device or tablet while you are taking the test. The test is in a multiple-choice format with five possible choices per question. The clinical COMAT examination is given after you have gained clinical knowledge about how to care for patients with certain medical and osteopathic conditions. The examination you are given is designed to test what you have learned in your clinical rotations. The examinations are structured so that the mean on the test is 100 points with a standard deviation of 10 points. In many ways, it tests not only your clinical skills but the teaching abilities of your college. The information from the examination scores are used to help the college improve their curriculum and standards. COMs are allowed to give a COMAT examination up to 10 times per year with each test being different but otherwise reliable and comparable to the other tests. The COMAT examinations are structured in two seamless dimensions. The first dimension involves patient presentation in multiple areas of each topic. The second dimension focuses on physician tasks, such as the history and physical examination, differential diagnostic processes, management of disease states and, in some cases, procedures necessary to be able to perform. The NBOME or National Board of Osteopathic Medical Examiners website offers specifics of how these things are
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weighted in each examination. This audio course has been designed to accurately reflect the subject material and question format you will encounter as part of the actual COMAT Examinations.
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CHAPTER ONE: ABDOMINAL AND GASTROINTESTINAL COMPLAINTS This chapter presents the abdominal and gastrointestinal complaints you will most likely encounter in an emergency medicine practice and reflects the content on the COMAT emergency medicine examination. Areas covered include abdominal pain, gastrointestinal bleeding, bowel obstruction, certain infectious processes, gallbladder disease, and hepatitis. As will be asked of you in all areas of the COMAT examination, you will focus on patient presentation, differential diagnosis, and management of the patient in an emergency situation.
GENERAL ASSESSMENT OF ABDOMINAL PAIN Abdominal pain is a common complaint and is not often a severe condition. The patient with sudden and severe abdominal pain, however, has a high chance of having intraabdominal disease that may require surgery. In some case, intestinal gangrene and perforation can complicate the clinical picture, leading to death within six hours of pain onset. The patients you need to worry about the most are those who are very young, the elderly patient, and the patient with some type of immunosuppression, including those taking corticosteroid drugs. You should always remember that not everyone reacts the same to painful circumstances. Infants and young children often cannot localize their pain well and there will be others who exaggerate their level of pain. Still other will be stoic, particularly the elderly, so any complaint of pain needs to be taken seriously until proven otherwise. The definition of the acute abdomen is pain with concerns based on the pain and physical or laboratory findings that suggest the need for a surgical consult. In evaluating the individual with abdominal pain, you need to consider that different types of pain will have different characteristics. Visceral pain originates in the abdominal viscera, which are innervated specifically by nerves of the autonomic nervous system. This type of pain does not localize easily but is described as dull, crampy, vague, 7
and/or nauseating. It is best described as upper, middle, or lower abdominal pain. Upper pain comes from the stomach, liver, duodenum, or pancreas. Middle pain or periumbilical pain is seen with early pain originating from the small bowel, appendix, or proximal colon. The hindgut structures will yield lower abdominal pain, coming from the genitourinary system or the distal colon. Pain that is well localized and sharp tends to be called somatic pain because it comes from irritation or inflammation of the parietal peritoneum. The underlying processes can be chemical, infectious, or inflammatory. Abdominal pain-related processes that progress over time generally start out visceral and become somatic as the parietal peritoneum becomes involved. Referred pain should always be considered when the pain is not explained by the examination. The perception of pain is different than its origin. It stems from the relationship of nerve fibers at the level of the spinal cord. Right scapular pain is a referred pain from the biliary tract, while left or right shoulder pain comes often from the diaphragm. Consider groin pain to be possibly referred pain from the kidneys and/or ureters. Peritonitis is best defined as inflammation of a structure in the peritoneal cavity. The most serious presentation of this comes from some type of gastrointestinal tract perforation. This can include perforation of the appendix, any part of the small bowel, or colonic diverticula. Mesenteric ischemia is particularly severe because it easily perforates the bowel and affects a large portion of the bowel. Pelvic inflammatory disease, ruptured ectopic pregnancy, pancreatitis, ruptured aortic aneurysms, and trauma lead to peritoneal inflammation due to the accumulation of blood or inflammatory cells. Bowel obstruction with strangulation of the bowel can cause this type of pain as well. The rare patient will develop spontaneous bacterial peritonitis from infection in the peritoneal cavity of hematogenous origin. Patients with cirrhosis and ascites have the greatest risk of spontaneous bacterial peritonitis. Patients who have peritoneal dialysis catheters, drains or shunts in the peritoneum will have an increased risk of peritonitis.
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Peritonitis rarely remains as an isolated event. There can be massive shifts in fluid into the peritoneal cavity, culminating in electrolyte disturbances and severe intravascular dehydration. The patient can develop shock, adult respiratory distress syndrome, disseminated intravascular coagulation, and multisystem organ failure, leading to death in some cases, despite adequate treatment. When evaluating the patient with abdominal pain, it helps to know the different common localizations seen in abdominal pain. Diffuse abdominal pain can be minor or ultimately severe, due to a variety of different possible etiologies. You should always consider extra-abdominal causes of abdominal pain. Pain located in the right upper quadrant is most likely to be associated with the gallbladder or liver but appendicitis can localize there in the patient who is in the advanced stages of pregnancy. Left upper quadrant pain is related to the stomach or spleen. Left lower abdominal pain is generally related to the colon, such as would be seen in diverticulitis, but gynecological causes and renal cause of the pain need to be considered. Right lower quadrant abdominal pain might also be renal or gynecological but is classically seen with appendicitis. Other considerations should include mesenteric adenitis and cecal or Meckel diverticulitis. Women with lower abdominal pain can have ovarian sources, endometriosis, ectopic pregnancy, or Mittelschmerz pain as causes of their pain. In men with lower abdominal pain, consider hernias or testicular torsion. If the patient is a neonate or infant, the differential diagnosis of probable abdominal pain should be expanded to include things not seen in older patients, such as meconium peritonitis, necrotizing enterocolitis, volvulus, imperforate anus, pyloric stenosis, atresia of the intestinal tract, and intussusception. The evaluation of all types of abdominal pain is basically the same, except that, for severe pain, a surgical consult is done earlier than with milder pain. All women of reproductive age should have a pregnancy test performed relatively early in the diagnostic process because the differential diagnosis changes markedly with a positive pregnancy test. The patient with milder pain can have diagnostics prior to surgical consultation.
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In obtaining a history, ask about the timing and characteristics of the pain. Ask about related GI symptoms, like nausea, vomiting, diarrhea, constipation, and heartburn. Ask about genitourinary symptoms as well as reproductive tract symptoms in both men and women. Medication history is important as many drugs have GI side effects. Alcohol and drug consumption should be asked about. The patient’s general appearance is very important as this represents how much of their energy is spent fighting the pain. Vital signs can help define a seriously ill patient versus one who is not as ill. Look and listen to the abdomen before percussion and palpation. Rectal and pelvic examinations may be necessary. In palpating, look for involuntary guarding of the abdominal muscles, rigidity, and rebound tenderness, which all suggest inflammation or irritation of the peritoneum. Palpate the inguinal area and all surgical incisions for the possibility of hernias. You should increase your concern for the patient if you uncover signs of peritonitis, shock, abdominal distention, or very severe pain. Specific things you should consider that come with your physical findings and history include the following: •
Bowel obstruction—look for distention, tympany, increased bowel sounds, or high-pitched peristaltic sounds.
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Peritonitis—look for the patient who does not want to move at all and who has a silent belly.
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Abdominal aortic aneurysm—look for back pain, shock, and a pulsatile mass.
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Ectopic pregnancy—look for vaginal bleeding and shock.
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Biliary colic or renal colic—look for patients who are writhing around in pain.
Your evaluation should include the standard CBC and urinalysis but these are not very specific or sensitive. Serum lipase elevations indicate a high likelihood of pancreatitis. Always do the pregnancy test as we have already discussed. If obstruction is expected, get a flat plate and upright or lateral recumbent film to look for air-fluid levels. This type of x-ray is unhelpful in almost all other cases. Ultrasound is a better test for ectopic pregnancy, abdominal aortic aneurysm, or appendicitis in children. Kidney stones can be seen on noncontrast helical CT scan. A CT with oral and IV contrast will be extremely
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helpful in the majority of other causes of pain and can decrease the rate of a negative laparotomy. Obvious symptoms and signs of a surgical abdomen, however, are best evaluated with a laparotomy. Pain can be treated, particularly after the examination. Consider morphine or fentanyl intravenously as these will decrease the patient’s anxiety and will not mask the evidence of peritonitis. There is no evidence that treating the pain has an adverse effect on the patient’s outcome and will keep the patient more comfortable during the workup of the pain.
AORTIC ANEURYSM In the emergency room, managing an aortic aneurysm usually means managing an aortic dissection. With an aortic dissection, there is a tear in the intimal layer of the artery with blood surging through the tear, leading to a false passage and secondary hemorrhage. Any part of the aorta may be affected with a dissection. The major predisposing factor for this is hypertension. Patients with an aortic dissection can have the sudden onset of chest or back pain that can be severe. About 20 percent of patients die before they are seen in the ED, while an additional third will die in surgery or from postoperative complications. It is particularly common in African-Americans, the elderly, and those with underlying hypertension. The peak ages are between 50 and 65 years of age. Patients who have Ehlers-Danlos syndrome or Marfan syndrome have an increased risk of dissection at a younger age. Figure 1 shows what a dissecting aortic aneurysm looks like:
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Figure 1.
There are a couple of ways to classify an aortic dissection. The DeBakey classification involves three types: •
Type I—the dissection begins in the ascending aorta and extends to the aortic arch.
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Type II—These start in the ascending aorta and are confined to this area.
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Type III—this is the least common and starts in the descending aorta. It may be above or below the diaphragm.
With the Stanford system, there are two types. In type A, the ascending aorta is involved, while in type B, the descending aorta is involved. The aorta is under varying degrees of hydraulic stress. The two areas most vulnerable are the right lateral aspect of the ascending aorta near the aortic valve and the proximal descending aorta. Dissections happen with preexisting aortic disease, such as atherosclerosis, hypertension, and connective tissue diseases like Marfan syndrome and Ehlers-Danlos syndrome. Smoking, cocaine use, and dyslipidemia all contribute to atherosclerosis. The major complications of an aortic dissection include having a compromise in the circulatory status in branches off the aorta, aortic valve regurgitation, heart failure, and
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rupture of the aorta into the pericardium, pleural space, or right atrium. This last complication is commonly fatal. The patient will have the sudden onset of pain between the scapula, chest pain, or abdominal pain. The person will feel a ripping kind of pain and comes on suddenly. The pain will migrate as the dissection gets larger with about one-fifth of patients having syncope for a variety of reasons, including pain and aortic baroreceptor activity. Interruptions in blood flow can lead to a myocardial infarction, stroke, intestinal infarction, paraplegia, or renal failure. The diagnostics of an aortic aneurysm include listening for an aortic regurgitation murmur, seen in half of all patients. One-fifth of patients will have decreases in pulses noted in one or more artery and heart failure can be seen if aortic regurgitation is present. Pleural effusions can be seen if blood or inflammatory fluid builds up in the pleural space. Cardiac tamponade can occur. Tests used to confirm the diagnosis include a transesophageal echocardiogram, magnetic resonance angiography, or CT angiography. Unequal pulses in the extremities should trigger these diagnostic tests. A chest x-ray will often show mediastinal widening from an underlying aneurysm. The CTA test is often the most available with a positive predictive value of 100 percent. MRA is the best test in terms of sensitivity and specificity but it is not suited for emergency detection of the aortic aneurysm. Contact a vascular surgeon early in the diagnostic process. The treatment in the emergency department is beta blockers to decrease blood pressure and prevent furthering of the dissection. Both endovascular and open repair can be used as definitive treatment for an aortic dissection. Intra-arterial blood pressure monitoring and urine output monitoring are used for the patient who doesn’t require emergency surgery. Don’t forget to type and crossmatch for a minimum of 4 units of packed red blood cells if surgery is anticipated. Blood pressure reducers for an aortic dissection include metoprolol, labetalol, esmolol, verapamil, or diltiazem. If nitroprusside is to be used, it should never be used alone as it will activate the sympathetic nervous system if not given along with a calcium channel blocker or beta blocker.
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Not all patients require surgical repair of their dissection. This is especially true for stable patients who have descending aortic dissections. Ascending aortic dissections are more serious and almost always require surgical repair. Surgical complications include paraplegia, stroke, renal failure, and death. A repeat of the dissection can happen as a late complication.
RUPTURED ABDOMINAL AORTIC ANEURYSM Abdominal aortic aneurysms are usually minimally symptomatic until they dissect or rupture. The patient with a ruptured aortic aneurysm may or may not know they have an aortic aneurysm. Most patients with a mild rupture have vague back pain, abdominal pain, and a palpable abdominal mass that is pulsatile. Less commonly, symptoms can be syncope, paralysis, groin pain, or a mass in the flank. It can easily be confused with lumbar disease, kidney stones, diverticulitis, or any other cause of abdominal pain. One key feature you might find is transient hypotension that can temporarily resolve until it leads to the rapid onset of shock over a few hours. These patients will be cyanotic with mottled skin, and will have hypotension, altered mental status, and rapid heart rate. About two-thirds of patients will rapidly progress to complete cardiovascular collapse and sudden cardiac death before arrival to an emergency department. Ruptures can happen into the vena cava, leading to an arteriovenous fistula that presents with a loud abdominal bruit, peripheral ischemic findings, congestive heart failure, leg swelling, and tachycardia. If the rupture is into the duodenum, expect to see massive upper GI bleeding and rapid exsanguination.
APPENDICITIS The most common cause of a surgical acute abdomen in the US is appendicitis, affecting 5 percent of people, usually in the teens and 20s. There is an increased risk with those who have inflammatory bowel disease, villous adenomas, localized cancer, diverticula, or carcinoid tumors. In most cases, the problem is caused by some type of obstruction of the lumen of the appendix because of the presence of a foreign body, fecalith, or worms. Lymphoid 14
hyperplasia can obstruct the lumen as well. Bacteria will overgrow and there will be inflammation and appendiceal ischemia, sometimes leading to necrosis and perforation. Abscesses can develop. Expect to see periumbilical abdominal pain, anorexia, nausea and vomiting in the beginning. This shifts to involve right lower quadrant pain and rebound tenderness at McBurney point, which is located along a line from the umbilicus to the anterior superior iliac crest. Figure 2 shows where McBurney point is located:
Figure 2.
Classic findings are seen with less than half of all patients. Patients can have diarrhea or constipation and RBCs or WBCs in the urine. Pregnant women can have atypical presentations from a gravid uterus. Clinical evaluation is nevertheless important as is an abdominal CT scan or ultrasound. If the signs on exam and laboratory evaluation are classical, a laparotomy should be done without further diagnosis. The CT scan is very
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accurate but involves radiation exposure. The ultrasound will sometimes be complicated by intestinal gases. The mortality rate is more than 50 percent if there is no treatment. If treated surgically, the mortality rate is less than one percent. The treatment is largely surgical but IV fluids and antibiotics play a role. Patients who have inflammatory bowel disease of the cecum should not have surgical excision. Third generation cephalosporins are most commonly used prior to surgery.
BOWEL OBSTRUCTION A bowel obstruction or intestinal obstruction is a mechanical blockage of the intestines with limited passage of intra-intestinal contents through the intestinal lumen. Patients will have a lack of flatus, obstipation, crampy pain, and vomiting. It can involve the large or small intestine. Most partial obstructions do not require surgery, while 85 percent of complete obstructions require surgery. The most common causes of obstruction include adhesions, tumors, and hernias. In the postoperative patient, adhesions are the most common cause of this problem. Other less common causes include intussusception, diverticulitis, volvulus, foreign bodies, and fecal impaction. If the obstruction is purely mechanical, it is rare to have vascular compromise. Fluid, secretions, and food will accumulate above the level of obstruction with distention of proximal bowel. There will be congestion and edema of the bowel, which progresses the problem. If the blood flow strangulates the bowel, this can lead to perforation secondary to gangrene. Perforation can be segmental in an ischemic segment; perforation can also be secondary to marked dilation of the intestine above the obstruction. Small bowel obstruction happens quickly, with periumbilical or epigastric pain, obstipation, and vomiting. Partial obstruction often leads to diarrhea. Steady pain suggests strangulation. Listen for hyperactive and high-pitched bowel sounds. Dilated loops of bowel may be palpable. If there is infarction, the bowel will be silent; late findings are oliguria and shock.
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Large bowel obstruction happens more slowly over time and involves fewer symptoms than is seen in small bowel obstruction. A major finding is increased constipation that leads to obstipation. Vomiting is less common. Patients will have lower abdominal cramps, abdominal distention and loud bowel sounds. The rectum will be empty. Sometime a mass can be detected on palpation. One difference between most causes of obstruction and volvulus is that the volvulus involves a more abrupt onset. As mentioned, a flat and upright of the abdomen or a flat and lateral recumbent film will be helpful in a bowel obstruction. Serial x-rays can sometimes detect strangulation early. If there is acidosis and leukocytosis, this can also suggest strangulation. A CT scan of the abdomen will also show obstructive pathology in the abdomen. Gas in the bowel wall suggests necrosis and gangrene. In treating the patient, provide IV fluids and nasogastric suction with IV antibiotics if bowel ischemia is suspected. Involve a surgeon early in the process. The antibiotic of choice is a third-generation cephalosporin, such as cefotetan. With duodenal obstruction, resection may be necessary; if it is not possible, a palliative gastrojejunostomy is performed. Gallstones are removed if these are causative but a cholecystectomy is not done if the patient is very sick. Hernias should be repaired and adhesions lysed if these are behind the obstruction. Recurrent adhesional obstruction are treated with NG tube insertion rather than surgery. Patients with obstruction secondary to cancer may be able to have tumor resection unless the cancer is disseminated. Specialized cases of obstruction include diverticulitis, which is often complicated by perforation. It may be difficult to remove the diverticula so a colostomy may be necessary with reanastomosis done at a later date. Fecal impaction can be cleaned out manually. A cecal volvulus can be resected with immediate anastomosis.
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CHOLECYSTITIS/CHOLELITHIASIS Acute cholecystitis involves gallbladder inflammation, often developing over several hours. It is almost always caused by an obstructing gallstone in the cystic duct. Common symptoms include right upper quadrant abdominal pain, nausea, vomiting, chills, and fever. More fluid builds up in the gallbladder lumen and there will be mucosal injury and ischemia or necrosis. Perforation can result from this. Acute acalculous cholecystitis involves gallbladder inflammation without stone formation. Only about five to ten percent of attacks are caused by this phenomenon. Predisposing factors include bile stasis from prolonged fasting or total parenteral nutrition, severe or critical illness, vasculitis, immunodeficiency, and shock. It is uncommon to have acute cholecystitis without prior attacks of cholelithiasis. The pain is more severe and long-lasting with cholecystitis versus cholelithiasis. A positive Murphy sign involves pain on deep inspiration when palpating the right upper quadrant. Guarding and low-grade fever are common. Older patients will have fever, malaise, anorexia, and weakness. It will resolve within a week in 85 percent of patients in the absence of treatment. About 10 percent of patients will perforate locally and one percent can have free perforation. Those with perforation have a high risk of peritonitis. Expect the possibility of perforation or empyema with pus in the gallbladder if you see evidence of rebound tenderness, high fever, rigors, ileus, and increasing abdominal pain. Jaundice is seen if there is cholestasis. Other complications include impaction of the cystic duct with compression of the common bile duct, called Mirizzi syndrome, gallstone pancreatitis, and erosion of the gallstone through the gallbladder wall, called a cholecystoenteric fistula. The diagnosis of acute cholecystitis can be made clinically with or without a diagnostic ultrasound, which is the best way to detect gallstones. Cholescintigraphy can be helpful, which looks at radionuclide filling of the gallbladder, which will be minimal in cases of acalculous cholecystitis. Morphine can be given as a provocative agent to minimize the risk of false-positive cholescintigraphy testing.
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Once you have determined that the patient has acute cholecystitis, admit the patient with IV fluids and analgesic therapy. Do not allow oral intake and use NG suction if there is vomiting or an ileus. The antibiotic choices used most often empirically are ceftriaxone plus metronidazole or piperacillin/tazobactam. Surgery is curative and should be done early if there is a low surgical risk, a high risk of complications, or evidence of perforation, gangrene, empyema, or acalculous cholecystitis.
DIVERTICULITIS Diverticulitis involves infection or inflammation of a diverticulum in the colon. Because these often obstruct the lumen of the diverticulum, these can lead to a bowel wall phlegmon, perforation, abscess, fistula formation, or peritonitis. Most people have multiple diverticula but rarely have true diverticulitis of more than one of these at a time. Figure 3 shows what diverticulitis looks like:
Figure 3.
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The majority of elderly people have diverticulosis, which is largely asymptomatic. Only about 4 percent of patients with diverticulosis develop diverticulitis. Diverticulitis can be acute or chronic with frequent recurrences. The process can be inflammatory or infectious and may be viral or bacterial. There is no relationship between eating seeds, corn, popcorn, or nuts and developing diverticulosis. Diverticulitis can be uncomplicated or complicated, with the majority being uncomplicated. Complicated disease involves obstruction, perforation, abscess formation, and fistulae. Abscess formation is seen in 15 percent of complicated cases. Common signs and symptoms include left lower quadrant abdominal pain, the finding of a palpable sigmoid colon, nausea, vomiting, and fever. Bladder irritation can lead to UTI symptoms. Those with abscesses or perforation have a high incidence of classic peritoneal signs. Fistula can present with air or feces in the urine or feces in the vaginal discharge. Abscesses can open out into the skin itself. Bowel obstruction is possible but GI bleeding would be rare. The diagnosis of acute diverticulitis is best made with an abdominal and pelvic CT scan. After resolution of symptoms, a colonoscopy can be diagnostic. Because other GI or gynecological conditions can mimic diverticulitis, diagnostic testing should be done. An MRI can be done if there are issues about radiation, such as would be seen in pregnant patients. The treatment largely depends on the severity of the disease process. Some can be managed with a liquid diet at home. Nothing by mouth is recommended for patients with more severe disease. Antibiotics, percutaneous drainage under CT guidance, or surgery may also be indicated. Antibiotics are no longer recommended in all cases, particularly if they are uncomplicated. If antibiotics are indicated, coverage should be for gram-negative bacteria and anaerobes. Choices include ciprofloxacin plus metronidazole, Bactrim plus metronidazole, amoxicillin plus clavulanate, or moxifloxacin plus metronidazole. The standard of care for abscesses is percutaneous drainage with ultrasound guidance. Surgery is reserved for those with peritonitis and free perforation or for people that are not responding to conservative treatment. An elective segmental colectomy is 20
recommended for those who have complicated diverticulitis after resolution of their symptoms. This is because an immediate reanastomosis can be performed.
GASTROENTERITIS Gastroenteritis represents some type of inflammation of the stomach, small and large intestinal linings. The majority of these will be infectious process, although drugs and toxins can lead to similar symptoms. Most of the causes will spread from the fecal-oral route, waterborne infectious organisms, or foodborne infectious organisms. Typical symptoms include nausea, vomiting, anorexia, vague abdominal pain, and diarrhea. This is usually a self-limited disease with fluid losses minimal and well-tolerated in the healthy person. It becomes more difficult and problematic for the very young or very old person, or in those who are immunosuppressed. The most common organisms are viruses, bacteria, or parasites. The most common virus infections of the GI tract are the norovirus and rotavirus infections. Viruses by themselves cause most cases of gastroenteritis. The viruses enter the enterocytes of the intestines, affecting carbohydrate absorption. The diarrhea will be watery without white blood cells or red blood cells in the feces. Norovirus is the main cause of gastroenteritis in adults but it can be seen in children as well. It is mainly seen in the winter months and is now more common in children because of rotavirus vaccinations given to babies. This can be a waterborne or foodborne infection and it is highly contagious in crowded facilities. It takes 24 to 48 hours before the symptoms become apparent. Rotavirus infections remain the most common infectious causes of gastroenteritis in young kids throughout the world but the incidence has dramatically decreased in the US because of vaccinations against the virus given to babies. It is highly contagious and passed through the fecal-oral route. It can also affect adults with an incubation period of 1 to 3 days. It is usually seen in the winter months. Less common causes of viral gastroenteritis include astrovirus, which is seen in all ages with a 3 to 4-day incubation period. Adenoviruses can also cause infectious diarrhea in
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the summertime, also through the fecal-oral route. Enterovirus and cytomegalovirus can cause gastroenteritis in immunosuppressed patients. There are many causes of bacterial gastroenteritis, including Campylobacter, Salmonella, Shigella, E. coli type O157:H7, and Clostridium difficile. The infection can develop because of enterotoxins, which adhere to the mucosa and block intestinal absorption of nutrients. Look for an enterotoxin being the cause in C. difficile infections, E coli infections, and Vibrio cholerae gastroenteritis. The person will have watery diarrhea as a result. Other bacteria will produce exotoxins, such as Staphylococcus aureus and Clostridium perfringens. The infection itself does not have to be present; the presence of the toxin is enough to cause the symptoms. The disease is usually foodborne and things like nausea, vomiting, and diarrhea are seen within 12 hours of the toxin ingestion. It resolves spontaneously. Those bacteria that cause disease through mucosal invasion include Campylobacter, Salmonella, Shigella, C. difficile, and some E. coli infections. There will be ulceration of the mucosa with GI bleeding and bloody diarrhea. The stool will show WBCs and RBCs in the sample. It can be transmitted in several different ways, usually from undercooked poultry, unpasteurized milk, animal-borne disease, undercooked eggs and unwashed vegetables in certain parts of the world. E. coli represents a unique case because there are many subtypes that can cause gastroenteritis, with differing symptoms. Enterohemorrhagic E. coli is the strain called O157:H7. It is the most common subtype and comes from unpasteurized milk or juice, undercooked ground beef, and contaminated water sources. It can be passed through the fecal-oral route or through water exposure in contaminated bodies of water. Hemolytic-uremic syndrome can develop as a complication in up to 10 percent of cases. Other E. coli subtypes include enterotoxigenic infections, which cause disease because of toxins. It commonly causes traveler’s diarrhea. Enteropathogenic E. coli leads to watery diarrhea and is seen in nurseries. Enteroinvasive E. coli infections are seen in the developing parts of the world and may lead to bloody or non-bloody diarrhea.
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Enteroaggregative E. coli is a milder type of gastroenteritis, which can be a cause of lingering traveler’s diarrhea. Clostridium difficile used to be causative mainly of hospital-based infections. In the last 20 years, however, a community-acquired strain called the NAP1 strain is in the environment, leading to the most common bacterial cause of diarrhea in the United States. It occurs outside of the hospital setting. Less common causes of bacterial gastroenteritis include Yersinia enterocolitica, Vibrio cholerae, Vibrio parahaemolyticus, and listeria infections. Aeromonas infections come from brackish water that is consumed or swam in. Plesiomonas infections happen when eating raw shellfish in tropical parts of the world. Parasitic infections usually involve Giardia or Cryptosporidium infections. Giardia can adhere to the intestinal mucosa, leading to typical gastroenteritis infection symptoms plus generalized malaise. It can be an acute or chronic infection that leads to malabsorption. It can be passed through the fecal-oral route or through drinking contaminated water. Cryptosporidium infections are self-limited in the healthy host and comes from drinking contaminated water. It can be gotten in swimming pools because it doesn’t kill easily through chlorination. Amoebiasis is common in developing countries but not in the US. Look for a sudden onset of typical symptoms in all cases of gastroenteritis, although some will lead to myalgias, malaise, and prostration. Muscle guarding can be present. Bowel sounds will be hyperactive. Look out for dehydration, which can lead to renal failure, shock, and cardiovascular collapse. Metabolic acidosis is seen with diarrhea, while metabolic alkalosis is seen with prominent symptoms of vomiting. Vomiting and diarrhea both can cause hypokalemia. Test the patient with stool testing, particularly if the diarrhea is bloody. Stool cultures can be done as well as a stool analysis for WBCs and RBCs. If there has been an outbreak, recent travel, or ingestion of possibly contaminated food or water, suspect gastroenteritis rather than something like appendicitis or ulcerative colitis. There now exists multiplex polymerase chain reaction testing that can get at the causative organism
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but these are expensive to do if you don’t have a strong suspicion of one organism over another. The CBC will be nonspecific but you should get serum electrolytes and kidney function studies. Obtain an acid-base status in the very sick patient. Eosinophilia in the blood points to a parasitic disease process. Kidney function testing can detect hemolyticuremic syndrome in its early stages. The treatment is supportive in the majority of cases. Rest and oral glucose plus electrolyte solutions can be helpful to treat mild dehydration. If there is more severe infection involved, consider IV fluid replacement. Children become more easily dehydrated than adults. Antidiarrheal agents should not be used for bloody diarrhea but can be used in watery diarrhea. Loperamide is the treatment of choice for diarrhea. Prochlorperazine and promethazine are used for vomiting but they can cause dystonia in some children. Ondansetron is safe and effective for kids. Probiotics are not effective but may shorten the course of the disease symptoms. Antimicrobial agents are used for some cases of traveler’s diarrhea, or when you suspect Shigella or Campylobacter infections. You should otherwise withhold antibiotics until you have a known agent. Antibiotics will increase the risk of hemolytic-uremic syndrome in E coli infections so they are not often used. Salmonella infections are not aided by antimicrobial agents and antibiotics do not help with toxic infections, such as Staphylococcus aureus or Clostridium perfringens infections. The treatment of choice for Clostridium difficile infections is vancomycin. Stop any contributory antibiotics. Giardiasis is treated with metronidazole or nitazoxanide, while cryptosporidiosis is treated primarily with nitazoxanide.
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ACUTE PANCREATITIS Acute pancreatitis can be seen in the emergency department and involves an acute inflammation of the pancreas, usually from alcohol abuse or gallstones. It can be mild to severe, based on associated symptoms along with the inflammation. Gallstones cause about 40 percent of cases by increasing the pressure inside the pancreatic ductal system. Bile itself may be toxic to the pancreatic tissue. Alcohol abuse causes 30 percent of cases; it is not always made more prevalent by drinking more alcohol because the susceptibility to the disease varies with the person. The cells of the pancreas metabolize alcohol so that it becomes a toxic metabolite that aids in the autodigestion of pancreatic tissues. It can also cause plugs of protein in the pancreatic ducts, leading to obstructive damage to the pancreas. There can be genetic causes of acute pancreatitis, which can be autosomal dominant. Cystic fibrosis itself can cause both chronic and acute pancreatitis. Patients who’ve had an ERCP will have a risk of acute pancreatitis as well. Hypertriglyceridemia is a common cause of acute pancreatitis in some people. Pancreatitis can be interstitial in nature or necrotizing in nature. Interstitial pancreatitis is seen with an enlarged pancreas and self-limited disease. Necrotizing pancreatitis is seen in up to 10 percent of cases. Because there is necrosis, the disease is prolonged and tends to be more severe. The disease can also be mild, moderate, or severe. Mild disease is confined to the pancreas, while moderate disease involves the possibility of systemic disease but no organ failure. Severe disease will lead to multiple organ failure and a high rate of death. The complications can be localized or systemic. Localized disease processes include collection of enzyme-rich pancreatic fluid and necrotic material around the pancreas. These can wall off, leading to pancreatic pseudocyst formation. Systemic complications include cardiovascular failure, shock, respiratory failure, and acute kidney injury. Look for systemic inflammatory response syndrome if the temperature is very high, very low, or if there is tachycardia, tachypnea, and either a very low or very high white blood cell count. Most patients who die will die of multiple organ failure within a week of onset.
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Look for the patient with acute, steady upper abdominal pain of moderate to severe intensity. Many will have pain radiating to the back. Sitting up or leaning forward will reduce the severity of the pain. There will be tachycardia, postural hypotension, fever, and altered sensorium. Some will have scleral icterus or true jaundice, depending on the cause. Ileus can be present and the abdomen will be severely tender. Ascites can be seen and, if there is ecchymosis around the umbilicus, this indicates a poor prognosis. The patient’s diagnosis can be confirmed with a serum amylase and lipase level. CT scanning with IV contrast can also show evidence of pancreatic inflammation. There are many different causes of pain that can be in the differential diagnosis; however, the lipase and amylase will usually provide the correct diagnosis. An abdominal ultrasound may be helpful but isn’t as helpful as the abdominal CT scan. Plain films of the abdomen will show calcifications of the gallstones, ileus, and chronic pancreatitis calcifications but will not prove acute pancreatitis. The chest x-ray will show atelectasis or a pleural effusion. Endoscopic ultrasound can be used but it isn’t as good as the CT scan of the abdomen. The treatment of acute pancreatitis is generally supportive. The patient is kept NPO and provided with IV fluids. Aggressive IV fluid resuscitation is often necessary in the first 24 hours. Lactated Ringer’s solution is preferred. Supplemental oxygen is provided with strict intake and output measured. Pain relief is done using hydromorphone or fentanyl. Medications for nausea and vomiting can be used. The diet can be advanced as tolerated, with TPN used to treat severely affected patients. Other patients can have a tube placed from the nose to the jejunum. Antibiotics are given if there is significant necrosis that becomes infected. Patients with gallstone-related disease who do not resolve spontaneously need an ERCP.
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KEY TAKEAWAYS •
Abdominal pain can present with visceral pain, somatic pain, or referred pain.
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Gastroenteritis presents with a constellation of symptoms that suggests an infectious process.
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The aorta can rupture or dissect, leading to a number of symptoms. Rupture almost always leads to hypotension and imminent death.
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Bowel obstruction is painful and results in abdominal distention, nausea, and vomiting.
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Look for free air in the abdomen whenever a perforation of the GI tract is suspected.
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Diverticulitis, cholecystitis, and appendicitis are specific infectious processes that lead to abdominal pain, leukocytosis, and the possible need for surgery.
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Acute pancreatitis involves pain in the abdomen, usually of non-infectious origin.
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QUIZ 1. You have seen several patients with abdominal pain as part of your day. Which patient is most likely to require an urgent surgical consult? a. The five-year old with crampy abdominal pain and diarrhea b. The twenty-five-year-old male with vomiting and epigastric pain c. The sixty-five-year old with the complaint of lower abdominal pain and constipation d. The nineteen-year-old female with lower abdominal pain of acute onset and a positive pregnancy test e. The forty-five-year-old female with vaginal bleeding and cramping in the lower abdomen Answer: d. The patient with abdominal pain may or may not have an actual gastrointestinal process happening. The sudden onset of lower abdominal pain in a woman of reproductive age represents an emergency situation, especially with a known positive pregnancy test so an OB/GYN surgical consultation is indicated. 2. You suspect that a young patient has early appendicitis. Based on what you know about the innervation of the abdomen, where would you expect to see the pain and what kind of pain would you expect? a. Vague epigastric pain b. Vague periumbilical pain c. Sharp lower abdominal pain d. Sharp epigastric pain e. Crampy lower abdominal pain Answer: b. The patient with early appendicitis would be expected to complain of vague pain that centers most in the periumbilical area. This would represent visceral pain from one of the midgut structures.
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3. The patient is a 27-year-old female with severe pain who is writhing around the table has symptoms most suggestive of what? a. Peritonitis b. Abdominal aortic aneurysm c. Ruptured ectopic pregnancy d. Biliary colic e. GI obstruction Answer: d. Patients who are writhing around in pain has a higher likelihood of having an obstructive process, such as biliary or renal colic as causes of the pain. 4. You suspect your patient has intestinal obstruction by their history and physical examination. What should your next step be in doing some type of diagnostic evaluation in this patient? a. Noncontrast CT scan b. Barium swallow x-ray c. Ultrasound of the abdomen d. Oral and IV contrast CT scan e. Flat and lateral recumbent x-ray Answer: e. Only with suspected intestinal obstruction should you consider a flat and lateral recumbent x-ray, which can show air-fluid levels and intestinal dilation if this is the cause of the patient’s abdominal pain. 5. What should the preferred confirmatory test be when ruling in or out an aortic dissection in the patient who has symptoms of this problem? a. Magnetic resonance angiography b. Transesophageal echocardiography c. Contrast aortography d. Computerized tomography angiography e. Surgical confirmation
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Answer: d. Of these confirmatory tests, the CTA or CT angiography is the fastest and most available test for the emergency detection of an aortic dissection. 6. You are attempting to lower the patient’s blood pressure after making the diagnosis of aortic dissection. What medication is least likely to be recommended as a single agent for this purpose? a. Labetalol b. Nitroprusside c. Esmolol d. Diltiazem e. Metoprolol Answer: b. Any type of beta blocker or calcium channel blocker can be used to control blood pressure in an aortic dissection as a single agent. Nitroprusside can be used but not as a single agent because it causes sympathetic overactivity that can worsen the dissection. 7. You have determined that an 80-year-old female patient has diverticulitis. What would most indicate that this has been complicated by a fistula? a. High fever b. UTI symptoms c. Fecal vaginal discharge d. Guarding of the abdomen e. Obstipation Answer: c. The presence of fecal vaginal discharge, air in the urine, or feces in the urine are all typical consequences of having diverticulitis complicated by an abscess.
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8. You suspect that a patient has diverticulitis based on signs and symptoms. In order to make the diagnosis, you should consider what diagnostic test first? a. Flat and upright of the abdomen b. Abdominal ultrasound c. Barium enema d. Abdominopelvic CT e. Colonoscopy Answer: d. The patient with suspected diverticulitis should have a confirmatory test with an abdominopelvic CT scan. Only after resolution should a colonoscopy be performed. 9. For which cause of gastroenteritis would you probably give vancomycin in order to treat this? a. Vibrio cholerae b. Clostridium difficile c. E. coli d. Salmonella e. Giardia Answer: b. You would most likely give vancomycin for Clostridium difficile infections but you will also stop any other contributing agents. 10. What can you expect to see as the most common cause of acute pancreatitis in a woman in her third trimester of pregnancy? a. Alcohol abuse b. Autosomal dominant pancreatitis c. Cystic fibrosis d. Hypertriglyceridemia e. Gallstones Answer: e. Gallstones is the most common underlying cause of acute pancreatitis, particularly in pregnant women.
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