ABEM-style cases presented on EM Clerkship are not my actual ABEM exam cases, and they are not derived from my actual exam cases. I will never be discussing my specific exam details with anybody, including on this podcast. The cases were created independently, by me, for the purpose of medical education and improving patient care. Topics are chosen from the publicly available ABEM model of clinical practice and are built from scratch using a my own custom template. If you would like a copy of this template, please email me and I can send you a copy.
Deep pelvic infections high in the reproductive tract frequently caused by sexually transmitted infection but can be caused by other infections (especially anaerobic infections) as well
Lower Abdominal Pain
Vaginal Symptoms (especially discharge)
High risk sex
IUD (Don’t need to remove if patient has PID, but needs to be noted)
It is controversial whether all women with pelvic complaints need a full speculum exam (my opinion is that they don’t and that it almost never changes management)
Cervical motion tenderness
Ultrasound to evaluate for tubo-ovarian ABSCESS
Patients who are septic, unable to keep antibiotics down, getting worse on oral antibiotics, pregnant, immunosuppressed, or with TOA generally get admitted for IV antibiotics.
Cefoxitin/cefotetan (2nd generation cephalosporins provides better anaerobic coverage than a third generation cephalosporins)
2nd generation cephalosporin
Ovary twists on its pedicle and becomes ischemic
NOTE: The ovary actually has a dual arterial blood supply. When the pedicle twists, it’s not the artery is being pinched off that causes ischemia, rather its the venous outflow becoming blocked and resulting in swelling of the ovary and the poor perfusion that results)
Sudden onset pain
Severe pain with vomiting
Usually unilateral pain (although 25% have bilateral pain)
Peritonitis in the lower abdomen
Large mass or adnexal tenderness on pelvic exam
Pelvic ultrasound (with doppler)
Large cyst/mass causing the torsion
IMPORTANT- You can frequently see normal arterial flow on the doppler (remember DUAL BLOOD SUPPLY)
CT scan with NORMAL ovaries 100% negative predictive value for torsion in some studies
Multiple conditions cause inflammation on a urinalysis. Anything that causes nearby inflammation (appendicitis, pelvic infections, diverticulitis) or slows urine output (dehydration, renal disease) can commonly elevate these markers.
Signs of bacterial presence (not present in ~25% of proven urinary tract infections!!!)
Generally should NOT be treated with antibiotics. If you were to randomly sample the population you would find bacteria present in approximately…
5% of young people
20% of old people
50% of patients in long term care
When to Diagnose UTI
Dysuria AND urinary frequency WITHOUT vaginal symptoms (+LR 20)
Patient self reports that they think their UTI is back (+LR 4)
Urinalysis shows BOTH signs of inflammation and bacterial presence
Combine pretest suspicion with urinalysis findings using clinical judgement
Indwelling Foley Catheters
All patients with an indwelling foley will have a grossly abnormal urinalysis and appearance of urine at baseline. The urinalysis is useless and diagnosis can only be made by clinical judgement
Geriatric patients have minimal symptoms regardless of diagnosis. They can have UTI’s with minimal symptoms. However they can also have appendicitis or kidney stones with minimal symptoms (and asymptomatic bacteriuria at baseline). BE CAREFUL.
Perforation takes time, frequently symptoms were either ignored or not noticed as can occurring in…
Elderly, diabetic, or immunosuppressed patients (frequently have minimal symptoms)
Pediatric patients (unable to or scared to mention symptoms)
Commonly have “peritoneal signs”
X-Ray? (not your primary test, but a common test question will show you an upright chest X-ray and you will see a rim of free air under the diaphragm (should NOT be there in a normal upright X-ray)
Broad spectrum antibiotics
Stat surgical consult
It is common to first learn this as a pediatric condition (Malrotation with Volvulus) however it is common in adults as well. The two most common subtypes are…
The history exam and testing plan is the same as with bowel obstruction. The primary difference is that volvulus without ischemia/gangrene is frequently treated with colonoscopy which is a GI CONSULTATION rather than surgical consultation.
Celiac truck supplies blood to the stomach and duodenum
SMA supplies blood to the rest of the small bowel and proximal colon
IMA supplies blood to the distal colon and rectum
Arterial flow can be blocked because of emboli (atrial fibrillation)
Venous flow can be blocked because of thrombosis (hypercoagulable states)
Effective flow can be severely decreased in shock states (sepsis, hemorrhage)
Pain with PO intake (intestinal angina)
The most classic finding is “Pain out of proportion to exam”
Lactic acid reportedly 100% sensitive according to some texts
CT scan WITH contrast (or even better, a CTA) for additional confirmation if your pretest suspicion is high
Analgesics and antibiotics. Surgery consult if intestines necrotic on imaging. Potentially vascular surgery consult as well if intestines salvageable.
Small Bowel Obstruction
QUESTION: What is the most common cause of mechanical small bowel obstruction?
Not all small bowel obstructions are mechanical, don’t forget that ileus can cause a similar pattern as well (electrolyte abnormalities, recent surgery, opiates, multi-system trauma)
Severe crampy pain with vomiting, bloating, and decreased bowel movements/flatus. History of multiple abdominal surgeries (high risk for adhesions)
Abdominal distention and tenderness. If peritoneal signs develop, this is a very bad condition and patient may be developing ischemic/necrotic bowel.
Most common test is CT scan with IV contrast
Abdominal x-ray sometimes gets ordered but has fallen out of favor for multiple reasons (decreased sensitivity, difficulty localizing obstruction, unable to rule out alternative diagnoses
Using oral contrast with the CT scan is also falling out of favor primarily due to the time constraints demanded of modern medicine.
Fluids, Analgesics, Antiemetics +/- Antibiotics if ischemia is developing. Obtain a surgery consult.
QUESTION: Should you order an NG tube?
ANSWER: NG tubes have been reported to be one of the most painful procedures one can endure. On the other hand, you can find online videos of people putting these in without any discomfort. It will end up being a risk/benefit discussion with your attending. The benefit is that decompressing the stomach will frequently improve the patient’s symptoms to a significant extent.
American College of Radiology mesenteric ischemia imaging (ACR)
American College of Radiology small bowel obstruction imaging (ACR)
Biliary Colic- A gallstone DOES NOT GET STUCK, but it slowly rolls out of the gallbladder, through the cystic duct, then the common bile duct and pancreatic duct. This results in several hours of crampy “colicky” pain as the stone passes.
Cholecystitis- A gallstone gets stuck IN THE NECK OF THE GALLBLADDER OR THE CYSTIC DUCT. Pressure builds up in the gallbladder and inflammation worsens as the patient develops persistent pain, fevers, and eventually perforation of the gallbladder wall.
Choledocolithiasis- A gallstone gets past the neck of the gallbladder and the cystic duct. However, it gets stuck IN THE COMMON BILE DUCT (CBD). The liver can’t drain bile and liver function tests increase.
Cholangitis- The patient has choledocolithiasis and INFECTION DEVELOPS
Gallstone Pancreatitis- A gallstone gets past the neck of the gallbladder AND the cystic duct AND the common bile duct but gets stuck in a PANCREATIC DUCT (ugh, so close). Lipase increases.
Biliary colic- Crampy RUQ abdominal pain that frequently radiates to right shoulder and resolves after a few hours
Cholecystitis- RUQ abdominal pain persists for more than a few hours and fevers develop.
Cholangitis- RUQ abdominal pain, fevers, and jaundice (Charcots Triad) eventually leading to shock and altered mental status (Reynolds Pentad)
Murphy’s Sign- Patient has pain and stops inhalation while you palpate under the right costal margin (Note: the same thing should NOT happen when palpating under the left costal margin)
The most appropriate test for biliary disease is RIGHT UPPER QUADRANT ULTRASOUND. However, CT scan is quite good as well (negative predictive value ~90% and identifies complications and alternative diagnoses well)
Asymptomatic gallstones and resolved biliary colic get outpatient surgery referral
Acute cholecystitis needs a surgery consult
Choledocolithiasis, Cholangitis, and Gallstone Pancreatitis needs a GI consult (for MRCP/ERCP)
Constant epigastric abdominal pain radiating to the back with lots of vomiting and retching
Mild pancreatitis may have nothing more than some epigastric tenderness. Severe pancreatitis will look a lot like sepsis (hyperthermia, hypotension, altered mental status)
Patients will have an elevated lipase and abnormal findings on a CT scan with IV contrast
Aggressive treatment of pain and nausea and NPO with slow advancing of the diet as tolerated.
American College of Radiology biliary disease imaging (ACR)
American College of Radiology pancreatitis imaging (ACR)