NURS 640 EXAMS 3 ALL QUESTIONS AND ANSWERS
SURE A+
✔✔lower abd diff dx diagnostics - ✔✔•Labs
-CBC with diff (particularly older adults with ↑ malignancy risk)
-Basic chemistry profile (renal, lytes, glucose)
-Pregnancy test (women, childbearing age)
•PE
-Fever
-LLQ: distension, tenderness, rectal bleeding
-RLQ: psoas sign, rigidity, rebound, guarding, rectal pain
•Imaging
-CT abdomen often used
•Pelvic or GU etiologies
-STI's, US abdomen
-Urine testing
•Appendicitis
-WBC, UA, CT abd
•SBO
-X-ray abd flat and upright (CT alternative)
•Diverticulitis
-CBC, CT abdomen
•AAA
-CBC, CT abdomen (US is an alternative)
•Ectopic pregnancy
-HCG (before any radiography), US
✔✔diffuse pain causes - ✔✔- peritonitis
- pancreatitis
- early appendicitis
- mesenteric adentitis, thrombosis
- gastroenteritis
- aneurysm
,- colitis
- intestinal obstruction
✔✔diffuse abd pain diff dx diagnostics - ✔✔•Diffuse / non-specific pain
•Labs
-CBC with diff
-Basic chemistry profile (renal, lytes, glucose)
-Ca
-Lipase or amylase
-Pregnancy test (women, childbearing age)
-Possible LFTs
•Imaging
-CT abdomen often used
✔✔abd pain - PE - ✔✔inspect: distention, pulsations, ecchymosis
auscultation: bowel sounds, bruits/abnormal sounds
percussion: oragnomegaly, masses
palpitation: light and deep, masses, tenderness, hernias, lymph nodes
rectal exam
✔✔Cholecystitis - ✔✔prolonged obstruction of gallbladder outlet
cholelithiasis (gallstone formation) in cystic is the most common cause
- resulting inflam worsens presentation
- other causes (2-5%): tumors or other "acalculous" causes
- not all stones cause cholecystitis
choledocholitiasis is migration of stone into common bile duct
acute cholecystitis men>women
overall incidence woman>men
✔✔cholecystitis - risk factors - ✔✔known cholelithiasis
increasing age
obesity
rapid weight loss
ethnicity
certain abd surgeries
inflammation
pregnancy
✔✔cholecystitis - subjective - ✔✔acute presentation after large fatty meal
- other presentations associated with recent major surgery or critical illness w long NPO
- sudden, severe epigastric/RUQ pain, continual, may radiate to R scapula
- tenderness/guarding
,- may eventually dissipate >12 hrs
- low to mod fever
- vomiting
- flatulence, belching, dyspepsia
- grey stool
✔✔cholecystitis - PE - ✔✔febrile
murphy sign
rigidity with guarding suggests other etiology
jaundice 25%
may have palpable mass 33%
high fever suggests bacterial infection
✔✔cholecystitis - testing - ✔✔CBC: WBC 12-15K
bili may elevate
alk phos, ASt, LDH may be elevated
amylase/lipase may be elevated (w pancreas involv)
bili >6 suggests other process
WBC >20K suggest complications
✔✔Testing - ✔✔ultrasound RUQ
- non invaseive daig test of choice
- stones, sludge, wallk thickening, fluid
HIDA scan
- more sensetive/specific
- used if US non-diagostic
CT scan
- part of acute abd eval
- alternative to US
abd x-ray
- non specific findings
- gallstones visualized in small % of cases
✔✔Cholecystitis - older adults - ✔✔-incidence of gallstones inc w age
-pay present w localized tenderness w/o pain/fever
-consider w sudden onset RUQ and vomiting
-higher incidnece of acalculous cholecystitis in older men
-consider malignancy higher on diff for older adult
✔✔cholecystitis differentials - ✔✔peptic ulcer disease
pancreatitis
, appendicitis
bowel obstruction
GERD
mesenteric ischemia
gastric ulcers
malignancy
✔✔cholecystitis - supportive care - ✔✔hydration
NPO
pain management
- anti inflam
- opioids
antibiotic therapy
broad spectrum, especially if surgery delayed
anticholinergics
- may be utilized in some
- avoid in elderly
antiemetics
surgical consult considered
✔✔cholecystitis management - ✔✔surgical
- lap>open
- treatment of choice in most cases
- relatively low risk surgery unless contraindicated (morbid obesity, high anesthesia risk,
perf, large stones, malig, ESRD)
non-surgical
- ERCP
✔✔Acute pancreatitis - ✔✔- auto digestion of the pancreas
- acute: a distinct episode of inj and inflam of pancreas
- chronic: develops after acute or subclinical pancreatitis, eveolves over time making it
difficult to pinpoint when acute becomes chronic
- 25% of acute have reocurence
- 10% of acute will develop chronic
✔✔pancreatitis causes - ✔✔acute
- gallstone obs of panc duct
- chronic excessive alcohol
-high triglycerides, hypercalcemia, meds, trauma, inf, auto-immune
chronic
- many factors (acute, combined w alc, tobacco, genetics, autoimmune)
- idiopathic 10%
✔✔pancreatitis subjective - ✔✔- abd pain, n/v
SURE A+
✔✔lower abd diff dx diagnostics - ✔✔•Labs
-CBC with diff (particularly older adults with ↑ malignancy risk)
-Basic chemistry profile (renal, lytes, glucose)
-Pregnancy test (women, childbearing age)
•PE
-Fever
-LLQ: distension, tenderness, rectal bleeding
-RLQ: psoas sign, rigidity, rebound, guarding, rectal pain
•Imaging
-CT abdomen often used
•Pelvic or GU etiologies
-STI's, US abdomen
-Urine testing
•Appendicitis
-WBC, UA, CT abd
•SBO
-X-ray abd flat and upright (CT alternative)
•Diverticulitis
-CBC, CT abdomen
•AAA
-CBC, CT abdomen (US is an alternative)
•Ectopic pregnancy
-HCG (before any radiography), US
✔✔diffuse pain causes - ✔✔- peritonitis
- pancreatitis
- early appendicitis
- mesenteric adentitis, thrombosis
- gastroenteritis
- aneurysm
,- colitis
- intestinal obstruction
✔✔diffuse abd pain diff dx diagnostics - ✔✔•Diffuse / non-specific pain
•Labs
-CBC with diff
-Basic chemistry profile (renal, lytes, glucose)
-Ca
-Lipase or amylase
-Pregnancy test (women, childbearing age)
-Possible LFTs
•Imaging
-CT abdomen often used
✔✔abd pain - PE - ✔✔inspect: distention, pulsations, ecchymosis
auscultation: bowel sounds, bruits/abnormal sounds
percussion: oragnomegaly, masses
palpitation: light and deep, masses, tenderness, hernias, lymph nodes
rectal exam
✔✔Cholecystitis - ✔✔prolonged obstruction of gallbladder outlet
cholelithiasis (gallstone formation) in cystic is the most common cause
- resulting inflam worsens presentation
- other causes (2-5%): tumors or other "acalculous" causes
- not all stones cause cholecystitis
choledocholitiasis is migration of stone into common bile duct
acute cholecystitis men>women
overall incidence woman>men
✔✔cholecystitis - risk factors - ✔✔known cholelithiasis
increasing age
obesity
rapid weight loss
ethnicity
certain abd surgeries
inflammation
pregnancy
✔✔cholecystitis - subjective - ✔✔acute presentation after large fatty meal
- other presentations associated with recent major surgery or critical illness w long NPO
- sudden, severe epigastric/RUQ pain, continual, may radiate to R scapula
- tenderness/guarding
,- may eventually dissipate >12 hrs
- low to mod fever
- vomiting
- flatulence, belching, dyspepsia
- grey stool
✔✔cholecystitis - PE - ✔✔febrile
murphy sign
rigidity with guarding suggests other etiology
jaundice 25%
may have palpable mass 33%
high fever suggests bacterial infection
✔✔cholecystitis - testing - ✔✔CBC: WBC 12-15K
bili may elevate
alk phos, ASt, LDH may be elevated
amylase/lipase may be elevated (w pancreas involv)
bili >6 suggests other process
WBC >20K suggest complications
✔✔Testing - ✔✔ultrasound RUQ
- non invaseive daig test of choice
- stones, sludge, wallk thickening, fluid
HIDA scan
- more sensetive/specific
- used if US non-diagostic
CT scan
- part of acute abd eval
- alternative to US
abd x-ray
- non specific findings
- gallstones visualized in small % of cases
✔✔Cholecystitis - older adults - ✔✔-incidence of gallstones inc w age
-pay present w localized tenderness w/o pain/fever
-consider w sudden onset RUQ and vomiting
-higher incidnece of acalculous cholecystitis in older men
-consider malignancy higher on diff for older adult
✔✔cholecystitis differentials - ✔✔peptic ulcer disease
pancreatitis
, appendicitis
bowel obstruction
GERD
mesenteric ischemia
gastric ulcers
malignancy
✔✔cholecystitis - supportive care - ✔✔hydration
NPO
pain management
- anti inflam
- opioids
antibiotic therapy
broad spectrum, especially if surgery delayed
anticholinergics
- may be utilized in some
- avoid in elderly
antiemetics
surgical consult considered
✔✔cholecystitis management - ✔✔surgical
- lap>open
- treatment of choice in most cases
- relatively low risk surgery unless contraindicated (morbid obesity, high anesthesia risk,
perf, large stones, malig, ESRD)
non-surgical
- ERCP
✔✔Acute pancreatitis - ✔✔- auto digestion of the pancreas
- acute: a distinct episode of inj and inflam of pancreas
- chronic: develops after acute or subclinical pancreatitis, eveolves over time making it
difficult to pinpoint when acute becomes chronic
- 25% of acute have reocurence
- 10% of acute will develop chronic
✔✔pancreatitis causes - ✔✔acute
- gallstone obs of panc duct
- chronic excessive alcohol
-high triglycerides, hypercalcemia, meds, trauma, inf, auto-immune
chronic
- many factors (acute, combined w alc, tobacco, genetics, autoimmune)
- idiopathic 10%
✔✔pancreatitis subjective - ✔✔- abd pain, n/v
