Advanced Practice Provider Academy

Transcription

1 (+)Dean T. Harrison, MPAS,PA C,DFAAPA Director of Mid Level Practitioners; Assistant Medical Director Clinical Evaluation Unit, Division of Emergency Medicine, Department of Surgery, Duke University Medical Center Advanced Practice Provider Academy April San Diego, CA Case Studies in Abdominal Pain: Performing the High Yield History and Physical Examination Abdominal pain accounts for approximately 5 percent of ED visits. Most patients do well but some patients have a life threatening illness that can t be missed. During this case based lecture, the speaker will emphasize the key points in the history and physical examination that will allow you to recognize the seriously ill patient. Objectives: Discuss the typical and atypical presentations of acute pyelonephritis, cholecystitis, pancreatitis, abdominal aortic aneurysm, testicular torsion and appendicitis. Describe specific questions that if answered affirmatively increase the likelihood of serious abdominal disease. Describe findings on physical examination (including the GU exam) that should alert the practitioner to the possibility of serious abdominal pathology. List key elements that should be included on each chart in the patient presenting with abdominal pain. Date: 4/15/2014 Time: 11:45 AM 12:15 PM Course Number: TU 23 (+) No significant financial relationships to disclose

2 Dean T Harrison, M.P.A.S, P.A. C, D.F.A.A.P.A San Diego, April 15,2014 Agenda At the end of this presentation you should be able to recognize the following patient presentations Acute Pyelonephritis Cholecystitis Pancreatitis Abdominal Aortic Aneurysm Testicular Torsion Appendicitis 1

3 Case 1 34 year old female negative past medical history 1 2 days of intractable nausea vomiting Past 24 hours low grade fever chills and back pain Exam HR 112 BP 110/70 RR 18 right sided CVAT TTP RLQ/LLQ What do you want to do? What is you diagnosis Case 2 55 year old obese female acute onset of RUQ pain a/w n/v after eating at work party Past Hx : HTN DM CAD Exam distressed due pain RUQ tenderness with guarding What do you want to do? What is your diagnosis 2

4 Case 3 24 year old male diffuse abdominal pain after a night of drinking celebrating graduation Past 12 hrs now has nausea/vomiting Exam 38.2 C HR 120 BP 120/90 rr 20 Abd diffuse tenderness What to you want to do? what is your diagnosis? Case 4 78 year old male with stabbing abdominal pain to his back past 2 hours PHX CAD HTN DM PVD Exam Bp 80/40 HR 130 RR 24 Abdomen Diffuse TTP What do you want to do? What is your diagnosis 3

5 Most Common Abdominal Pain Presentations Non specific abd pain 34% Appendicitis 28% Biliary tract dz 10% SBO 4% Gyn disease 4% Pancreatitis 3% Renal colic 3% Perforated ulcer 3% Cancer 2% Diverticular dz 2% Other 6% Determining the Correct Diagnosis CAN BE CHALLENGING!!!! 4

6 Differential Diagnosis Gastritis, ileitis, colitis, esophagitis Ulcers: gastric, peptic, esophageal Biliary disease: cholelithiasis, cholecystitis Hepatitis, pancreatitis, Cholangitis Splenic infarct, Splenic rupture Pancreatic psuedocyst Hollow viscous perforation Bowel obstruction, volvulus Diverticulitis Appendicitis Ovarian cyst Ovarian torsion Hernias: incarcerated, strangulated Kidney stones Pyelonephritis Hydronephrosis Inflammatory bowel disease: crohns, UC Gastroenteritis, enterocolitis pseudomembranous colitis, ischemia colitis Tumors: carcinomas, lipomas Meckels diverticulum Testicular torsion Epididymitis, prostatitis, orchitis, cystitis Constipation Abdominal aortic aneurysm, ruptures aneurysm Aortic dissection Mesenteric ischemia Organomegaly ACS Pneumonia Abdominal wall syndromes: muscle strain, hematomas, trauma, Neuropathic causes: radicular pain Non specific abdominal pain Group A beta hemolytic streptococcal pharyngitis Rocky Mountain Spotted Fever Toxic Shock Syndrome Black widow envenomation Drugs: cocaine induced ischemia, erythromycin, tetracyclines, NSAIDs Mercury salts Acute inorganic lead poisoning Electrical injury Opioid withdrawal Mushroom toxicity AGA: DKA, AKA Adrenal crisis Thyroid storm Hypo and hypercalcemia Sickle cell crisis Vasculitis Irritable bowel syndrome Ectopic pregnancy PID Urinary retention Ileus, Ogilvie syndrome How Do You Approach the patient with Abdominal Pain? Knowing the location and type of pain History and Physical Examination Laboratory Analysis Imaging Studies High Risk Patients Knowing the potential Land Mines Knowing when to engage consultants 5

7 OLD CARS Mnemonic for Pain O Onset L Location D Duration C Character A Alleviating/Aggravating Factors R Radiation S Severity Visceral Involves hollow or solid organs; midline pain due to bilateral innvervation Steady ache or vague discomfort to excruciating or colicky pain Poorly localized Epigastric region: stomach, duodenum, biliary tract Periumbilical: small bowel, appendix, cecum Suprapubic: colon, sigmoid, GU tract Parietal Involves parietal peritoneum Localized pain Causes tenderness and guarding which progress to rigidity and rebound as peritonitis develops Referred Produces symptoms not signs Based on developmental embryology Ureteral obstruction testicular pain Subdiaphragmatic irritation ipsilateral shoulder or supraclavicular pain Gynecologic pathology back or proximal lower extremity Biliary disease right infrascapular pain MI epigastric, neck, jaw or upper extremity pain 6

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9 Relevant Associated ROS General Fever weight loss dizziness Cardiac chest pain palpitations lightheadedness GI nausea vomiting hemetemesis anorexia diarrhea melena constipation GU urgency dysuria hematuria incontinence GYN vaginal bleeding vaginal discharge dysprunia History Taking IMPORTANT!! Similar episodes? Other Medical Conditions DM/CAD/HIV/Cancer Past Surgical History Think Adhesions /Infections Past GU History UTI/Pyelonephritis/Kidney Stones Past GYN Sexual Activity /Contraception /PID/STD 8

10 History Taking Social History Drugs Tobacco ETOH Work Environment? Physical Abuse Medications NSIDS PPI s Immunosuppressive Agents Anti coagulants Physical Examination Start at the Door General Appearance Vitals Signs Can tell you a lot Make sure you include Cardiac /Pulmonary Exam Make sure patent is undressed Don t forget Gent/Pelvic exam when indicated 9

11 Consistent Approach to Exam Inspection Distention/scars/masses Auscultation All 4 Quadrants BS Absent Hyper/Hypo Palpation Tenderness Masses AA Organomegaly Rebound Guarding Rigidity Percussion Check for Tympany Acute Pyelonephritis What is it? Sudden and Severe kidney infection What are the bacterial etiologies? E coli 75 95% Proteius Klebsiella Pseudomonas Serraitia Enterocci 10

12 How Do They Present? Fever > 38 degree C Chills Back/Flank Pain Nausea/Vomiting Anorexia May Mimic PID/STD in Female Patients Especially in Inner City Locations Dysuria/Pyuria/Urgency/Hematuria Physical Findings Febrile May be dehydrated from vomiting CVA tenderness Diffuse or localized pain on abdominal exam Remember to perform Pelvic Examination to R/O Gyn process 11

13 Laboratory Evaluation Elevated WBC with Left shift Urine positive for LE/Nitrates May have WBC cast? Renal origin Electrolytes may reflect dehydration Imaging CT with contrast if concern about altercations in renal perfusion/abscesses Imaging CT without contrast concerned about obstructive process ie. infected stone Ultra sound if unable to have CT Treatment Plan Urine cultures Antibiotics extend coverage as clinically indicated Hydration Antiemetic Pain Management Complications Renal Abscess Peri Nephric Abscess Papillary Necrosis Urosepsis 12

14 Take Home Points! Assume all females or pregnant until proven they are not Inner city patients may have GYN process Always perform a Pelvic Exam you may have two processes simultaneously If patient is not improving as expected Your initial diagnosis may not be correct! Easily treated significant complications if missed! Acute Cholecystitis What is it? The gallbladder neck or cystic duct is obstructed Increased intraluminal pressure along with irritation from bile and stones can lead to mucosal damage and inflammation of the gallbladder wall Potentially can lead to ischemia 13

15 Acute Cholecystitis Acute Cholecystitis 14

16 How Do They Present? RUQ Pain Radiation to back or shoulder Nauseated /Vomiting Low grade fever Tachycardia Pain lasting greater than 6 hours Look sick 15

17 What do you Find on Examination? Patient appears sick May be febrile May have tachycardia RUQ pain with positive Murphy s sign (place hand RU Costal Margin ask pt to take deep breath pt will experience pain and catch their breath as the GB descends and contacts the palpating hand ) Peritoneal signs may signify perforation What will the labs show? Leukocytosis If CBD obstruction elevated bilirubin /LFTs Elevated lipase suggestive of gallstone pancreatitis Gallbladder Ultra Sound Thicken GB wall Pericholecystic fluid Gallstones or sludge Sonographic Murphy Sign HIDA scan more sensitive/specific 16

18 What Do I Do? Surgical Consult NPO IV Fluids Pain Management NG if indicated Antibiotics Ceftriaxone 1 gm IV If septic broaden coverage Take Home Points! Most people with asymptomatic gallstones remain asymptomatic Patients that develop Acute Cholecystitis will present with pain Acute Cholecystitis and its complications are potentially life threatening and require prompt diagnosis Bedside GB /US with positive Murphy's sign can help expedite the diagnosis 17

19 Acute Pancreatitis What is it? Usually a relatively mild disease may become a lifethreatening illness characterized by infection and necrosis of pancreatic tissue How do They Present? Abdominal pain is the most common complaint Usually is severe and constant Pain may be diffuse but may be localized to epigastric region and LUQ Nausea/Vomiting H/O ETOH abuse is common 1 10% In non ETOH patients 60% will have gallstones 18

20 What do Find on Physical Exam? Pain is exacerbated by recumbency and relieved by sitting up and flexing forward due to retroperitoneal irritation May have Guarding LUQ and epigastric region May have signs of peritoneal irritation Cullen sign Bluish discoloration around the umbilicus (hemorrhagic process) Grey Turner sign Bluish discoloration of the flanks (hemorrhagic process) May be febrile May have tachycardia May also be diaphoretic Dehydrated from vomiting What will the Labs Show? Elevated WBC Elevated Lipase high specificity Elevated Amylase others processes can elevate do not rely only on this test US can show pancreatic edema/pseudo cyst can be difficult to visualize due to adipose tissue or distended loops of bowel CT NOT necessary to diagnose pancreatitis useful to evaluate complications 19

21 What Do I Do? 90 % of cases can be treated with supportive care Rest the pancreas IVF Advance diet as tolerated NG tube if indicated Pain management Correct electrolyte imbalance Antiemetic Trend lipase Take Home Points! High suspicion with patients with ETOH dependency Significant Physical Exam findings LUQ Elevated Lipase isolated value is it trending upward or downward? Chronic pancreatitis is usually manifested by recurrent episode of acute pancreatitis Adequate pain management 20

22 Abdominal Aortic Aneurysm What it Is The most frequent catastrophic event involving the aorta Starts with a tear in the inner most layer of the vessel Tear allows blood to penetrate down to the middle layer causing separation 21

23 Ruptured AAA Often asymptomatic and unknown prior to presentation Rupture is the worry Presents with midline abdominal pain with tearing sensation to the back Patients often present in shock Exam revels pustule abdominal mass Aortic Dissection What to Think About it You Do NOT want to miss this Diagnosis!! Chest pain with associated back pain/abdominal pain H/O Hypertension H/O Connective Tissue Diseases H/O Atypical Chest Pain H/O Atypical Back Pain Diminished or Absent Peripheral Pulses 22

24 Physical Exam Pt will present in 3 ways asymptomatic symptomatic 50% of asymptomatic AAA are palpable ruptured Classic triad in ruptured patients back pain hypotension pulsatile mass What to do Laboratory studies not usually helpful for diagnosis but helpful for baseline references Coagulations studies should be evaluated Type and Cross US is quick and accurate for presence of AAA CT provides greater detail and more accurate measurement Management is tailored to the patients presentation 23

25 Take Home Points High Suspicion in an unstable patient requires emergent surgical consultation and surgery Aggressive resuscitation of shock with fluids and blood products as necessary US is helpful in establishing the presence or absence of AAA but it cannot provide evidence that the AAA is not ruptured,leaking, or expanding AAA are frequently misdiagnosed in obese patients Testicular Torsion 24

26 Testicular Torsion How do they Present? Sudden onset of severe testicular pain If torsion is repaired within 6 hours of the initial insult, salvage rates of % are typical. These rates decline to nearly 0% at 24 hours. Approximately 5 10% of torsed testes spontaneously detorse, but the risk of retorsion at a later date remains high. Most occur in males less than 20yrs old but 10% of affected patients are older than 30 years. 25

27 What will I see on exam? What do I do? Stat Ultrasound Stat Urology Consult Time is Testicular Survival True Urological Emergency Pain Management Prep for OR No Urology available Manual detorsion 26

28 Take Home Points 50% of testes lost because of misdiagnosis at presentation Scrotal erythema and swelling usually associated with infection Do not delay consultation with Urologist Manual detorsion is the most rapid means of establishing blood flow Acute Appendicitis Classic Presentation ( How often do you see that?) Anorexia, nausea, vomiting Periumbilical pain Pain localized to RLQ This presentation occurs in majority of patients. 26% of appendices are retrocecal and cause pain in the flank 4% patients will present with RUQ pain. Males may present with pain in their testicles 27

29 Physical Exam Varied depends on duration of symptoms Can have rebound, voluntary guarding,rigidity, tenderness on rectal exam Positive Psosas sign Positive Obturator sign Obturator sign 28

30 Psoas Sign Appendicitis: Psoas Sign 29

31 Laboratory Findings CBC not sensitive or specific Abdominal x ray may see localized ileus,blurred right psoas muscle, free air US +/ CT pericecal inflamation abscess, periappendiceal phlegmon, fluid collection, localized fat stranding 30

32 What do I do? Positive CT call surgeon NPO IVF Cover anaerobes, gram negative and eterococci Zosyn grams iv or Unasyn 3 grams iv Suspect but have not pulled the CT trigger Place in Observation trend exam and clinical changes 31

33 Take Home Points. Abdominal Pain and tenderness are present in nearly 100% of patients with acute appendicitis Use caution in your evaluation of the young elderly pregnant female! And don t forget the intoxicated male! Do not rely on the CBC Back to the Cases 32

34 Case 1 34 year old female negative past medical history 1 2 days of intractable nausea vomiting Past 24 hours low grade fever chills and back pain Exam HR 112 BP 110/70 RR 18 right sided CVAT TTP RLQ/LLQ What do you want to do? What is you diagnosis Case 1 Lab WBC 15,000 with left shift U/A positive nitrates positive LE positive Ketones micro wbc/hpf Electrolytes normal Pregnancy negative DX : Acute Pyelonephritis Treatment plan antibiotics antiemetic fluids pain management urine c/s 33

35 Case 2 55 year old obese female acute onset of RUQ pain a/w n/v after eating at work party Past Hx : HTN DM CAD Exam distressed due pain RUQ tenderness with guarding What do you want to do? What is your diagnosis Case 2 Lab WBC 20,000 with left shift Electrolytes normal U/A normal LFTS T Bilirubin 1.9 GB /US positive for obstructive stones /CB dilatation DX: Acute Cholecystitis Plan : Admission Antibiotics Surgical Consult Supportive Care 34

36 Case 3 24 year old male diffuse abdominal pain after a night of drinking celebrating graduation Past 12 hrs now has nausea/vomiting Exam 38.2 C HR 120 BP 120/90 rr 20 Abd TTP over McBurney point What to you want to do? what is your diagnosis? Case 3 Lab WBC Electrolytes K+ 3.1 Bun 28/Creat. 1.6 CT positive for dilated appendix with stranding Diagnosis Acute Appendicitis / Mild dehydration Plan: NPO Surgical Consult Antibiotics Pain Management IVF K replacement 35

37 Case 4 78 year old male with stabbing abdominal pain tearing sensation radiating to his back past 2 hours PHX CAD HTN DM PVD Exam Bp 80/40 HR 130 RR 24 Abdomen Diffuse TTP palpable pulsating mass decreased distal pulses What do you want to do? What is your diagnosis Case 4 Bedside US positive for AAA DX Rupturing AAA p/ Stat Surgical Page Aggressive Management Prep for OR 36

38 Summary Bullets Patient Assessment and Management Always perform genital examination when lower abdominal pain is present in males and females Females are pregnant until proven otherwise Sudden, severe pain suggest serious disease Pain awakening the patient from sleep should be taken as an indicator of serious disease In older patents remember to think about AAA Significant abdominal tenderness should never be attributed to gastroenteritis Documentation MUST!!! or it will come back to bite you latter Remember if it is not documented it wasn t done Remember to document you medical decision process Pitfalls Incomplete exams (rectal pelvic genital) Incomplete histories Missing lab results/vs Not performing serial exams and documenting Gastroenteritis Diagnosis!!! Change of shifts dilemma The Intoxicated or altered patient Documentation of Consultants Recommendations 37

39 Thank You for Your Time and Attention!! 38