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what are the seven areas of the abdomen?

epigastric
periumbilical
supra pubic
RUQ
LUQ
RLQ
LLQ

What characterizes surgical abdominal pain?

Sudden onset
awakens pt from sleep
causes pt to pass out
pain presents prior to n/v
steady pain for >6hrs

what are the quality of pain designators and what do they mean?

Colic - intermittent
cholelithiasis, urolithiasis, gastroenteritis
Burning=> PUD
Boring=> Pancreatitis
Sharp=> Cholecystitis
Aching=> Appendicitis

when will ulcer pain present?

around two hours after meals

when will cholelithiasis pain present?

after fatty meals

when will perotinitis pain present?

upon inspiration

what do dark tar like stools indicate?

upper GI bleed
iron supplementation
pep to use

what does bright red blood in the stool designate?

lower GI bleed, usually in the colon or rectum

what does pale or coay colored stool indicated?

biliray tract disease/hepatitis

what are the five F's of an abdominal distension?

fat
fluid
flatus
fetus
feces

what is Cullin's sign?

ecchymosis on the periumbilical area

what does hyperactive bowel sounds indicate?

diarrhea or oartial obstruction

what do absent bowel signs indicate?

over 2mins is an ileus due to:
anesthesia
obstruction
hypotension

*requires medevac

what is Grey-Turner's sign?

ecchymosis on the flanks

what does free air in the abdomen indicate?

rupture of the colon or stomach

what does Kehr's sign indicate?

left shoulder means lower lobar pneumonia or spleen

right pain means lower lobe pneumonia

what does Rovsing's sign indicate?

deep palpationin LLQ causes pain in RRQ may indicate appendicitis

what does a heel tap sign indicate?

heel percussion pain in the abdomen indicates possible appendicitis

what does a psoas test indicate?

pain on stretch or contraction indicates appendicitis

what does murohy's sign indicate?

hooking the liver places pain on the aggrivated gall bladder, cholecystitis

What does Markle's sign incidcate

dropping in the heels will cause appendix pain

what does dunohy's test indicate

coughing causes appendix pain, appendicitis

which pathologies refer pain to the back?

splenic - shoulder point
pancreatic inflammation - mid spine
diaphragm or lower lobar pneumonia - trap
billary colic - scapula point
renal colic - renal area
uterine enlargement - sacrum

which rays should be taken for an abdominal pain pt, and when?

chest
abdominal - flat and upright

ultrasound for blunt trauma
get the following labs:
electrolytes, bilirubin, amylase, and liver enzymes
always cbc with differential, stool guiac, urinalysis, O and P

who is at the greatest risk from diarrhea?

immunocompromised
dehydrated
malnourished
peds and geri's

what are the four major host defense systems in the GI tract?

gastric acidity - most effective
small bowel motility
colonic flora
local antibody production

what is the drug of choice for clostridium difficile?

flagyl

what is the difference between small and large bowel diarrhea?

small - large volume, infrequent events, watery, no fever/low fever, short term

large - frequent events, small volume, mucosy poo, fever, long term

how does an e.coli infection present?

afebrile
leukocytosis
bloody stool

avoid antobiotic therapy

what are the two main groups of viruses that lead to gastroenteritis?

Norwalk virus
rotavirus

in us, gastroenteritis is generally caused by viruses. small bowel pattern

how is the norwalk virus transmitted?

person to person
airbirne droplets
food and beverage
fomites

what is the major pathogen in infantile gastroentiritis?

rota virus, common in fall season
lasts five to eight days

what are the types of invasive gastroenteritis? (large bowel pattern)

typhoid fever
salmonellosis
shigellosis
campylobacter

what bacteria causes typhoid fever?

salmonella typhi (-)
sewage, flies, shellfish

lines intestinal wall in peyers patches
threes stages of about a week a piece
relative bradycardia

what drug is containdicated byTyphoid fever?

salycilates, asprin

what is the most common source of salmonella?

raw eggs and egg shell ingestion, and reptiles

what is the most communicable diarrhea disease?

Shigellosis

how does shigellosis present?

tenesmus (gotta-go-meow syndrome)
gripping abdominal pain
explosive diarrhea
vomiting is unusual

starts as watery stool, progresses to multiple bloody stools per day
can create a toxic megacolon (>4cm)

what group of medications are contraindicated by gross bloody stool?

antiperistaltics, can create toxic megacolon

what is the leading cause of acute diarrhea worldwide?

Campylobacter jejuni
commonly from undercooked poultry

Abrupt high fever
severe abdominal pain in RLQ
large bowel pattern
vomiting rare

may cause febrile seizures, reactive arthritis, Guillan-Barre syndrome

what is the most common carrier of staph food poisoning?

unrefrigerated foods

vomiting overshadows diarrhea
small bowel pattern
treat symptomatically

what is the most fatal form of food poisoning?

botulism

found in improperly canned foods (most common in Alaska)
powerful exotoxin
fever uncommon
neurological disorders, approaching paralysis

refer!

wtf is clostridium perfingens?

contaminated meat
exotoxin creates GI upset
vomiting rare

treat supportively

vibrio cholera

sewage contaminated water ingestion
sudden onset of effortless, painless diarrhea
rice water stool
fever rare

treat with doxy and rehydration
50-100ml/kg every four hours

bacillus cereus

small bowel pattern
contaminated rice

what are the three fish toxidromes?

scromboid
ciguatera
paralytic shellfish poisoning

scromboid

histamine poisoning
improper temperature control
anaphylaxis
diarrhea

treat with antihistamines and epi

ciguatera fish poisoning

non-bacterial
found between 35n and 35s lat
pain, NVD, parasthesia
paradoxical temperature reversal
ataxia, vertigo, paralysis

treat with:
activated charcoal w/I four hours
treat symptomatically

shellfish poisoning

biggest risk is respritory depression
no cardiac effect, ddx from ciguetera

traveler's diarrhea

most common etiology:
salmonella
shigella
campybacter
EHEC

three or more unformed stools in under 24hrs
usually large bowel pattern
tenesmus

make best guess and treat appropriately

what are the two types of inflammatory bowel disease?

ulcerative colitis
Crohn's disease

presents with chronic diarrhea

ulcerative colitis

always starts in rectum
presents with abdominal pain,fever, weight loss

can lead to toxicmegadolon, could mean cancer

refer

Crohn's disease

insidious onset, affects small intestine
abdominal pain, perianal disease
usually RLQ tenderness
occasional RLQ mass
frequent bloody stools

refer

Gastritis

imbalance of mucosa lining with generally inflammatory response

presents with
n/v
epigastric discomfort relives with food and antacid

Pancreatitis

etiology:
alcohol, gall stones, elevated triglycerides, high intake of refined carbs

presents with:
boring and intense epigastric pain goin through to mid back
n/v
pain relieved by sitting up and leaning forward
glycosuria

lab tests:
u/a
amylase

treat with:
npo/ ng suction
1L fluid/hr, then titrate to 50ml of urine/hr
Opioid analgesia, no morphine!!
evac/refer

cholelithiasis, cholecystitis

etiology: gallstone formed by mostly cholesterol, some by calcium
risk factors: fat, female, preggers, estrogen use

presents with: RUQ colicky pain (fixed with cystitis) referred to back or right subscapula, Murphy's sign
stones visible on ultrasound

treat with: antispasmodic agents, analgesics (no morohine), antiemetics, referral
cystitis: npo/ng suction, IV fluids, antiemetic, analgesia but no morphine, if febrile ampicillin REFER

Intestinal obstruction

Etiology:
small bowel: adhesion from previous surgery, hernias
large bowel: cancer (most common), diverticulitis, volvulus, intussusception

presents with: obstapation, abdominal pain/distention, lack of/irregular bowel noises, bloody stools
feculant or billious vomit=small bowel obstructin

treat with:
npo/ng suction, analgesic, evac/referral

appendicitis

etiology: most common surgical condition
fecolith, lymphatic hyperplasia, parasites, foreign body

presents with: periumbical pain, low grade moving to high fever, n/v, anorexia, RLQ pain and tenderness
Mcburney's pt, psoas sign, obturator sign, flank pain

treat with: surgery

what are the specific tests for appendicitis?

psoas sign
obturator sign
Rovsing's sign
Heel percussion test
Markle's sign
Dunphy's sign

ddx for appendicitis

mesenteric adentis - pain shifts with positioning, no elevated wbc, fever, or peritoneal signs

gastroenteritis - n/v precedes pain, diarrhea, peritoneal signs rare

diverticulitis- hx of recurring symptoms, might need surgical consult to dx

UTI- cells and bacteria in urine, no peritoneal signs

Urolithiasis- migratory pain, visible on ultrasound

peritonitis

etiology: pancretitis, ectopic pregnancy, perforated ulcer, bacterial infection of internal organ

presents with: intense abdominal pain, tachycardia, tachypnea, fever
rebound tenderness, guarding, sepsis, and death

treat with: analgesia, broad spectrum abx (carbapenum, flagyl), npo/ng suction, Foley, referral

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