Empa Mem6214-B Gi/gu

Front 1

What is the leading cause of acute pancreatitis?

Back 1

Gallstones

p 558

Front 2

What is the second leading cause of acute pancreatitis?

Back 2

EtOH consumption

'p. 558

Front 3

Some drugs known to cause pancreatitis?

Back 3

More likely: Azathioprene, Valproic Acid, Mesalamine, Opiates, Tetracycline, Bactrim, Sulfasalzine, Lasix, --not listed: Accutane
Likely: Rifampicin, Lamivudine, Tegretol, Tylenol, E-mycin, Interferon...

p. 558 Table: 82-2

Front 4

A patient presents with persistent epigastric abdominal pain, to areas around her waist, sometimes localized to RUQ and occasionally to LUQ. Earlier the pain that is radiating to her back was mild, but is now causing a ton of distress. You found her sitting up knees flexed to chest, because "laying down is too painful". + N/V. What does she have?

Back 4

Acute pancreatitis.

p. 558

Front 5

What PE's possess: Tachycardia, fever, HoTn when disease is severe. Sometimes shock. HOwever, Diminished BS's, and Upper abdominal TTP and guarding are present.

Back 5

Pancreatitis

p. 559

Front 6

Turner Gray sign and Cullen's sign, suggest what in pancreatitis?

Back 6

Pancreatic hemorrhage and Necrotizing pancreatitis.

p. 559

Front 7

Acute pancreatitis requires two of what three things to make the dx?

Back 7

1. abdominal pain
2. serum amlylase and/or lipase 3 times the upper limit of NML
3. characteristic findings of acute pancreatitis on CT scan or u/s

p. 559

Front 8

T/F: In the setting of abdominal pain, the serum amylase elevated to three times the level of NML supports dx of pacreatitis?

Back 8

True

p. 559

Front 9

What is the preferred serum lab test for pancreatitis?

Back 9

Lipase

p. 559: However, it does not excluse the dx of pancreatitis when NML

Front 10

What is the imaging modality of choice for acute pancreatitis?

Back 10

Multidetector -Row spiral CT

p. 559

Front 11

What is both dx and therapeutic for obstructing bile duct and pancreatic lesions?

Back 11

ERCP

Last paragraph: p 559

Front 12

What is used to determine the severity of pancreatic dz?

Back 12

Ranson's Criteria

p. 560: only useful after 48 hrs, limited use in the ED mgt of pancreatitis

Front 13

What should be done (generally) for the tx of acute pancreatitis?

Back 13

VS/Pulse OX (q 2-4 hrs x 24 hrs), Aggressive crystalloid therapies; Monitoring of labs: HCT, Glucose, Calcium, and Albumin; Parenteral Narcs, Antiemetics, Abxs, and Consultation for ERCP.

p. 562 Table: 82-6

Front 14

When should calcium be corrected in pancreatitis?

Back 14

When ionized calcium is low or when showing systemic signs of hypocalcemia: tetany, chvostek sign, etc

p. 561

Front 15

T/F: Abx are indicated for mild pancreatitis>

Back 15

False

p. 561

Front 16

When are abxs appropriate for pancreatitis?

Back 16

Infected pancreatitis
Pancreatic necrosis
Pancreatic abscess
Infected pseudocyst
Peripancreatic fluid collection

p 561

Front 17

When can a patient with mild pancreatitis be discharged to home?

Back 17

1. When they can tolerate PO fluids
2. Their pain is controlled.

* Need to f/u 24-48 hrs
p. 562

Front 18

What are the risks for the development of acute acalculous cholecystitis?

Back 18

1. Old age
2. Critical Illness
3. Burns
4. Trauma
5. Major Surgery
6. Long term total Parenteral Nutrition
7. DM
8. Immunosuppression
9. Childbirth

p. 562

Front 19

What is ascending infection of the gallbladder, from partial or complete obstruction?

Back 19

Cholangitis

p. 562

Front 20

What is responsible for gallstone synthesis and peripheral uptake?

Back 20

Hepatocytes

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Front 21

An individual who is fasting for an extended period of time is at risk for? (Few gallstones or more gallstones)

Back 21

More gallstones.

- the gallbladder empties in response to meals. Impaired gallbladder contraction is also seen: pregnancy, obseity, rapid weightloss in obese patients, DM, or total parental nutrition.

p. 562

Front 22

RUQ pain, around waistline, back and then to scapula. + N/V, and at periods of between 2100 hrs-0400 hrs (MC: 0100). What does this suggest?

Back 22

Acute Gallbladder Dz

p. 563

Front 23

What is the pain that sets on for 1-5 hrs then remits, when indicated gallbladder sources?

Back 23

Colic pain

p. 563

Front 24

What PE onm gallbladder dz has the highest sensitivity?

Back 24

Murphy's Sign

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Front 25

What PE/Dx sign will not likely be present in a patient with suspect/known gallbladder disease who has DM or ganganeous cholecystitis?

Back 25

Sonographic Murphy's sign.

p. 564

Front 26

What should be considered in a patient who has U/S evidence of gallbladder wall > 3 mm?

Back 26

Cholecystitis

- also percholecystic fluid and dilated biliary duct > 7 mm. Additionally, Fever, elevated CRP, WBC, RUQ pain.

p. 564

Front 27

Tx for biliary colic?

Back 27

NSAID and/or Opioid.

p. 565

Front 28

All medications of this drug type have a neglible risk of sphinter oddi spasm when provided for sx chole dz?

Back 28

Opioids.

p 565

Front 29

What is the classic triad for acute cholangitis

Back 29

Charcot triad: fever, jaundice and RUQ pain

p. 565
Reynold pentad: AMS, shock, fever, jaundice and abdominal pain.

Front 30

What is the gas forming anaerobe associated with emphysematous cholecystitis?

Back 30

C. Perfringens

p. 565

Front 31

MC cause of the luminal obstruction of the vermiform appendix, causing atraumatic abdominal pain?

Back 31

(ie appendicitis)
fecolith

p. 574

Front 32

How many patients with appendicitis will have an atypical presentation?

Back 32

1/3

p. 574, ex: retroceccal appendix will often have right flank and pelvic pain, whereas malrotation of the colon (transpositionof the appendix) will cause sxs in the LUQ. Also RUQ pain in the prego is possible, tho RLQ remains MC

p. 574

Front 33

What is suggested in an appendiceal patient who reports that their pain is worse with deep inspiration or the ride in the car to the hospital, esp when bumps in road were hit?

Back 33

Progression to peritoneal involvement/process.

p. 574

Front 34

Rebound tenderness and involuntary guarding in your appendicitis patient, "what's up with that"

Back 34

peritonitis

p. 574

Front 35

Rosvings (palpation to LLQ causes pain to RLQ); Psoas and obturator support...

Back 35

Appendicitis and possible involvement to adjacent structures...

-p. 574
- reverse rosvings: supports/suggests diverticulitis- Dr Carrol, EM basic

Front 36

Abdominal rigidity, +psoas, fever, rebound, Tenderness...support, but are not specific for:

Back 36

Appendicitis

p. 574

Front 37

No hx of appendectomy, RLQ, hx of periumbilical pain and/or flank pain...what should u be thinking?

Back 37

Appendicitis...

-seriously if you were not thinking this...reconsider your calling (LOL)
p574

Front 38

W/o elevated WBC, you cannot have appendicitis. What is this called?

Back 38

A bold face lie.

p. 575. However, MC leukocytosis, tho mild, will be present. You can increase the sensitivity of WBC exam with a CRP. : sensitivity of 98% unlikely.

Front 39

What should be done prior to obtaining imaging on a likely appendicitis patient?

Back 39

Contacting surgery

p. 575

Front 40

Initial imaging modality for appendix in pregos and children?

Back 40

U/S

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Front 41

What u/s finding suggests appendicitis?

Back 41

Thickened, noncompressible appendix > 6 mm in diameter

p 576

CT will als show > 6 mm size as well as fat stranding around the structure and possibly even identify the fecolith

Front 42

T/F: non-con CT cannot be used for appendectomy work up.

Back 42

False, it is acceptable (tho not preferred) and results in faster imaging

p. 576

Front 43

What is the MC surgical emergency in the Prego?

Back 43

Appendicitis

p. 578

Front 44

What should be done for a prego patient who has an indeterminant U/S and you suspect appendicitis?

Back 44

Will need: Pelvic U/S, CT or MRI...because they can still have other sources: appendicitis, torsed ovary, heterotopic pregnancy, etc.

p. 578

Front 45

Intestional obstruction: Mechanical vs. Adynamic (Paralytic) Ileus: Which is more common?

Back 45

Adynamic (Paralytic) ILeus- MC self limiting and does not require surgery

p. 581

Front 46

What is the MC cause of SBO?

Back 46

Adhesions

p. 581- MC this occurs several months to yrs after surgery, can also occur as early as few weeks.

Front 47

A 40 ish y/o man comes to see you complaining of increasing abdominal pain that began after he finished the AF a few days ago. States that he has been unable to pass gas, have a bowel movement and has lost his appetite and even feels he may have a fever. He appears ill, but not toxic...what do you suppose is the EXACT cause of this mans discomfort?

Back 47

Mesenteric defect causing his SBO

p. 581

Front 48

What is the name of the condition prediosposing the 10-30 yr age group to SBO (hemartomatous polyps)?

Back 48

Peutz-Jeghers Syndrome

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Front 49

May be the "leading point of Intususception" leading to SBO?

Back 49

Lymphoma

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Front 50

SBO in children, from seat belt use?

Back 50

Duodenal Hematoma

intrabdominal pain, vomiting.

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Front 51

MC cause of large bowel obstruction?

Back 51

Neoplasm

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Front 52

After Neoplasm and Diverticulitis as a source of large bowel obstruction, what comes next?

Back 52

Sigmoid Volvulus

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Front 53

Who is at most risk for a volvulus?

Back 53

Elderly taking anticholinergic medication

may c/o of prior constipation hx

p. 582

Front 54

What often accompanies mechanical obstruction?

Back 54

Bowel Distention

p. 582: distention is secondary to the accumulation of fluids in the bowel lumen. This causes a pressure gradient in the vessels and the lymphatics secondary to the accumulation of fluid, with enhance peristaltic contractions. THis leads to bowel ischemia, septicemia and necrosis...SUCKS! Mortality at this point: 70%

Front 55

Pain consistent with obstruction?

Back 55

MC: all will have abdominal pain, usually crampy,/intermittent and episodic. Lasts usually for few minutes, may be periumbilical or diffuse. Proximal obstruction: emeisis. Large bowel pain is Usually hypogastric. Also: unable to pass gas or have BM. Partial obstruction: can have flatus and BM.
p582

Front 56

T/F: a vaginal pessary can cause a colonic obstruction.

Back 56

True: extrinsic compression of the colon.
p. 582

Front 57

What should be suspected in obstruction patient with leukocytosis: > 20,000/mm3 or left shift?

Back 57

Gangrene of bowel, intrabdominal abscess, or peritonitis.
> 40,000 suggests: messenteric vascular occlusion
p. 582

Front 58

What is the Diagnostic method of choice for bowel obstruction?

Back 58

CT with IV and Oral contrast

p. 583
If renal insufficiency>oral contrast only.

Front 59

What are the risk factors for Ogilvie syndrome?

Back 59

Pseudo-obstruction (Ogilvie syndrome):
1. advanced age
2. anticholinergic or TCA therapies...

- TX NOT SURGICAL. Colonscopy can be dx and therapeutic- providing decompression after identifying lesions.
p. 583

Front 60

What is the MC of death associated with ARF (Acute Renal Failure)?

Back 60

Sepsis and Acute Renal Failure...

- Since the advent of dialysis.
- MC hospital causes: Intrarenal dz
- MC community: volume depletion causes prerenal dz
p. 615

Front 61

MC of intrinsic renal failure?

Back 61

Acute Tubular Necrosis- when renal perfusion is decreased so much that the kidney parenchyma suffers ischemic injury
p. 615 (read this section)

Front 62

What sxs can be attributed to uremia in ARF?

Back 62

Nausea
Vomiting
Drowsiness
Fatigue
Confusion
Coma
p. 615

Front 63

Pre-renal, renal or postrenal dz?
Orthostatic lightheadedness, thirst, decreased urine output, Excessive vomiting, hemorrhage and fever, as well as sweating can worsen this...

Back 63

Pre-Renal disease.

-read bottom p. 615, and all of p. 616

Front 64

In the setting of obstruction, significant/permanent loss of renal fxn occurs over the course of how many days.

Back 64

10-14 days

p. 617

Front 65

An individual can lose how much of their functioning nephrons before developing elevated Creatinine levels?

Back 65

more than 1 half

p. 619

Front 66

When does radiocontrast induced nephropathy become a big concern: (renal labs)

Back 66

GFR < 60


Gadolinium based contrast in MRI should not be given when GFR < 30- due to risk of nephrogenic systemic fibrosis.

p. 621

Front 67

How should male patients be placed for their GU examination?

Back 67

They should be examined both lying and sitting.
Ensure room is well lit and warm- if needs be, place warm towel over site.
p. 646

Front 68

How does Fournier Gangrene MC begin?

Back 68

This virulent, polymicrobial surgical emergency MC begins as a benign infx of simple abscess that quickly becomes virulent- esp in immunocompromised individual.

p. 647

Front 69

Firs tmgt og Fournier Gangrene?

Back 69

IV fluid mgt, Gram +/- and Anaerobe coverage a must. and surgery...sometimes hyperbaric mgt after surgery.

PE: exquisite tenderness, swelling, ecchymosis, and crepitus common.
40% mortality

p. 647

Front 70

What can often be the sole presenting sign of DM?

Back 70

Balanoposthitis- when recurrent. THis is inflammation of the glans and foreskin. (Balanitis-glans irritation, posthitis-foreskin inflammation)
p 647

Front 71

What presents with swelling of the glans in uncircumcised males 3-5 y/o.

Back 71

penile hair tourniquet syndrome

p. 648- this is not a sign of child abuse.

Front 72

What manner is used to "detorse" a torsed teste?

Back 72

Open book procedure

p. 648

Front 73

What should be considered in all males c/o abdominal pain?

Back 73

Testicular torsion

p. 649

Front 74

The ovary should not be palpable how long after menapause?

Back 74

5 yrs.

- if palpable/enlargement, this is BAD
p. 666

Front 75

MC cause of abnormal vaginal bleeding in women?

Back 75

Pregnancy related badness

p. 667

Front 76

Most frequently occurring pelvic tumor?

Back 76

Leiomyoma

p 668= improved with BCP's and menopause (if worse with menopause- it is CA until proven otherwise)- rare, but possible source of pain

Front 77

What has to be considered in >35 y/o female, or younger if bad risk factors, who present with abdominal pain and vaginal bleeding?

Back 77

Endometrial hyperplasia or endometrial CA

p. 668- amt of bleeding does not relate to the significance of disease

Front 78

What are some common causes of abnormal bleeding, vaginally.

Back 78

- Endocrine of course...
- OCP"s are the most common cause
- eating disorders
- excessive weightloss
- stress
- exercise

p 670

Front 79

In a patient, who has been est with lab study as non-prego, and has vag bleeding...what are the only things that have to be ruled out in ED?

Back 79

1. trauma
2. bleeding dyscrasias
3. infection
4. retained foreign body

p. 670

Front 80

What is Usually indicated in a patient with severe, persistent, uterine bleeding?

Back 80

Immediate D&C

p 670- conjugated estrogen can be used when waiting: unless known contraindications.

Front 81

What is not required to eval and tx adolescent patient in the Emergency Room?

Back 81

Parental Consent

p. 671

Front 82

T/F: Trauma from intercourse and even bimanual examination have been implicated as sources of ectopic rupture.

Back 82

True
p. 676

Front 83

What is MC presenting complaint of ectopic prego?

Back 83

Abdominal pain: 90%

15% will not have missed menses

p. 676

Front 84

What is a cervix with a bluish hue?

Back 84

Indicator of pregnancy

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Front 85

What are two relaible signs to exclude ectopic pregnancy?

Back 85

1. fetal heart tones
2. tissue from the os.

p. 677

Front 86

In vitro fertilization efforts as well as ovulation inducing drugs have increased the risks of...

Back 86

heterotopic pregnancy

- even if IUP is found, ensure no other is lingering...
p. 678

Front 87

When u/s reveals IUP and no other abnormalities, Ectopic has been effectively ruled out; unless the patient possess risk factors for:

Back 87

Heterotopic

p. 679

Front 88

Treatment for ectopic pregnancy?

Back 88

Med mgt: Methotrexate
Surg Mgt: Laparoscopy- salpingostomy
However, in ruptured: Laparotomy

p. 680

Front 89

Tx failure with methotrexate

Back 89

36%

p. 681- signs of tubal rupture require prompt tx: abdominal pain, bleed, weakness, dizziness, syncope- after tx.
Refrain from Nookie: 14-21 days

Front 90

What is an abortion complicated by pelvic infx?

Back 90

Septic abortion

review table: 101-6 p. 682