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Abdo Pain
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Abdominal Pain (acute and chronic)

Subjective

  • LOCATION of pain is starting point of abdo pain evaluation

      • Is it pulm, urinary, or hepatobiliary?

      • UTI/kidney stone → urinalysis

      • colic/fever/steatorrhea/Murphy’s → u/s

      • If suspected appendicitis, also get urgent surg consult

      • Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc)

  • Onset, duration, severity, quality, exacerbating/remitting factors

  • Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention

    • Manning criteria (3 or more of) for IBS

  • Red flags

    • New onset of pain, Change in pain, Altered bowel habits in elderly

      • Check if all 3 are particular to elderly, or just the altered bowel habits

    • Wt loss (GI malignancy)

    • Pain radiating to back (pancreatitis, AAA)

    • Appendicitis (from highest to lowest PPV)

      • RLQ PAIN, pain migration from periumbilical to RLQ, fever, anorexia

    • Pain radiating to groin (testicular torsion, hernia, renal colic)

    • Bleeding per rectum, melena stool (GI bleed, Meckel’s, malignancy in elderly)

    • Anemia

    • Supraclavicular nodes

    • personal/family hx of serious bowel patho

    • Pain waking pt at night

    • Current abx/steroids (can mask peritoneal sx’s)

    • Cardiac hx incl. Afib, HTN (ischemic bowel, AAA, MI)

    • Bowel obstruction (highest to lowest PPV)

      • CONSTIPATION, abdo distention, ↓ pain after vomiting, colic, prev abdo surg

    • Antipsychotic use (ileus, obstruction, toxic megacolon)

    • EtOH (risk factor for p

...
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#pdev
Można uzyskać kontrolę nad tym, jak upływa czas, prowadząc przez trzy dni spis wszystkich czynności wykonywanych w ciągu dnia. Zwróć uwagę na to, ile czasu poświęcasz łącznie na każdą czynność. Następnie, dzieląc wynik przez trzy, otrzymasz szacunkową przeciętną ilość czasu poświęcaną na każdą z czynności. Prawnicy, architekci, konsultanci i inni specjaliści stosują podobną procedurę do określenia liczby „godzin rozliczeniowych” przepracowanych dla każdego z klientów.
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Back Pain
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Back Pain (acute and chronic)

*Just use the core back tool, it’s so good*

Subjective

Objective

Plan

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Dizziness/Vertigo
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Dizziness/Vertigo

Approach to patient with Dizziness

Subjective

  • “Does it feel like either the room is spinning or that you are spinning?” and/or “Is it triggered or worsened by turning your head or rolling over in bed?”

    • Yes = vertigo

      • BENIGN PAROXYSMAL POSITIONAL VERTIGO (most common)

        • brief, recurrent episodes (seconds to minutes), +/- nausea and vomiting

      • Vestibular Neuritis

        • rapid onset, severe, persistent (days), N/V, imbalance

      • Ménière’s Disease

        • recurrent episodes (minutes to hours), fluctuating hearing loss, tinnitus, and sensation of aural fullness

      • Vestibular Toxicity

        • aminoglycosides (eg. gentamycin), loop diuretics, ASA, NSAIDs, amiodarone, quinine, cisplatin

    • No = other forms of dizziness

      • Presyncopal Dizziness – “feels like nearly fainting or blacking out”

        • ECG

        • Triggered by exertion? Chest pain/palpitations? Known structural heart dz? FmHx of sudden death? Abnormal ECG? (if pt stable, fax ECG for urgent advice)

          • If yes to any, suspect cardiac etiology. Refer to Emergency

          • If no, orthostatic hypotension?

            • Yes = investigate underlying cause. meds/alcohol? Consider CBC/lytes

            • No = likely vasovagal/situational etiology. If recurrent episodes or pt is at risk of injury, consider referral for tilt test (+/- carotid sinus massage if >40 yo)

      • Disequilibrium Dizziness – “unsteadiness while walking”

        • Often multifactorial, common in elderly, risk of falls. Complete neuro and MSK exams to rule out peripheral neuropathy, Parkinsonism, MSK d/o, CVA, etc

      • Nonspecific Dizziness – “woozy”, “giddy”, “light-headed”

        • DDx: hypoglycemic (glucose), thyroid disease (TSH), pregnancy (β-HCG), meds, psychiatric disorders, alcohol/drugs, menstruation, previous head trauma

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#fm #has-images

LOCATION of pain is starting point of abdo pain evaluation

    • Is it pulm, urinary, or hepatobiliary?

    • UTI/kidney stone → urinalysis

    • colic/fever/steatorrhea/Murphy’s → u/s

    • If suspected appendicitis, also get urgent surg consult

    • Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc)

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Abdo Pain
Abdominal Pain (acute and chronic) Subjective LOCATION of pain is starting point of abdo pain evaluation Is it pulm, urinary, or hepatobiliary? UTI/kidney stone → urinalysis colic/fever/steatorrhea/Murphy’s → u/s If suspected appendicitis, also get urgent surg consult Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc) Onset, duration, severity, quality, exacerbating/remitting factors Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of




#fm

Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention

  • Manning criteria (3 or more of) for IBS

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Abdo Pain
; Not just hx of fever/ds, physical findings too (e.g. distention, tenderness, rectal blood, etc) Onset, duration, severity, quality, exacerbating/remitting factors <span>Pain relief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention Manning criteria (3 or more of) for IBS Red flags New onset of pain, Change in pain, Altered bowel habits in elderly Check if all 3 are particular to elderly, or just the altered




#fm

Red flags

  • New onset of pain, Change in pain, Altered bowel habits in elderly

    • Check if all 3 are particular to elderly, or just the altered bowel habits

  • Wt loss (GI malignancy)

  • Pain radiating to back (pancreatitis, AAA)

  • Appendicitis (from highest to lowest PPV)

    • RLQ PAIN, pain migration from periumbilical to RLQ, fever, anorexia

  • Pain radiating to groin (testicular torsion, hernia, renal colic)

  • Bleeding per rectum, melena stool (GI bleed, Meckel’s, malignancy in elderly)

  • Anemia

  • Supraclavicular nodes

  • personal/family hx of serious bowel patho

  • Pain waking pt at night

  • Current abx/steroids (can mask peritoneal sx’s)

  • Cardiac hx incl. Afib, HTN (ischemic bowel, AAA, MI)

  • Bowel obstruction (highest to lowest PPV)

    • CONSTIPATION, abdo distention, ↓ pain after vomiting, colic, prev abdo surg

  • Antipsychotic use (ileus, obstruction, toxic megacolon)

  • EtOH (risk factor for pancreatitis, varices)

  • Sexually active (ectopic pregnancy, STIs)

  • Cholecystitis (highest to lowest PPV)

    • RUQ pain, fever, jaundice

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Abdo Pain
ief w/ bowel mvnt, More freq stools w/ onset of pain, Loose stools w/ onset of pain, Passage of mucus, Sensation of incomplete evacuation, abdo distention Manning criteria (3 or more of) for IBS <span>Red flags New onset of pain, Change in pain, Altered bowel habits in elderly Check if all 3 are particular to elderly, or just the altered bowel habits Wt loss (GI malignancy) Pain radiating to back (pancreatitis, AAA) Appendicitis (from highest to lowest PPV) RLQ PAIN, pain migration from periumbilical to RLQ, fever, anorexia Pain radiating to groin (testicular torsion, hernia, renal colic) Bleeding per rectum, melena stool (GI bleed, Meckel’s, malignancy in elderly) Anemia Supraclavicular nodes personal/family hx of serious bowel patho Pain waking pt at night Current abx/steroids (can mask peritoneal sx’s) Cardiac hx incl. Afib, HTN (ischemic bowel, AAA, MI) Bowel obstruction (highest to lowest PPV) CONSTIPATION, abdo distention, ↓ pain after vomiting, colic, prev abdo surg Antipsychotic use (ileus, obstruction, toxic megacolon) EtOH (risk factor for pancreatitis, varices) Sexually active (ectopic pregnancy, STIs) Cholecystitis (highest to lowest PPV) RUQ pain, fever, jaundice IBS algorithm Objective General inspection Change in men




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IBS algorithm

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Abdo Pain
(risk factor for pancreatitis, varices) Sexually active (ectopic pregnancy, STIs) Cholecystitis (highest to lowest PPV) RUQ pain, fever, jaundice <span>IBS algorithm Objective General inspection Change in mental status (infection - UTI) Shock (perforated viscera, GI hemorrhage, severe panc




Abdo Pain
#fm
Objective
  • General inspection

    • Change in mental status (infection - UTI)

    • Shock (perforated viscera, GI hemorrhage, severe pancreatitis, MI, sepsis)

  • Vitals

  • Upper abdo pain - pay attention to Cardiac (ischemia) & lung (pneumonia) exams

    • Tachypneic (pneumonia)

  • Abdo

    • peritoneal signs

    • Carnett’s sign (high ppv for abdo wall pain)

      • ↑ pain when supine pt raises head & shoulder, tensing abdo wall

    • Murphy’s sign (high ppv for choleycystitis)

    • Psoas sign (high ppv for appendicitis)

    • Sever pain out of proportion (ischemic bowel, pancreatitis)

    • restless/writhing (biliary/renal colic, testicular torsion)

    • LLQ tenderness (diverticulitis)

  • Rectal & pelvic exams if lower abdo & pelvic pain

    • DRE - fecal impaction, palpable mass, occult blood in stool

      • Tenderness & fullness on R of rectum suggests retrocecal appendix

    • Pelvic - vaginal discharge (vaginitis), cervical motion tenderness & peritoneal signs (ectopic pregnancy or other gyne complications e.g. tubo-ovarian abscess)

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Abdo Pain
Cholecystitis (highest to lowest PPV) RUQ pain, fever, jaundice IBS algorithm <span>Objective General inspection Change in mental status (infection - UTI) Shock (perforated viscera, GI hemorrhage, severe pancreatitis, MI, sepsis) Vitals Upper abdo pain - pay attention to Cardiac (ischemia) & lung (pneumonia) exams Tachypneic (pneumonia) Abdo peritoneal signs Carnett’s sign (high ppv for abdo wall pain) ↑ pain when supine pt raises head & shoulder, tensing abdo wall Murphy’s sign (high ppv for choleycystitis) Psoas sign (high ppv for appendicitis) Sever pain out of proportion (ischemic bowel, pancreatitis) restless/writhing (biliary/renal colic, testicular torsion) LLQ tenderness (diverticulitis) Rectal & pelvic exams if lower abdo & pelvic pain DRE - fecal impaction, palpable mass, occult blood in stool Tenderness & fullness on R of rectum suggests retrocecal appendix Pelvic - vaginal discharge (vaginitis), cervical motion tenderness & peritoneal signs (ectopic pregnancy or other gyne complications e.g. tubo-ovarian abscess) S&S of surgical abdo Fever Protracted (prolonged) vomiting syncope/pre-syncope Evidence of GI blood loss




#fm
S&S of surgical abdo
  • Fever

  • Protracted (prolonged) vomiting

  • syncope/pre-syncope

  • Evidence of GI blood loss

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Abdo Pain
retrocecal appendix Pelvic - vaginal discharge (vaginitis), cervical motion tenderness & peritoneal signs (ectopic pregnancy or other gyne complications e.g. tubo-ovarian abscess) <span>S&S of surgical abdo Fever Protracted (prolonged) vomiting syncope/pre-syncope Evidence of GI blood loss Psychosocial factors assc w/ chr & recurrent abdo pain Assessment Common causes IBS (discomfort/pain assc w/ a




Abdo Pain
#fm
Assessment
  • Common causes

    • IBS (discomfort/pain assc w/ altered bowel habits >3d/mo in prev 3 mo)

  • Less common but important causes

    • Appendicitis

    • Acute cholecystitis

    • Diverticulitis

    • Acute pancreatitis

    • Perforated ulcer

    • Bowel infarction

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Abdo Pain
Fever Protracted (prolonged) vomiting syncope/pre-syncope Evidence of GI blood loss Psychosocial factors assc w/ chr & recurrent abdo pain <span>Assessment Common causes IBS (discomfort/pain assc w/ altered bowel habits >3d/mo in prev 3 mo) Less common but important causes Appendicitis Acute cholecystitis Diverticulitis Acute pancreatitis Perforated ulcer Bowel infarction Plan (for acute abdo pain) - acute abdo = sudden, non-traumatic disorder needing urgent dx & tx Labs CBC (infection/blood loss)




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Plan (for acute abdo pain) - acute abdo = sudden, non-traumatic disorder needing urgent dx & tx
  • Labs

    • CBC (infection/blood loss)

    • Amylase + lipase (pancreatitis)

    • LFT (RUQ pain)

    • Urinalysis (hematuria, dysuria, flank pain - UTI/kidney stone)

    • Beta hcg (women in childbearing age)

    • Chlamydia + gonorrhea (women @ risk of STIs)

  • Imaging (based on location)

    • U/S (RUQ pain)

      • abdo/transvag ultrasound for pregnant women, even for LLQ/RLQ pain

      • Transvag u/s for ectopic pregnancy

    • CT w/ IV contrast media (adults w/ acute RLQ pain)

    • CT w/ oral + IV contrast media (LLQ pain) - for sigmoid diverticulitis

    • LUQ pain (many causes so depends)

      • Suggested esophageal/gastric patho = endoscopy or upper GI series

      • Others = CT (can image pancreas, spleen, kidneys, intestines, vasculature)

    • Xray

      • Free air under diaphragm (=perforation of GI tract)

      • Abn calcifications (10% gallstones, 90% kidney stones)

      • Mult dilated loops of bowel & air-fluid lvls (bowel obstruction)

        • May see with paralytic ileus

    • *occult UTI, perforated viscus, ischemic bowel ds* - potentially fatal, often missed or dx late in elderly pt

      • CONSIDER IN ALL OLDER PTS w/ abdo pain

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Abdo Pain
#13; Appendicitis Acute cholecystitis Diverticulitis Acute pancreatitis Perforated ulcer Bowel infarction <span>Plan (for acute abdo pain) - acute abdo = sudden, non-traumatic disorder needing urgent dx & tx Labs CBC (infection/blood loss) Amylase + lipase (pancreatitis) LFT (RUQ pain) Urinalysis (hematuria, dysuria, flank pain - UTI/kidney stone) Beta hcg (women in childbearing age) Chlamydia + gonorrhea (women @ risk of STIs) Imaging (based on location) U/S (RUQ pain) abdo/transvag ultrasound for pregnant women, even for LLQ/RLQ pain Transvag u/s for ectopic pregnancy CT w/ IV contrast media (adults w/ acute RLQ pain) CT w/ oral + IV contrast media (LLQ pain) - for sigmoid diverticulitis LUQ pain (many causes so depends) Suggested esophageal/gastric patho = endoscopy or upper GI series Others = CT (can image pancreas, spleen, kidneys, intestines, vasculature) Xray Free air under diaphragm (=perforation of GI tract) Abn calcifications (10% gallstones, 90% kidney stones) Mult dilated loops of bowel & air-fluid lvls (bowel obstruction) May see with paralytic ileus *occult UTI, perforated viscus, ischemic bowel ds* - potentially fatal, often missed or dx late in elderly pt CONSIDER IN ALL OLDER PTS w/ abdo pain Initial investigations & basic management for chr/recurrent abdo pain IBS Exercise: vigorous 3-5/week (all types of IBS)




#fm
Initial investigations & basic management for chr/recurrent abdo pain
  • IBS

    • Exercise: vigorous 3-5/week (all types of IBS)

    • Laxatives: OTC ( polyethylene glycol (PEG - osmotic) - Miralax); only helps w/ constipation

    • Antidiarrheal: OTC loperamide (imodium); likely only helps diarrhea

    • Probiotics: in some OTC supplements & yogurts (lactobacillus, bifidobacterium, streptococcus)

      • To prevent worsening sx

    • Abx

      • Diarrheal/mixed: rifaximin (Xifaxan); prevent worsening global sx over 4wk

      • Constipation: neomycin; improve constipation & bloating

    • Antispasmodics: hyoscyamine (Levsin), dicyclomine (Bentyl)

    • Selective C-2 chloride channel activators: lubiprostone (Amitiza) - constipation

    • Antidepressants

      • SSRI - citalopram (celexa), fluoxetine (prozac), paroxetine (paxil)

      • TCA - amitriptyline , desipramine (norpramin), doxepin , imipramine (tofranil), trimipramine (surmontil)

    • Other: relaxation, herbals, peppermint oil

    • Not routinely recommended: CBC, lytes, thyroid, stool testing for ova & parasites, abdo img

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Abdo Pain
#13; *occult UTI, perforated viscus, ischemic bowel ds* - potentially fatal, often missed or dx late in elderly pt CONSIDER IN ALL OLDER PTS w/ abdo pain <span>Initial investigations & basic management for chr/recurrent abdo pain IBS Exercise: vigorous 3-5/week (all types of IBS) Laxatives: OTC (polyethylene glycol (PEG - osmotic) - Miralax); only helps w/ constipation Antidiarrheal: OTC loperamide (imodium); likely only helps diarrhea Probiotics: in some OTC supplements & yogurts (lactobacillus, bifidobacterium, streptococcus) To prevent worsening sx Abx Diarrheal/mixed: rifaximin (Xifaxan); prevent worsening global sx over 4wk Constipation: neomycin; improve constipation & bloating Antispasmodics: hyoscyamine (Levsin), dicyclomine (Bentyl) Selective C-2 chloride channel activators: lubiprostone (Amitiza) - constipation Antidepressants SSRI - citalopram (celexa), fluoxetine (prozac), paroxetine (paxil) TCA - amitriptyline, desipramine (norpramin), doxepin, imipramine (tofranil), trimipramine (surmontil) Other: relaxation, herbals, peppermint oil Not routinely recommended: CBC, lytes, thyroid, stool testing for ova & parasites, abdo img <span><body><html>




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Adult Headache Algorithm
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Headache
Headache Adult Headache Algorithm Subjective Objective Plan




Headache
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Headache
Headache Adult Headache Algorithm Subjective Objective Plan Non-pharm for migraine: &#




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Headache
Headache Adult Headache Algorithm Subjective Objective Plan Non-pharm for migraine: &#




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Plan



Non-pharm for migraine:



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Headache
Headache Adult Headache Algorithm Subjective Objective Plan Non-pharm for migraine: