NBME Shelf Review (Part 8) – Abdominal Pain

EM Clerkship

Zack Olson, MD ; Mike Estephan, MD ; Maddie Watts, MD

Health & Fitness, Science, Education, Medicine, Life Sciences

4.9 • 816 Ratings

🗓️ 18 November 2018

⏱️ 11 minutes

🔗️ Recording | iTunes | RSS

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Summary

Acute Mesenteric Ischemia

* History of atrial fibrillation* “Pain out of proportion to exam”

Bowel Obstruction

* History* Abdominal pain* Bloating/Distention* Vomiting* Decrease stool/flatus* Exam* Abdominal tenderness and distention* If guarding/rigidity/rebound tenderness (aka peritonitis)* Consider perforated bowel* Testing* Obtain CT abdomen with IV contrast* Treatment* Fluids* NPO* NG Tube

Acute Diverticulitis

* NOTE: DiverticulOSIS is what causes GI bleeding* History/Exam* Fever* Left lower quadrant pain/tenderness* Testing/Treatment* CT abdomen with IV contrast* Liquid diet* Antibiotics* Complications* Abscess* Stricture* Fistula* Perforation* Obstructions

Abdominal Aortic Aneurysm

* If suspected, perform bedside ultrasound of the abdomen* Aortic diameter >3 cm

Spontaneous Bacterial Peritonitis

* Diagnose by performing a paracentesis* Look for >250 white blood cells* Treat with ceftriaxone

Kidney Stones

* CT without contrast* If the stone is <5mm* Treat with analgesics and tamsulosin* If the stone is >5mm* Consult urology

Common Indications for Emergency Dialysis

* Mnemonic: AEIOU * Acidosis (pH <7.1)* Electrolytes (K > 6.5)* Intoxication* Lithium* Ethylene Glycol* Methanol* Aspirin* Overload of volume resistant to diuresis* Uremia that is symptomatic* Altered mental status* Pericarditis

Ectopic Pregnancy

* Testing* BhCG QUANTITATIVE* Type and screen for Rh Status* Pelvic ultrasound* IUP = Gestational sac PLUS a Yolk sac* Beware “heterotopic” pregnancy in fertility treatment patients (IVF)* Treatment* If no IUP visualized, ectopic pregnancy is a possibility, and management depends on hCG* If <1500* Consider sending stable patients home and repeat hCG in 48 hours* If >1500* Ectopic until proven otherwise, consult OBGYN* Rh- needs RhoGAM* Prevents complications in future pregnancies

Additional Reading

* Ectopic Pregnancy (EM Clerkship)* Abdominal Aortic Aneurysm (EM Clerkship)

Transcript

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0:00.0	Hello, med students. This episode has been sponsored by Freed AI. Do you dread the thought of
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0:34.1	and you can cancel at any time if you decide it's not right for you. You can learn more at
0:39.3	www.gitfreed.a.i. Hey guys, what's going on? This is Mike Estefan from the University of Rochester
0:50.2	School of Medicine, bringing you episode 8 in the Emergency Medicine shelf exam review series.
0:56.8	We're going to begin where we left off last week, covering more causes of abdominal pain
1:02.1	that are high yield for your examination. All right, let's talk about acute mesenteric
1:08.5	ischemia. So the way this will be presented on the exam to you is an older patient coming in with
1:15.3	pain out of proportion to our physical examination.
1:20.9	Typically this patient will have a history of a fib or they will have had a recent embolectomy.
1:27.2	Both of these scenarios would predispose the patient to arterial-emolic events.
1:33.1	Now, what is the gold standard diagnostic test for acute mezzanteric ischemia?
1:40.8	Good.
1:42.2	Mezenteric angiography is the gold standard test and will be the correct answer on your exam.
1:48.0	Now let's say the next patient comes in and they're complaining of abdominal bloating and distension and on and off abdominal pain and their last bowel movement was like eight days ago. This scenario is concerning for a bowel obstruction.
2:04.6	Now if this pain is very severe or if they're parotinetic on exam,
2:10.6	what diagnostic test do you want to order first?
2:14.6	So this would be an upright chest x-ray to look for free air under the diaphragm.
	...

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