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.

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Clinical problem solving when you are on call
CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL

  • Speaker: Jon Tomada, MD


Clinical problem solving when you are on call1
CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL

  • How to work-up and manage

  • ABDOMINAL PAIN


Acute surgical abdominal
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
Phone Call

  • severity?

  • localized or generalized?

  • vital signs?

  • new or recurrent?

  • reason for admission?

  • steroids?


Acute surgical abdomen
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 time1
Travel Time

Liver

Gallbladder

Hepatic Flexure

Right lower lung


Travel time2
Travel Time

Heart

AAA

Stomach

Pancreas

Kidney(L)


Travel time3
Travel Time

Spleen

Splenic flexure


Travel time4
Travel Time

Appendix

Terminal ileum

Ovary(R)


Travel time5
Travel Time

Kidney(R)

Intestines

Ovary

Fallopian tubes

Bladder


Travel time6
Travel Time

Left Colon

Ovary(L)


Travel time7
Travel Time

Infection

Obstruction

Inflammatory bowel disease

Appendicitis

Peritonitis

DKA



Bedside
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


Bedside1
Bedside

  • Precipitating/alleviating factors

  • Quality

  • Region/Radiation/Referred pain

  • associated Symptoms

  • Time

P

Q

R

S

T


Bedside2
Bedside

  • Physical exam

    • rectal and pelvic exam!

  • Selective chart review


Acute surgical abdomen1
Acute Surgical Abdomen

  • A quick review



Acute surgical abdomen3
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 abdomen4
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



Acute pancreatitis
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
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
Acute Pyelonephritis

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

  • flank tenderness, suprapubic tenderness

  • blood cultures, urine culture, CT abdomen

  • empiric IV antibiotics, anti-emetics


Nephrolithiasis
Nephrolithiasis

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

  • IV fluids, pain management

  • rule out urinary tract infection


Infectious gastroenteritis
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
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
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 call2
CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL

  • How to work-up and manage

  • ABDOMINAL PAIN