Clinical case: Abdominal pain Carla B. Aamodt, MD, Heidi Chumley, MD, Michael Kennedy, MD University of Kansas Schoo

1. Clinical case: Abdominal painCarla B. Aamodt, MD, Heidi Chumley, MD, Michael Kennedy, MDUniversity of Kansas School of MedicineKansas City, Kansas

2. Your patient A 39 year-old female comes in to the emergency room with a chief complaint of abdominal pain

3. What are your top 10 differential diagnoses? Clinicians begin to think of diagnoses as soon as they hear the chief complaint The differential gets refined as you hear more problems How would your differential be different if this patient were 70 years old? 8? Would your differential be different if the patient had presented to outpatient clinic?

4. Consider VINDICATES as a place to start V: vascular I: infectious N: neoplastic D: degenerative I: intoxication/ingestion (and drug side effects) C: congenital A: allergic/autoimmune T: trauma E: endocrine S: supratentorial/psych N: neuro

5. History of present illness Location: epigastric Other symptoms: nausea, vomiting, feels warm, sweaty, anorexia Chronicity: similar symptoms occasionally in past, but nothing this severe. This week has had several episodes of pain, but they didn�t last. Tonight pain has been much worse and present for 3 hours.

6. History of present illness, cont. Alleviating factors: nothing seems to help, in past has tried Tums, ibuprofen, tonight tried Tylenol 2000 mg Things that make it worse: Seems to have gotten bad after eating rehearsal dinner Experience of the pain: sharp, wave-like episodes Severity: 8/10

7. Now what are your top 10 differentials? Put them in order of likelihood Put them in order of lethality Clinicians weigh both of these as they decide how to proceed What information do you need to help you commit to a �Most Likely Diagnosis�?

8. Past medical history Hypertension Crohn�s dz (dx age 26 with ileitis and arthropathy�quiescent�last colonoscopy ok 6 mo ago). Transfused 2 U PRBCs for this in past Depression G2P2, regular menses Previous surgery for C-section x 2 Meds are: Hydrochlorothiazide 25 mg, Zoloft 100 mg a day, Methotrexate 10 mg a week, Ortho-Tri-Cyclen, Tylenol ES 6 a day

9. Time to refine your differential How has it changed? Anything new to add to the list? Would your differential be different if this was a patient with HIV?

10. Social History Married bank teller�2 daughters: 17 and 19. The 19 year-old is getting married this weekend. Drinks 3-4 drinks a day. No tobacco. Cocaine and marijuana in teens. None since. Sedentary lifestyle �Meat and potatoes� diet

11. FH FH: Father died of heart disease at age 42�he had high cholesterol and HTN. Mother, age 64 dx breast cancer 10 yr ago, doing well. 2 bros and 1 sister all with HTN, hyperlipidemia. Remainder of FH either unknown or negative.

12. What Review of Systems do you want?

13. Any change in your differential? What physical exam do you want? Think: What physical exam will help you determine which differential diagnosis is correct?

14. Physical exam Vitals: T 38.6C, BP 100/58, HR 112, RR 20 Gen: Well developed overweight WF who appears in mild distress HEENT, Heart and Lung exams: All within normal limits (WNL) except slight yellowish tinge to sclerae

15. Physical exam, cont Abd: Obese abdomen, with decreased bowel sounds, soft, tender with guarding in RUQ and epigastrium, no rebound, liver is 12 cm in diameter at the mid-clavicular line, with a soft edge felt 2 cm below the right costal margin. Spleen not palpable. Extremities and Neuro exams within normal limits

16. A few quick questions What do you think of this exam? Is this an �acute abdomen�? No rebound, although there is guarding. Could do other tests�jostle bed, etc. What do you think about the liver size? Liver is a little larger than normal span (normal is about 10 cm in mid-clavicular line), and palpable slightly lower than normal. What do you think about the sclerae? Likely jaundice�usually means bilirubin >= 3.0

17. What labs do you want?

18. Laboratory studies CBC Hemoglobin/hematocrit: 10/30 White blood cell count: 12 K: 80% segs; 10% bands Platelet count: 100 K LFTs Serum bilirubin: 4.0 mg % AST/ALT: 60/95 mg/dl Albumin: 2.8 mg/dl Alkaline phosphatase: 250 units

19. Labs, cont Chem 7 Na 132 K 3.4 Cl 100 CO2 18 BUN 28 Cr 1.4 Glu 108 Coags PT 15 (INR 1.5) PTT 30 Amylase 32 Lipase 28

20. What do you think of the labs?What is abnormal? What other labs do you wish you had?

21. Abnormal labs Anemic (normal Hb about 12-14), mild thrombocytopenia Minimally elevated white blood cell count with a left shift Amylase/lipase minimally elevated What about the liver tests? High bilirubin and alk phos Minimally elevated transaminases Albumin low but normal PT/PTT: 2.8 mg/dl

22. Abnormal labs Mildly elevated PT/PTT Mild hyponatremia, hypokalemia Likely metabolic acidosis with low bicarbonate and elevated anion gap Increased BUN: Creatinine (>=20) ratio suggests dehydration

23. What diagnoses are most likely? What are you going to do next?

24. What do you order BEFORE you get your imaging? IV Fluids: typical hydration fluids for dehydrated patients are either Normal (isotonic) Saline (0.9% NaCl) OR Lactated Ringer�s (aka LR) Potassium replacement�likely IV as pt is nauseated IV antibiotics�broad-spectrum given clinical presentation consistent with cholangitis Pain control Surgical/GI consults�involve consultants early rather than late

25. CT abdomen Gallstones with dilated biliary ducts, thickened gallbladder wall, gallstones Remainder of abdomen CT unremarkable

26. What makes cholangitis the most likely diagnosis? Clinical diagnosis: Charcot�s triad: fever, RUQ pain, jaundice Elevated WBC�it appears mild, but there is a clear left shift AND patient is immune suppressed (methotrexate)�so WBC nl�ly low Additionally, signs of possible sepsis: BP is low (particularly concerning in a normally hypertensive patient), pt tachycardic

27. Which antibiotics would you use and why? What pathogens do you need to cover? E coli, Enterococcus, Klebsiella, Enterobacter What types of organisms are these? Need gram positive anaerobic and aerobic coverage Which antibiotics cover these? Could use ticarcillin�clavulanic acid OR ceftriaxone plus metronidazole OR ciprofloxacin plus metronidazole

28. What is the definitive treatment? ERCP to remove stones and/or cholecystectomy Initially may temporize by putting in a biliary stent

29. Oral Presentations Medicine vs. Surgery Dealing with your attending

30. General Advice Organization Systems Roundsmanship �When I rounded on Ms. Jones 2 hours ago, her RR was 30�

31. Clinical Case: Acute Renal Failure

32. The patient 76 yo male patient is seeing you in the outpatient clinic Recent labs show that he has a creatinine of 2.0 mg/dL. Six months ago, his creatinine was 1.2 mg/dL. What is your differential diagnosis?

33. What else do you need to know? PMH: HTN, osteoarthritis. No PSH Meds: lisinopril 10 mg a day, Aleve (naproxen sodium) 500 mg BID SH: Widower. Lives alone. 3 children. Never drank alcohol. Smoked 20 pk year, but quit in 1976. No drugs. TV dinner diet�mainly Lean Cuisine FH: Father died of prostate CA. Mother died of stroke with Alzheimer�s. Sibs with HTN, high cholesterol. Children healthy.

34. How has your differential dx for the acute renal insufficiency changed? Is there additional information you�d like to know? Taking same dose of all meds for last 3 years. What are general categories of renal insufficiency?

35. Categories of renal failure Pre-renal: the volume coming into the kidney is too low (hemorrhage, hypotension, dehydration, pump failure (CHF), etc.) Intrinsic renal: dysfunction of the kidney itself cause renal failure (glomerulonephritis, acute interstitial nephritis, toxins, etc.) Biggest category Post-renal: obstruction. BUT, you can still have a fairly normal creatinine if one ureter is obstructed, so think obstruction of the urethra (BPH, a large kidney stone, etc.)

36. What history questions could help you determine type of renal failure? Think: What might be symptoms of pre-renal, intrinsic renal OR post-renal failure?

37. Our patient Feels pretty good. Hasn�t really noted much in the way of symptoms. However, ROS positive for: Sneezing, itchy eyes, nasal congestion in spring Chronic dry cough�a couple times a day Diarrheal illness two weeks ago, has been a little fatigued since Nocturia 3 times a night. Sometimes feels like bladder does not completely empty.

38. Our patient Notes some swelling of ankles�especially at the end of hot days Has some indigestion with spicy foods

39. What is your differential diagnosis now?

40. History: some symptoms that might suggest pre-renal azotemia Change in blood pressure medicine (h/o HTN) Nausea/vomiting/diarrhea Hx suggestive of GI bleed: Heartburn, melena, hematochezia (=BRBPR=bright red blood per rectum) Dizziness/lightheadedness Fatigue Swelling in ankles or legs History of CHF, liver disease (hepatitis)

41. Intrinsic renal: History LOTS of causes for intrinsic renal failure (IgA nephropathy, acute interstitial nephritis, lupus nephritis, hypertension induced nephropathy, etc.) so, LOTS of possible symptoms So, you need to take a good, thorough history and do a good thorough exam Some specifics: ask about recent illness, joint problems, rashes, new medications (incl OTCs), BP control, constitutional symptoms

42. Post-renal azotemia: History BPH Sx: dribbling urine, difficulty starting urine stream, frequency, nocturia, feeling of not emptying bladder, etc. Nephrolithiasis sx (kidney stone): flank or pubic pain, blood in urine, past history of stones, use of certain medicines like furosemide Medicines that may cause urinary retention (tricyclic antidepressants, opiates, etc.)

43. Has this additional information refined your differential any? What physical exam would you do?

44. Physical exam findings BP 142/92, HR 74, RR 12, Ht 5�10� Wt 178 Gen: WD WN AAM in NAD HEENT, Lungs, CV: WNL Abd: ND, NABS, soft, NT Ext: no C/C, 1+ edema, 2+ pulses, multiple small non-tender varicose veins Rectal: enlarged prostate without nodularity or masses; hemoccult negative

45. Physical exam: some signs that might suggest pre-renal azotemia Hypotension/orthostatic hypotension (most fairly acute causes will lead to one of these) Tachycardia (esp. with fairly acute causes) Pale skin/conjunctivae/mucus membranes (if hemorrhage a cause) Rectal exam with melena, red blood or simply guaiac positive brown stool Dry mucus membranes, rarely decreased skin turgor (in the case of dehydration) S3 gallop, peripheral edema, displaced PMI in the case of low ejection fraction/CHF Ascites, peripheral edema in the case of end-stage liver disease

46. Post-renal azotemia: Physical exam Enlarged prostate (BPH) Supra-pubic mass (often an enlarged bladder) from urine retention

47. Labwork: some findings that might suggest pre-renal azotemia BUN/Cr ratio of greater than 20 Urinalysis showing increased specific gravity (esp. greater than 1.020) Fractional excretion of sodium <1% (this is Urine Na/Plasma Na divided by Urine osmolality/Plama osmolality) Low hemoglobin/hematocrit (in case of hemorrhage)

48. Some labwork suggestive of intrinsic renal disease Urine eosinophilia (for acute interstitial nephritis) FeNa greater than 1-2% Abnormal UA findings: proteinuria (>3 grams per day is suggestive of , red cell casts (glomerulonephritis), muddy brown casts (ATN) Elevated BNP (in CHF), abnormal LFTs (possible in liver disease) Positive ANA (lupus), HIV test (HIV-associated nephropathy), etc.

49. Post-renal azotemia: Labwork Before you get labwork, try putting a Foley catheter in your patient (if you get lots of urine out or if you can�t get the catheter in, you probably have your diagnosis) Ultrasound may show enlarged bladder or BPH PSA may be enlarged�esp for prostate CA, but small elevations also common in BPH

50. Our patient Foley catheter released 2 LITERS of urine and was left in place. PSA done and moderately elevated at 7. Pt placed on medications for BPH. Urology performed prostate biopsy and found no cancer. TURP performed and patient doing well.

51. Write-up (A/P depends on what point you do it!) Cc: increased creatinine HPI: 76 yo male called to come to clinic to follow up on abnormal creatinine. Cr was 1.2 6 mos ago, now 2.0. Pt has not noted any new symptoms except fatigue after a bout with diarrhea 2 wks ago. However, he does have nocturia x3 at night and a feeling of incomplete bladder evacuation. Ankles swell with heat. No new medications in last 6 mos. Denies dribbling, hematuria, dysuria, edema, urine incontinence.

52. H and P cont PMH: HTN, OA. No PSH Meds: Lisionopril 10 mg po qday, Aleve 500 mg po BID NKDA SH: Remote 20 pk year cigarrette smoker. No EtOH. No drugs. Retired widower. Lives alone. FH: F died prostate CA, mother died CVA/Alzheimers. Sibs HTN, hyperlipidemia.

53. H and P cont ROS: Constitutional: see HPI, no dizziness/ fevers/chills/sweats/wt loss or gain HEENT: sneezing/itching eyes/nasal congestion in spring�none currently Lungs: chronic dry cough (2 yr), no dyspnea/wheezing CV: no CP/pressure/edema/orthopnea/DOE/ palpitations Abd: diarrhea 2 wk ago, now resolved. Indigestion with spicy foods. Currently no N/V/diarrhea/constipation/abd pain/hematochezia/ melena GU: see HPI Msk: chronic arthritis is knees and hands for several years. No joint swelling or warmth. Derm: no rashes, change in moles Lymph: no LAD

54. H and P cont BP 142/92, HR 74, RR 12, Ht 5�10� Wt 178 Gen: WD WN AAM in NAD HEENT, Lungs, CV: WNL Abd: ND, NABS, soft, NT Ext: no C/C, 1+ edema, 2+ pulses, multiple small non-tender varicose veins Rectal: enlarged prostate without nodularity or masses; hemoccult negative

55. H and P Labs (6/20/06): Na 135, K 4.4, Cl 100, CO2: 27, BUN 18, Cr 2.0, Glu 86 Procedure: upon insertion of Foley catheter 2000 cc of pale yellow urine drained out. Catheter left in place. A: Elevated creatinine in setting of urinary retention. Possible causes: prostate CA, BPH, urethral stricture P: 1. 23 hour Admit to Medicine for eval and treatment. 2. Urology C/S for eval, possible bx, possible surgery. 2. Check PSA/chem 7 in AM. 3. Leave Foley catheter in place for now. 4. Trial of doxazosin and tamsulosin. 5. U/S of prostate. 6. Hydrate with � NS at 75 cc/hr during post-obstructive diuresis. 7. Stop Aleve and lisinopril. Doxazosin for BP

56. SOAP note the following day S: Pt tired of catheter b/c it pulls. Ready to go home. ROS negative O: T 37 C BP 124/72 HR 76 RR 14 General: WDWM in NAD Lungs: BCTA CV: RRR no M/R/G Abd: ND, NABS, soft, NT GU: Foley catheter in place with pale yellow urine, no erythema, no blood Labs: BUN 12 Cr 1.8 PSA 7 Prostate US: showed enlarged prostate without dominant masses

57. SOAP cont A/P: 76 yo M with HTN/OA admitted for urinary obstruction 1. Urine obstruction: Urology to perform prostate bx as outpt, recommend leaving Foley catheter in until follow up in 5 days. Social work to teach patient Foley care. D/c IVF. Cont tamsulosin/doxazosin. Recheck Cr at f/u with Urology. 2. HTN: doxazosin 2 mg po qday for now. (Lisinopril stopped.) 3. OA: Tylenol prn for pain. Avoid NSAIDs 4. Discharge: to home today

58. EMR

59. EHR Documentation Some clinics have EHR. Benefits: Added structure � your note will look fantastic; previous notes are legible Common pitfalls: Forms Information carried forward Click boxes, especially normal Easy access to peoples� information; but traceable

60. Clinical Case: A Child with Cough

61. The patient 4 year-old brought by mom to the office for �cough� What is your differential diagnosis? Try to generate a differential based on age and chief complaint before entering the room.

62. What else do you need to know? HPI: about 4 months; worse when sleeping; worse outside playing; tried Claritin once without relief PMH: Normal birth and development; Immunizations UTD; Eczema until 4 y/o Meds: None SH: Lives with mom and dad; 2 siblings; first grader, no school problems; dad smokes outside FH: Mom with allergies

63. How has your differential dx for the cough changed? Shift to causes of chronic cough What are causes of chronic cough in children? Hints for a great differential diagnosis Think in broad categories first (i.e. infection v. adenovirus infection) Think about common and dangerous (if applicable)

64. Causes of cough in children Reactive changes : Asthma or Postnasal discharge Infection :Viral causes , Pertussis , Mycoplasma pneumonia, Tuberculosis Passive smoke Cystic Fibrosis Foreign body

65. What specific questions could help you determine the cause? Think: What might be symptoms of reactive or infectious?

66. Our patient Feels pretty good. Hasn�t really noted much in the way of symptoms. She and mom tell you� ROS positive for: Gets out of breath easily ROS negative for: Fevers, chills, fatigue Runny nose, itchy eyes Wheezing or chest tightness

67. Has this additional information refined your differential any? What physical exam would you do? What parts do you think you could leave out?

68. Physical exam findings BP 90/50, HR 98, RR 14, 50% height and weight Gen: WD WN WF in NAD HEENT: no nasal discharge; no swollen turbinates; no fluid behind TMs; normal pharynx Lungs: Clear to auscultation CV: RRR without murmurs Abd: NDNT, no HSM Ext: no C/C/E Skin: no rashes

69. Assessment What/how much to write differs by setting Look at prior notes General guidelines OK to use symptom, followed by diff. diagnosis Often more than 1, include health maintenance Chronic cough: asthma, allergies, or chronic infection Expand either in writing or presentation Edit after discussion with attending

70. Plan Always have a plan What/how much to write differs by setting Look at prior notes General guidelines Match plan items to assessment Have a plan for every assessment Plans can be watch, provide reassurance, lifestyle changes, medications, tests or procedures, etc. Edit after discussion with attending

71. What makes a good note Legible with legible signature/printed name Order � SOAP or H&P Relevant positives and negatives *Demonstrates your understanding* Matched assessment and plan Accurate record of visit Clear to an outsider what was going on

72. What makes a bad note? Illegible Disordered Containing personal biases/beliefs (yours) Advised that (some behavior) is wrong Inaccurate or misleading I listened to the heart yesterday � nothing changed Neuro exam � WNL Check boxes on electronic health record

73. Yes, this was actually written� She has no rigors or chills, but her husband states she was very hot in bed last night. The pelvic exam will be done later on the floor. She stated that she had been constipated for most of her life until she got a divorce. On the second day the knee was better and on the third day it had completely disappeared. Between you and me, we ought to be able to get this lady pregnant.

74. What about this� Patient is non-compliant with medications Previous physician did not order an XRay General rule: Nothing you wouldn�t show the patient. Did not take meds due to concerns about safety.

75. Sometimes it is hard� Patient refuses to consider smoking cessation even though I told her that is causing her child�s asthma. Discussed risks of smoking concerning child�s asthma. Patient voiced understanding and is pre-contemplational.

76. Panel Discussion What questions do you have for us?