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Sector Of Gastroenterological Disorder
- 1. Sector of GastroenterologicalDisorderMunzur Morshed, Pharm D. candidate 2011Arnold & Marie Schwartz College of Pharmacy and Health SciencesInternal Medicine-Advanced Pharmacy PracticeMaimonides Medical Center
- 2. ObjectivesProvide brief overviewof the patients caseDiscuss the disease state, presentation and signs and symptomsExplain pharmacological management options that are availableDisplay the place in therapy of each medicationsProvide a synopsis of a major landmark trialDiscuss the patient’s appropriate management options
- 3. Case PresentationHistory ofPresent Illness LZ is a 49 y/o male, PMH significant of mild chronic gastritis, who came in to the ER, complaining of abdominal pain of moderate severity in the epigastric and RUQ that had started while the patient was sleeping last night. He subsequently had two episodes of nausea and vomiting and was brought in to the ER for further evaluation.
- 4. Case presentation-History ofpresent illness cont…PMH: GastritisFH: UnknownSH:UnknowmNKDAVS: Temp: 98 ° F, BP: 139/76 mm Hg, HR: 58 BPM, RR:21 BPM, Pain scale: 10/10-Terrible pain to the abdomen
- 5. Case presentation- PhysicalsPhysicalFindings:ABW: 63.2 kg, Height: 5’5, IBW: 57 kgMental status: alert awake and oriented x 3; PERRLHEENT: Normocephalic, atraumatic, normal oropharynxLungs: Normal chest excursion, respiration breath sounds are clear and equal bilaterally. No wheezes, rhonchi, or rales.CV: Normal S1, S2, no murmur, rubs or gallopsExtremities: Normal range of motion (ROM) in all four extremeties, non-tender to palpitation, distal pulses are intact.GI:Tender abdomen, nausea, and vomittingCXR: Not PerformedEKG: Normal sinus rhythym and elevation of the ST-segment.Abdominal Ultrasound: Distended gall bladder with thickening of the wall. This could represent cholecystitis. No stones were seen. If clinical suspicion is high, recommend HIDA scan
- 6. Case presentation-Lab FindingsNa:139 mEq/LK: 3.8 mEq/LCl: 1o3 mEq/LCO2: 28 mEq/LSCr: 0.9 mg/dLBG :188 mg/dL ABG analysis pCO2: 46 ↑ , pO2: 26↓ ↓, 02Sat:100WBC: 8.6Hgb: 14.8 g/dLHct: 41.8% ↓Neutrophils: 84.5 ↑ ↑Plt: 132x 10^3/mm^3Anion Gap: 8.0 ↓
- 7. Case presentation- MedicationsPTAOmeprazole (Prilosec) 20 mg PO Daily
- 8. DiagnosisAbdominal pain withnausea and vomitting
- 9. Abdominal PainPerceived locationof pain not necessarily to its site of origin,which may be remote from the abdominal cavityCaused byInflammation (e.g.- appendicitis, colitis)Organs being stretched or distended (e.g.- Hepatitis, gallstones) Lack of blood supply to the organs (e.g.- Ischemic colitis)Abnormal contractions of the intestinal muscles (IBS)
- 10. EpidemiologyNearly 5 millionAmerican patients presents to the ED with complaints of abdominal pain per yearAccounts for 5-10% of all ED visits50% were hospitalized Contributing to overall mortality of 10%American College of Emergency Physicians. Clinical policy:critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumaticacute abdominal pain. Ann Emerg Med. October 2000;36:406-415 Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. AmJEmerg Med. 1995;13:301-303. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 EmergencyDepartment Summary. Advanced data from Vital and Health Statistics, No. 293. Hyattsville,MD: National Center for Health Statistics; 1997.
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- 18. Approach to treatmentAscertainurgent surgical intervention is required Provide pain and other symptomatic reliefInitiatate empiric ABX therapy if intraabdominal infection is suspectedDecrease the risk of developing serious complications such as dehydration, shock, etc
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- 27. Empiric AntimicrobialInitiate empiricantibiotic therapy if intra-abdominal infection is suspectedSecond generation cephalosporin PLUS metronidazole is the corner stone of therapy
- 28. Monitoring ParameterMonitor closelyevery hour for improvement in pain Toxicity such as decrease blood pressure, respiratory rate, and symptoms of GI constipationFollow-up with frequent re-examination as soon as possible
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- 30. Landmark Trial cont…PaceS., Burke ET. Intravenous Morphine for Early Pain Relief in Patients with Acute Abdominal Pain. Academic Emergency Medicine. 1996:3 (12,); 1086–1092.
- 31. ConclusionDefinitive therapy isdependent on the etiology of the painMainstays of therapy include providing adequate analgesia and symptomatic reliefPrescribe empiric antibiotic if only suspecting intra-abdominal infectionMonitor patient very closely for symptomatic pain
- 32. Patient Case: Findingspertaining to the problemPatient came in to the ED complaining of mid upper abdominal pain that is at a scale of 10/10On admission, abdominal ultrasound had shown a distended gall bladder with thickening of the gall bladder wallLab work had shown that the patient has an anion gap of 8.0-suggesting a serious intra-abdominal processHas an elevated neutrophil count, suggesting possible inflammation
- 33. Patient Case: Etiologyof the problemIt was unknown
- 34. Patient Case: TreatmentMorphinesulfate 5 mg IV STATMorphine is indicated for the treatment of moderate to severe painNo contraindications presentNo asthma, low blood pressure, or any reports of hypersensitivity Appropriate to use to control the pain according to the package insert and clinical trialsOther alternative are meperidine (Demerol), fentanyl citrate (Sublimaze).The dose is also appropriate to use at timeSome toxicities that can occur are Respiratory depression BradycardiaHypotension.No drug-interactions presentNot on any benzos, cimitedine, chlorpromazine, codeine, etc. Patient should be monitored for improvement in the pain level for efficacyMonitor respiratory rate and symptoms of GINausea, vomiting, constipation and hypotension
- 35. Patient Case: Treatmentcont…Zofran 4 mg IV STAT- To control nausea/vomittingPatients abdominal pain and vomiting improved and patient was discharged on:Cipro 500 mg PO BID x 7 daysMetronidazole 250 mg- 2 TAB PO TID for 7 daysFollow up with Dr.Wasserman in his office on Monday.ReferencesAmerican College of Emergency Physicians. Clinical policy:critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumaticacute abdominal pain. Ann Emerg Med. October 2000;36:406-415 Powers RD, Guertler AT. Abdominal pain in the ED: stability and change over 20 years. AmJEmerg Med. 1995;13:301-303. McCaig LF, Stussman BJ. National Hospital Ambulatory Medical Care Survey: 1996 EmergencyDepartment Summary. Advanced data from Vital and Health Statistics, No. 293. Hyattsville,MD: National Center for Health Statistics; 1997.http://www.merckmanuals.com/professional/sec02/ch011/ch011b.html#sec02-ch011-ch011b-398. Accessed on 12/18/2010Bryan DE. Abdominal Pain in Elderly Persons.E-Medicine.Available at http://emedicine.medscape.com/article/776663-print . Accessed on 12/18/2010
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Editor's Notes
- #11 It is one of the most common problem in the field of emergency medicine.
- #13 Many intra-abdominal disorders cause abdominal painSome are trivial while others may be life threatning, requiring rapid diagnosis and possible surgery
- #16 Patients who arehemodynamically unstable are at risk for having had a catastrophe such as ruptured aortic aneurysm and will require immediate surgery