1. Joshua Sapkin, MD Associate Program Director LAC+USC Internal Medicine Residency Program

2. Case 1 The nurse calls you because your patient who returned from the GI suite 2 hours ago is complaining of diffuse abdominal pain. The patient is a 55 year old man who was admitted for symptomatic anemia. The lower endoscopy performed earlier that demonstrated diverticulosis without evidence of bleeding.

3. Case 1 What is the next best step in the management of this patient? A. Ask the nurse to obtain a set of vital signs. B. Tell the nurse to call the GI fellow who endoscoped the patient. C. Tell the nurse to give the patient 2 mg of morphine sulfate IV x 1 dose. D. Immediately evaluate the patient.

4. Case 1 Upon arriving at the patient’s bedside, you find him slightly diaphoretic and grimacing in pain. Vital signs: Blood Pressure: 94/52. Heart rate 100. Respirations: 24. Temperature: 99.2. Oxygen saturation 99% on room air. P.E. HEENT: Anicteric. No conjunctival pallor. Cardiac: Tachycardic. Chest: Lungs clear to auscultation Abdomen: Mild distention. Absent bowel sounds. Tympanitic to percussion. Diffuse tenderness to palpation. Difficult exam secondary to guarding. Rectal: Normal sphincter tone. No mucosal masses. No stool in the rectal vault.

5. Case 1 Why are vital signs called “vital” signs? A. They are a necessary component of the medical documentation in order to bill health insurances (vital for reimbursement) B. They are important clues to the patient’s diagnosis (vital for establishing a diagnosis). C. The nurses consider them essential pieces of information before paging a physician (vital for paging a physician) D. They reflect physiologic processes that are essential to sustaining life.

6. Case 1 All of the following measures would be appropriate a this time EXCEPT: A. Check the patient’s blood pressure in the supine and sitting position. B. Ensure the patient has two large bore peripheral IV sites. C. Contact the GI fellow who performed the procedure. D. STAT General Surgery consult E. Ask the nurse if he/she would like to join you for a drink at Barbara’s Brewery after work.

7. Case 1

8. Case 2 A 26 year-old young man with a long history of alcohol abuse complains of a 7 day history of upper abdominal pain, nausea and vomiting. He reports gaining 30 lbs. over the past 2 months. His skin and sclera have turned yellow during this period of time. His last drink was 6 days ago. P.E. Height: 5’ 9” Weight: 240 lbs. Vital Signs: Blood pressure: 138/82. Heart Rate: 100 Respirations: 14. Temperature: 102.0. General: Non-toxic appearing young male who appears comfortable. HEENT: Icteric sclera. Tachycardic with a 2/6 systolic ejection murmur auscultated throughout the precordium Abdomen: Distended with bulging flanks. Dull to percussion throughout. There is tenderness to deep palpation in the mid-epigastrium and right upper quadrant. The liver edge is palpated in the midline three finger breadths below the costal margin. It is smooth and tender. No bruits auscultated. Extremities: 1+ pitting edema over bilateral shins Genitourinary: No lesions on the penile shaft. Testes descended bilaterally without masses or tenderness. No inguinal hernias or lymphadenopathy. Rectal: Normal sphincter tone. No mucosal masses palpated. Light brown stool in the vault.

9. Case 2 All of the following should be included in the differential diagnosis for this individual’s abdominal pain EXCEPT: A. Decompensated cirrhosis B. Pancreatitis C. Hepatic abscess D. Sclerosing cholangitis E. Metastatic colon cancer

10. Case 2 In terms of establishing a diagnosis, which labs would you order? Be prepared to justify your answer.

11. Case 2 In terms of establishing a diagnosis, which radiologic imaging study would you order? Be prepared to justify your answer.

12. Case 2 WBC: 15,000 (82, 10, 7, 1) Hgb: 12.7 MCV 104 Platelets: 65,000 T. Bili 16.0 D. Bili 12.5 AST: 80 ALT38 Alk Phos: 140 Pro Time: 30 seconds INT: 2.5 Abdominal Ultrasound Large ascites The liver is enlarged, measuring 21 cm in diameter. There is increased echogenicity consistent with fatty infiltration. Common bile duct measures 6 mm in diameter. No intrahepatic ductal dilatation. There is reversal of portopedal flow, recanulization of the umbilical vein and splenomegaly. The pancreas is not well visualized because of overlying bowel gas. The kidneys are normal in size and echoctexture. No hydronephrosis.

13. Case 3 A 53 year-old woman with a 25 year history of diabetes type 2 is admitted for chronic post-prandial abdominal pain, nausea and vomiting. She has not been able to keep down any liquids or solid food for more than 30 minutes for the past 2 days. In between episodes, she is asymptomatic except for mild nausea. She underwent an open cholecystectomy 20 years ago for symptomatic cholelithiasis. Vital signs are normal. Her abdominal exam is only significant for minimum tenderness in the midepigastrium and left upper quadrant. An abdominal series performed in the DEM reveals a non- obstructive bowel gas pattern.

14. Case 3 Which piece of data provides the best evidence that this woman does not have a partial small bowel obstruction? A. Her cholecystectomy was performed 20 years ago. B. The timing and duration of her symptoms C. The results of her abdominal series D. Her abdominal exam

15. Case 4 A 75 year old woman with a history of Crohn’s disease limited to the terminal ileum complains of abdominal pain, distention and decreased flatus for the past two days. She has no appetite and has vomited after every attempt to drink liquids. Vital signs are normal. Abdominal exam is significant for distention, absent bowel sounds and diffuse mild tenderness. There is no rebound tenderness or hepatosplenomegaly. GU and rectal exams are normal.

16. Case 4

17. Obstruction is present if the small-bowel loop is greater than 2.5 cm in diameter dilated proximal to a distinct transition zone of collapsed bowel less than 1 cm in diameter. Bowel wall thickening, pneumatosis, and portal venous gas all suggest strangulation. CT differentiates between the etiologies of SBO--extrinsic causes such as adhesions and hernia from intrinsic causes such as neoplasms or Crohn's disease. CT can identify causes of acute abdominal pain such as abscess, hernia, tumor, or inflammation. CT should be obtained with both PO and IV contrast, unless the patient has renal failure or IV contrast allergy.

18. Case 5 A 28 year old 2 nd year internal medicine resident develops low grade fever, periumbilical abdominal pain that migrates to his right lower quadrant over a 24 hour period. On exam, obturator and Rovsing’s signs are positive. He is admitted for presumed acute appendicitis and given IV Abx. CT scan with oral and IV contrast demonstrates “no evidence of appendicitis.”

19. Key Points Rely on your own history and physical exam to create a differential diagnosis Stabilize the patient before proceeding with the work-up Be selective when ordering lab tests and imaging studies Consult the surgical services earlier than later Take advantage of the radiologists Do not be afraid to commit to a diagnosis