IV Notes 💉

A tender left lower quadrant mass with leukocytosis and fever is consistent with acute diverticulitis. The inflamed diverticula that are situated in the distal sigmoid colon can be palpated on digital rectal examination CT scan of the abdomen with contrast (oral and intravenous) is the test of choice for diagnosing diverticulitis. Typical CT findings include bowel wall thickening (> 4 mm) and inflammation of the pericolonic fat with fat stranding (visible traces of fluid in the fat). A CT scan is also helpful in ruling out complications such as abscess , obstruction (dilated intestinal loops, air-fluid levels), perforation (free air in the abdominal cavity), and fistula (air in organs other than the bowel). Abdominal x-ray is not useful to confirm the diagnosis of diverticulitis, as it may fail to demonstrate the presence of colonic diverticula and the expected bowel wall thickening. However, it can be used to visualize some of the complications of diverticulitis, such as abscesses, obstructions, ileus, and perforation (pneumoperitoneum). Exploratory laparotomy may be considered in patients with severe abdominal pain that cannot be evaluated sufficiently by noninvasive diagnostic methods. This patient's clinical presentation strongly suggests diverticulitis, which can be confirmed or ruled out with a diagnostic test. Abdominal ultrasound is not the test of choice for the diagnosis of diverticulitis. However, can be performed if other imaging techniques are unavailable Colonoscopy is contraindicated in this patient with an acute episode of diverticulitis because the inflammation may be exacerbated by the procedure and the risk of perforation is increased. Colonoscopy is typically performed once the inflammation has subsided (typically after 6 weeks) to assess the extent of diverticulitis and rule out malignancy. Rectal cancer is an important differential diagnosis in a patient with a palpable mass on DRE. However, given the acute presentation with systemic signs of inflammation (fever, leukocytosis) and the tenderness of the mass, diverticulitis is more likely.

A 55-year-old obese smoker woman comes to the emergency department because of a 24-hour history of severe lower abdominal pain. She has had two episodes of nonbloody vomiting today . She didn't pass stool since yesterday. She has hypertension, hyperlipidemia, and osteoarthritis. She had a cholecystectomy 5 years ago. Current medications include thiazide diuretic, atorvastatin, and Brufen. Her temperature is 38.8°C , pulse is 102/min, respirations are 20/min, and blood pressure is 118/78 mm Hg. There is moderate left lower quadrant tenderness. A tender mass is palpated on digital rectal examination. There is no guarding or rebound tenderness. Laboratory studies show: Hemoglobin 13.3 g/dL Hematocrit 40% Leukocyte count 17,000/mm3 Platelet count 188,000/mm3 Serum Na+ 138 mEq/L K+ 4.1 mEq/L Cl- 101 mEq/L HCO3- 22 mEq/L Urea nitrogen 18.1 mg/dL Creatinine 0.9 mg/dL

This patient has an anterior STEMI causing acute heart failure with pulmonary edema demonstrated by dyspnea, lung crackles, and hypoxemia. Emergency coronary reperfusion is the main ttt To help stabilize a patient with acute heart failure for emergency PCI, a loop diuretic (eg, furosemide) should be administered along with ventilatory support (eg, intubation) as needed. Loop diuretics stimulate potent diuresis to reduce cardiac preload and relieve acute pulmonary edema. Intravenous nitrates can also help reduce cardiac preload and relieve acute pulmonary edema. However, both loop diuretics and nitrates can worsen hypotension and must be used with caution. amlodipine is primarily used for the management of hypertension and are not indicated for acute MI. Digoxin slows conduction through the atrioventricular node and also increases cardiac contractility. The increased contractility increases myocardial oxygen demand, making digoxin relatively contraindicated in acute MI. metoprolol improve mortality in acute MI, likely due in part to decreased myocardial oxygen demand and reduced infarct size. However, beta blockers are contraindicated in decompensated heart failure because their negative chronotropic and inotropic effects may worsen pulmonary edema. Intravenous normal saline is indicated in the management of acute right ventricular MI, which should be suspected when there is ST-segment elevation in the inferior leads. Pulmonary edema is not expected with right ventricular MI and is indicative of left ventricular MI, for which intravenous fluids are contraindicated.

A 65-year-old man comes to the emergency department due to substernal chest pain, severe shortness of breath, and diaphoresis that began suddenly 40 minutes ago. The pain radiates to his left arm and does not remit with sublingual nitroglycerin. The patient has vomited twice since the pain started. ECG shows ST elevations in the anterior leads. Temperature is 36.9 C , blood pressure is 110/70 mm Hg, pulse is 60/min, and respirations are 32/min. Oxygen saturation is 90% on 4 L/min oxygen by nasal cannula. Basilar crackles extending halfway up the lung fields bilaterally are noted on auscultation. The patient is given aspirin, clopidogrel, and atorvastatin, and anticoagulation is started.

This patient's postprandial dull and constant abdominal pain in the RUQ, nausea, and vomiting suggest biliary colic. This condition is caused by increased intraluminal gallbladder pressure as a result of gallbladder contraction against an occluded cystic duct, most commonly due to gallstones. Referred pain to the shoulder and interscapular region, as seen here, can also occur secondary to diaphragmatic irritation via the phrenic nerve. Patients with uncomplicated cholelithiasis usually have normal laboratory values, as seen here; fever and leukocytosis should raise concern for acute cholecystitis or acute cholangitis, and jaundice and hyperbilirubinemia suggest choledocholithiasis Stones in CBD means Choledocholithiasis which can manifest with postprandial nausea, vomiting, and RUQ pain that radiates to the back and right shoulder, all of which are seen here. However, choledocholithiasis typically also manifests with findings of cholestasis (e.g., jaundice, hyperbilirubinemia), which are not seen in this patient. Infection in biliary tract means Acute cholangitis which can manifest with RUQ pain, nausea, and vomiting, all of which are seen here. However, other typical findings, such as leukocytosis, hyperbilirubinemia, and jaundice and high fever (together with RUQ pain, these are referred to as the Charcot triad), are not present. Inflammation of gall bladder mucosa means Acute cholecystitis  which manifests with postprandial RUQ pain that radiates to the right shoulder, nausea, vomiting, and normal AST and ALT values, all of which are seen here. However, other typical features of acute cholecystitis, such as fever, leukocytosis, and a positive Murphy sign, are absent in this patient.

A 43-year-old obese woman comes to the emergency department because of a 3-hour history of upper abdominal pain that radiates to her right shoulder and upper back. During this period, she has also had nausea and one episode of nonbloody vomiting. She says the pain is dull and constant. One hour prior to the onset of her current symptoms, she was eating fast food. She has hypertriglyceridemia and hypertension. Her temperature is 36.3°C , pulse is 84/min, respirations are 22/min, and blood pressure is 135/85 mm Hg. The abdomen is soft and there is mild right upper quadrant tenderness to palpation; there is no guarding or rebound. Laboratory studies show a leukocyte count of 9,000/mm3, AST 35 U/L, and ALT 36 U/L; total bilirubin is 0.9 mg/dL.

This patient's persistent cough and substernal chest pain are consistent with gastroesophageal reflux disease (GERD), for which obesity is a risk factor. GERD is a known trigger of asthma and is associated with difficult-to-treat disease. It is thought to worsen asthma as a result of chronic microaspiration of stomach contents into the upper airways. Asthma that worsens when lying down or after meals should raise concern for GERD-induced disease. Since this patient has only had a partial response to her recently initiated asthma medication, a trial of empiric therapy with a proton pump inhibitor is the most appropriate next step in management. systemic steroids are used to treat acute asthma exacerbations or severe, therapy-refractory chronic asthma. This patient does not present with acute dyspnea and wheezing, which makes an acute asthma exacerbation unlikely. Salmeterol is a long-acting beta agonist that is used in the management of moderate chronic asthma. Salmeterol would be a reasonable next step in the escalation of her asthma therapy because this patient currently uses a short-acting beta agonist and a corticosteroid inhaler. However, other comorbidities that potentially worsen asthma should be treated before escalating asthma therapy. An echo may be considered to evaluate underlying cardiac pathologies. This patient's recurring chest pain, exertional dyspnea, and cough exacerbation when lying supine are possible symptoms of heart failure. In some cases, severe mitral valve stenosis may lead to hoarseness due to recurrent laryngeal nerve damage by an enlarged left atrium. However, further signs and symptoms of heart failure such as peripheral pitting edema, increased jugular venous distention would be expected at this point. Moreover, except for obesity, this patient has no risk factors for heart disease (e.g., history of smoking, rheumatic fever, or hypertension), making a different etiology of her symptoms more likely.

A 42-year-old obese woman comes to you for follow-up. Two months ago, she was diagnosed with asthma after a 1-year history of a chronic cough and dyspnea with exertion. Her symptoms have improved since starting inhaled salbutamol and beclomethasone, but she still coughs most nights when she is lying in bed. Over the past 2 weeks, she has also had occasional substernal chest pain. She does not smoke. Vital signs are within normal limits. She has a hoarse voice and frequently clears her throat during the examination. The lungs are clear to auscultation.

حد سألني بما إن هنا حصل Mechanical bowel obstruction بال stone اللي موجودة طيب ليه المشكلة دي اسمها gallstone ileus برغم إنك بتقول في الفويس إن فيه فرق واضح ما بين ال Mechanical obstruction & ileus ده فيه حاجة سادة ال intestine وبيبقى presented في الأول ب hyperactive bowel sound عكس ال ileus اللي بتكون functional problem وبتيجي من الأول ب silent bowel الإجابة إن الإسم ده " gallstone ileus " إسم غلط أصلا 😄 بس هما زمان سموه كدة ومعرفناش نغيره لدلوقتي وده بقى الإسم المتعارف عليه ولكن لو كنا بنحاول نوصفها علميا فده مش ileus الحقيقة لأن فيه mechanical obstruction

Cholecystoenteric fistula is an abnormal connection between the gallbladder lumen and the adjacent bowel (usually duodenum). The fistula allow passage of gallstones from the gallbladder into the bowel and for air from the bowel into the biliary system (pneumobilia) Large gallstones can become lodged in the distal ileum (most commonly the ileocecal valve), causing gallstone ileus.