CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL

1. CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL • Speaker: Jon Tomada, MD

2. CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL • How to work-up and manage • ABDOMINAL PAIN

3. Acute “Surgical” abdominal • an acute intra-abdominal condition • abrupt onset • usually requires emergency surgical intervention • inflammation • perforation, rupture of abdominal organs • obstruction • infarction

4. Phone Call • severity? • localized or generalized? • vital signs? • new or recurrent? • reason for admission? • steroids?

5. 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)

6. Travel Time

7. Travel Time Liver Gallbladder Hepatic Flexure Right lower lung

8. Travel Time Heart AAA Stomach Pancreas Kidney(L)

9. Travel Time Spleen Splenic flexure

10. Travel Time Appendix Terminal ileum Ovary(R)

11. Travel Time Kidney(R) Intestines Ovary Fallopian tubes Bladder

12. Travel Time Left Colon Ovary(L)

13. Travel Time Infection Obstruction Inflammatory bowel disease Appendicitis Peritonitis DKA

14. Travel Time

15. 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

16. Bedside • Precipitating/alleviating factors • Quality • Region/Radiation/Referred pain • associated Symptoms • Time P Q R S T

17. Bedside • Physical exam • rectal and pelvic exam! • Selective chart review

18. Acute Surgical Abdomen • A quick review

19. Acute Surgical Abdomen

20. 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)

21. 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

22. Common causes of Acute Non-surgical Abdomen • A quick review

23. 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

24. 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

25. Acute Pyelonephritis • fever, nausea, vomiting, intermittent urination +/- dysuria • flank tenderness, suprapubic tenderness • blood cultures, urine culture, CT abdomen • empiric IV antibiotics, anti-emetics

26. Nephrolithiasis • colicky abdominal pain radiating to inguinal area, blood tinged urine • IV fluids, pain management • rule out urinary tract infection

27. 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

28. Acute Cholecystitis • female, fat, forty; nausea, vomiting • history of GB stones • RUQ tenderness • empiric IV antibiotics, RUQ UTZ, HIDA scan • rule out ascending cholangitis

29. Always remember... • Call your senior resident if you need some assistance. • Perform proper hand-offs and sign-out

30. CLINICAL PROBLEM SOLVING WHEN YOU ARE ON CALL • How to work-up and manage • ABDOMINAL PAIN