EM Clerkship

Women have two additional diseases that must be added to the differential diagnosis of their abdominal pain. PID and ovarian torsion.

Pelvic Inflammatory Disease (and Tube-Ovarian Abscess)

Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well

History

* Symptoms* Lower Abdominal Pain* Fevers* Vaginal Symptoms (especially discharge)* Red Flags* High risk sex* Delayed presentations* IUD (Don’t need to remove if patient has PID, but needs to be noted)

Exam

It is controversial whether all women with pelvic complaints need a full speculum exam (my opinion is that they don’t and that it almost never changes management)

* Bimanual Exam* Cervical motion tenderness* Adnexal/Uterine tenderness

Testing

* Gonorrhea* Chlamydia* CBC* Ultrasound to evaluate for tubo-ovarian ABSCESS

Treatment

Patients who are septic, unable to keep antibiotics down, getting worse on oral antibiotics, pregnant, immunosuppressed, or with TOA generally get admitted for IV antibiotics.

* Treat chlamydia* Doxycycline* Treat gonorrhea* Cefoxitin/cefotetan (2nd generation cephalosporins provides better anaerobic coverage than a third generation cephalosporins)* Ceftriaxone* Treat anaerobes* 2nd generation cephalosporin* Metronidazole

Ovarian Torsion

Ovary twists on its pedicle and becomes ischemic

NOTE: The ovary actually has a dual arterial blood supply. When the pedicle twists, it’s not the artery is being pinched off that causes ischemia, rather its the venous outflow becoming blocked and resulting in swelling of the ovary and the poor perfusion that results)

History

* Sudden onset pain* Severe pain with vomiting* Usually unilateral pain (although 25% have bilateral pain)

Exam

* Peritonitis in the lower abdomen* Large mass or adnexal tenderness on pelvic exam

Testing

* Pelvic ultrasound (with doppler)* Swollen/edematous ovary* Large cyst/mass causing the torsion* IMPORTANT- You can frequently see normal arterial flow on the doppler (remember DUAL BLOOD SUPPLY)* CT scan with NORMAL ovaries 100% negative predictive value for torsion in some studies

Treatment

OBGYN consult for surgery

Additional Reading

* Pelvic inflammatory disease review (Medscape)* Ovarian torsion review (Medscape)

How to Read a Urinalysis

* Signs of Inflammation* Leukocyte Esterace* WBCs

Multiple conditions cause inflammation on a urinalysis. Anything that causes nearby inflammation (appendicitis, pelvic infections, diverticulitis) or slows urine output (dehydration, renal disease) can commonly elevate these markers.

* Signs of bacterial presence (not present in ~25% of proven urinary tract infections!!!)* Nitrites* Bacteria

Asymptomatic Bacteriuria

Generally should NOT be treated with antibiotics. If you were to randomly sample the population you would find bacteria present in approximately…

* 5% of young people* 20% of old people* 50% of patients in long term care

When to Diagnose UTI

* Dysuria AND urinary frequency WITHOUT vaginal symptoms (+LR 20)* Patient self reports that they think their UTI is back (+LR 4)* Urinalysis shows BOTH signs of inflammation and bacterial presence* Combine pretest suspicion with urinalysis findings using clinical judgement

Indwelling Foley Catheters

All patients with an indwelling foley will have a grossly abnormal urinalysis and appearance of urine at baseline. The urinalysis is useless and diagnosis can only be made by clinical judgement

Geriatric Patients

Geriatric patients have minimal symptoms regardless of diagnosis. They can have UTI’s with minimal symptoms. However they can also have appendicitis or kidney stones with minimal symptoms (and asymptomatic bacteriuria at baseline). BE CAREFUL.

Additional Reading

* The best UTI resource I have seen (First10EM)

All women of childbearing age who present with abdominal pain need a pregnancy testa core teaching of EMergency medicine

Ectopic pregnancy is the leading cause of maternal death in the first trimester

History

* Abdominal pain present in 90% of cases* Amenorrhea present in 70% of cases* Vaginal bleeding present in 50% of cases

The biggest red flag with this complaint is history of receiving fertility treatments (increased risk of heterotopic pregnancy)

Exam

* Abdominal tenderness and peritoneal signs* Adnexal tenderness* Paradoxical bradycardia (vagal response caused by peritoneal blood)

Testing

* Type and screen* Rh- mother requires RhoGam if exposed to fetal blood* Transfusion if develops hemorrhagic shock* Pelvic ultrasound* If no intrauterine pregnancy (IUP) is seen in a pregnant patient, regardless of B-hCG level, the patient might have an ectopic pregnancy* B-hCG quantitative* If no IUP is seen and >1500, strongly suspect ectopic pregnancy* If no IUP is seen and <1500, ectopic pregnancy is still possibile

Treatment

* If patient has no IUP and hCG >1500, consult OBGYN* If patient has no IUP and hCG < 1500, disposition based on clinical appearance

Additional Reading

* Ectopic pregnancy overview (Medscape)

Bowel Perforations

History

Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in…

* Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms)* Pediatric patients (unable to or scared to mention symptoms)

Exam

Commonly have “peritoneal signs”

* Guarding* Rebound Tenderness* Rigidity

Testing

* CT Scan* X-Ray? (not your primary test, but a common test question will show you an upright chest X-ray and you will see a rim of free air under the diaphragm (should NOT be there in a normal upright X-ray)

Treatment

* Broad spectrum antibiotics* Stat surgical consult

Volvulus

It is common to first learn this as a pediatric condition (Malrotation with Volvulus) however it is common in adults as well. The two most common subtypes are…

* Cecal Volvulus* Sigmoid Volvulus

The history exam and testing plan is the same as with bowel obstruction. The primary difference is that volvulus without ischemia/gangrene is frequently treated with colonoscopy which is a GI CONSULTATION rather than surgical consultation.

Additional Reading

* Management of colonic volvulus (PubMed)

Mesenteric Ischemia

* Celiac truck supplies blood to the stomach and duodenum* SMA supplies blood to the rest of the small bowel and proximal colon* IMA supplies blood to the distal colon and rectum

Arterial flow can be blocked because of emboli (atrial fibrillation)

Venous flow can be blocked because of thrombosis (hypercoagulable states)

Effective flow can be severely decreased in shock states (sepsis, hemorrhage)

History

* Atrial fibrillation* Pain with PO intake (intestinal angina)* SEVERE pain

Exam

The most classic finding is “Pain out of proportion to exam”

Testing

* Lactic acid reportedly 100% sensitive according to some texts* CT scan WITH contrast (or even better, a CTA) for additional confirmation if your pretest suspicion is high

Treatment

Analgesics and antibiotics. Surgery consult if intestines necrotic on imaging. Potentially vascular surgery consult as well if intestines salvageable.

Small Bowel Obstruction

* QUESTION: What is the most common cause of mechanical small bowel obstruction?* ANSWER: Adhesions

Not all small bowel obstructions are mechanical, don’t forget that ileus can cause a similar pattern as well (electrolyte abnormalities, recent surgery, opiates, multi-system trauma)

History

Severe crampy pain with vomiting, bloating, and decreased bowel movements/flatus. History of multiple abdominal surgeries (high risk for adhesions)

Exam

Abdominal distention and tenderness. If peritoneal signs develop, this is a very bad condition and patient may be developing ischemic/necrotic bowel.

Testing

* Most common test is CT scan with IV contrast* Abdominal x-ray sometimes gets ordered but has fallen out of favor for multiple reasons (decreased sensitivity, difficulty localizing obstruction, unable to rule out alternative diagnoses* Using oral contrast with the CT scan is also falling out of favor primarily due to the time constraints demanded of modern medicine.

Treatment

Fluids, Analgesics, Antiemetics +/- Antibiotics if ischemia is developing. Obtain a surgery consult.

* QUESTION: Should you order an NG tube? * ANSWER: NG tubes have been reported to be one of the most painful procedures one can endure. On the other hand, you can find online videos of people putting these in without any discomfort. It will end up being a risk/benefit discussion with your attending. The benefit is that decompressing the stomach will frequently improve the patient’s symptoms to a significant extent.

Additional Reading

* American College of Radiology mesenteric ischemia imaging (ACR)* American College of Radiology small bowel obstruction imaging (ACR)

F→ Episode Summary

Biliary Diseases

* Biliary Colic- A gallstone DOES NOT GET STUCK, but it slowly rolls out of the gallbladder, through the cystic duct, then the common bile duct and pancreatic duct. This results in several hours of crampy “colicky” pain as the stone passes.* Cholecystitis- A gallstone gets stuck IN THE NECK OF THE GALLBLADDER OR THE CYSTIC DUCT. Pressure builds up in the gallbladder and inflammation worsens as the patient develops persistent pain, fevers, and eventually perforation of the gallbladder wall.* Choledocolithiasis- A gallstone gets past the neck of the gallbladder and the cystic duct. However, it gets stuck IN THE COMMON BILE DUCT (CBD). The liver can’t drain bile and liver function tests increase. * Cholangitis- The patient has choledocolithiasis and INFECTION DEVELOPS * Gallstone Pancreatitis- A gallstone gets past the neck of the gallbladder AND the cystic duct AND the common bile duct but gets stuck in a PANCREATIC DUCT (ugh, so close). Lipase increases.

History

Asymptomatic gallstones

Biliary colic- Crampy RUQ abdominal pain that frequently radiates to right shoulder and resolves after a few hours

Cholecystitis- RUQ abdominal pain persists for more than a few hours and fevers develop.

Cholangitis- RUQ abdominal pain, fevers, and jaundice (Charcots Triad) eventually leading to shock and altered mental status (Reynolds Pentad)

Exam

Murphy’s Sign- Patient has pain and stops inhalation while you palpate under the right costal margin (Note: the same thing should NOT happen when palpating under the left costal margin)

Testing

The most appropriate test for biliary disease is RIGHT UPPER QUADRANT ULTRASOUND. However, CT scan is quite good as well (negative predictive value ~90% and identifies complications and alternative diagnoses well)

Treatment

Asymptomatic gallstones and resolved biliary colic get outpatient surgery referral

Acute cholecystitis needs a surgery consult

Choledocolithiasis, Cholangitis, and Gallstone Pancreatitis needs a GI consult (for MRCP/ERCP)

Pancreatitis

History

Constant epigastric abdominal pain radiating to the back with lots of vomiting and retching

Exam

Mild pancreatitis may have nothing more than some epigastric tenderness. Severe pancreatitis will look a lot like sepsis (hyperthermia, hypotension, altered mental status)

Testing

Patients will have an elevated lipase and abnormal findings on a CT scan with IV contrast

Treatment

Aggressive treatment of pain and nausea and NPO with slow advancing of the diet as tolerated.

Additional Reading

* American College of Radiology biliary disease imaging (ACR)* American College of Radiology pancreatitis imaging (ACR)

Appendicitis

History

Vague nonspecific abdominal cramping and nausea (Nonspecific Phase) gradually progresses to localized pain (Localized Phase). The pain most commonly localizes in the RIGHT LOWER QUADRANT near McBurney’s Point.

Exam

* Focal tenderness in the right lower quadrant* McBurney’s Point: 1/3 the distance traveled from anterior superior iliac spine (ASIS) to the navel. * Psoas Sign: Pain with hyperextension of the right hip (while patient is laying on left side)* Obturator Sign: Pain when flexing right hip to 90 degrees and rotating* Rovsing Sign: Pain felt in the right lower quadrant when pushing on the left lower quadrant

Testing

Fact 1: The urinalysis can be abnormal in appendicitis

Fact 2: The white blood cell count can be normal in appendicitis

As far as imaging when appendicitis is suspected…

* Most people get a CT scan * Most pregnant women get MRI * Most pediatric patients get an ultrasound

Treatment

* Analgesia (example- 4mg IV morphine)* Antiemetics (example- 4mg IV ondansetron… aka Zofran)* Antibiotics (example- 4.5mg IV piperacillin/tazobactam.. aka Zosyn aka “pip-tazo”)

Diverticulitis

History

Similar to appendicitis. Vague nonspecific cramping and nausea gradually progressing to localized pain. This pain most commonly is located in the LEFT LOWER QUADRANT. Stool related complaints such as constipation and bleeding also common

Exam

Tenderness in the left lower quadrant

Testing

Easy… Get a CT scan

Treatment

If the patient has severe symptoms, big risk factors such as immunosuppression, or complications of diverticulitis (abscess, perforations, etc). Treat the same as appendicitis… Admit, antibiotics, surgery consult

If the patient has mild symptoms, they commonly are sent home on oral antibiotics and close follow up.

Additional Reading

* American college of radiology imaging options for appendicitis (ACR)* American college of radiology imaging options for diverticulitis (ACR)

EM Clerkship’s 10 Step Patient Presentation

* Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)* At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)* Red Flags/Pertinent Positives and Negatives* Vital Signs* Focused Physical Exam of the Complaint* Suspected Diagnosis* Can’t Miss Diagnosis* Testing Plan* Treatment Plan* (If Asked) Anticipated Disposition

Vital Signs

“Vitals in triage showed a MILD TACHYCARDIA which she still does have in room. AFEBRILE here. Otherwise stable”Address the vital signs

It is important you mention any abnormal vital signs from triage and that you rechecked them on your examination. You do not need to repeat normal vitals and it is usually acceptable to say something like “vital signs otherwise within normal limits”

PEARL: Frequently, triage OVERESTIMATES the patient’s heart rate and UNDERESTIMATES the respiratory rate. You get serious bonus points if you recheck vitals yourself and find a true discrepancy.

Focused Physical Exam of the Chief Complaint

“Abdominal exam shows nonspecific tenderness throughout, no focal guarding or rigidity. No masses. No CVA tenderness”A Focused Exam

A common error by medical students is that they present a brief generalized exam of each body system rather than a detailed examination of the body system most pertinent to the case.

For example, a great medical student will perform the following…

* If the patient complains of back pain: palpate the spine, perform reflexes, ambulate the patient, do a straight leg raise.* If the patient complains of headache: test cranial nerves, visual fields, finger to nose, gait stability, motor, sensation, speech* If the patient complains of chest pain: auscultate the heart, examine the legs for DVT, look for JVD, obtain pulses in all 4 extremities.

Suspected Diagnosis

“I don’t have any particular diagnosis that I think is most likely yet”Identify your most suspected diagnosis (or lack thereof)

Can’t Miss Diagnoses

“We do need to rule out the life threats of ECTOPIC PREGNANCY, DKA, and APPENDICITIS“List several pertinent life threats

List 2-3 life threats you specifically considered and which seem MOST pertinent to the patient’s specific complaint and examination. If your attending requests more, then give more as needed.

Testing Plan

“For my testing plan I would like to get a PREGNANCY TEST, ELECTROLYTES, CBC, LIPASE, LIVER FUNCTION, and a CT SCAN WITH CONTRAST “A TESTING PLAN

Common tests for abdominal pain potentially include (but are not required)…

* CBC* Electrolytes (CHEM, BMP)* Liver Function Tests* Lipase* Urinalysis* Urine Pregnancy Tests* Troponin* EKG* CT scan with (or without) contrast* Ultrasound (especially common with right upper quadrant pain, pelvic pain, and with pediatrics)

Treatment Plan

“For my treatment plan I would like to get her 4mg Zofran, 4mg of morphine along with some FLUIDS“a Treatment Plan

***A COMMON MISTAKE BY MEDICAL STUDENTS IS THAT THEY GIVE A GREAT TESTING PLAN BUT FORGET TO GIVE A BASIC TREATMENT PLAN

With abdominal pain, memorize a few basic antiemetics, pain medications, and types of fluids (with doses) so that you can give a treatment plan during your shift.

EM Clerkship’s 10 Step Patient Presentation

* Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)* At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)* Red Flags/Pertinent Positives and Negatives* Vital Signs* Focused Physical Exam of the Complaint* Suspected Diagnosis* Can’t Miss Diagnosis* Testing Plan* Treatment Plan* (If Asked) Anticipated Disposition

Demographics (Age, Gender, Pertinent Medical/Surgical History, Chief Complaint)

“I have a 48 year old, FEMALE with a past medical history of INSULIN DEPENDENT DIABETES, AND NO HISTORY OF ABDOMINAL SURGERY, who presents with ABDOMINAL PAIN“a Typical demographics statement

Age

The reason age is so important (especially with abdominal pain) is because it adds additional (frequently forgotten) items to your basic differential. For example…

* Pediatric Patients* Intussusception* Necrotizing Enterocolitis* Henoch Schonlein Purpura* Testicular and Ovarian Torsion* Geriatric Patients* Abdominal Aortic Aneurysm* Mesenteric Ischemia* Volvulus* Myocardial Infarction

Interesting Fact: In some studies, geriatric abdominal pain has a mortality of almost 10%!!!

Gender

The reason gender is so important (especially with abdominal pain) is because ECTOPIC PREGNANCY is the most important life threatening diagnosis in women of child bearing age.

Pertinent Past Medical and Surgical History

This is the only place in your presentation when the patient’s medical and surgical history is included. Keep it focused on the most important items.

* Always include previous abdominal surgeries (or say “no history of abdominal surgery”)* Always include an overview of previous GI workups* Diabetes, immunosuppression, active cancer, and blood thinners are almost always pertinent medical conditions regardless of chief complaint* Obvious GI diagnoses should be included such as inflammatory bowel disease, peptic ulcers, cirrhosis, etc

At Least 4 Descriptors (Location, Quality, Severity, Duration, Timing, Context, Modifying Factors)

“She describes it as a SEVERE, GENERALIZED, abdominal pain that STARTED LAST NIGHT and has been GRADUALLY WORSENING since then”An example of giving 4 Descriptors

Most attendings think about (and document) the history of present illness as a list of descriptors. This is for billing reasons. A “level 5” chart requires 4 “HPI Elements” to be documented.

Red Flags/Pertinent Positives and Negatives

“She has had some subjective FEVERS but NO HISTORY OF AFIB, and NO VOMTING, DARK TARRY STOOLS, URINARY SYMPTOMS, or VAGINAL BLEEDING OR DISCHARGEAn example of Giving red flags and pertinent positives/negatives

Abdominal pain is not typically a complaint known for having a big list of “red flags” that need to be asked. In my opinion, examples of true red flags with abdominal pain would potentially be the following…

* History of Atrial Fibrillation* History of Bariatric Surgery

However, it is generally expected that you give a thorough list of pertinent positives as well.

* Fever, Chills, Malaise* Chest Pain, Shortness of Breath* Nausea, Vomiting, Diarrhea* Vaginal Bleeding/Discharge* Dysuria, Urinary Frequency/Urgency, Hematuria* Melena

Additional Reading