Approach to Abdominal Pain

Abdominal Pain History:

  • Position/palliating and provoking factors
  • Quality (sharp, dull, sore, burning, cramping)
  • Region, radiation, referral
    • Ask patient to use one finger to confirm location
    • Referred pain: Kehr’s sign (diaphragmatic irritation can cause shoulder pain), Ipsilatral scapula (biliary disease)
  • Severity
  • Temporal factors (time/mode of onset, progression, previous episodes)
    • Remember to ask about recent surgeries or procedures, new medications, social history (tobacco use in AAA, ob/gyn history)

Physical Exam:

  • Palpation strategies/questions: Work from least to most painful areas, do not be afraid to push, care the complaints out of proportion to exam, when did they get pain meds?
  • Peritonitis: Perforation, malignancy, mesenteric ischemia, strangulated hernia
    • Evaluation Techniques: Cough test, Inspiration test, peritoneal irritation (tapping heel, bumping bed)
    • Specific Maneuvers:
      • Murphy’s Sign- Inspiratory arrest during pressure to RUQ while patient taking a deep breath.
      • Psoas Sign- pain with passive hip extension
      • Obturator Sign- pain with passive internal/external rotation of right hip
      • Rovsing Sign- pain in RLQ when there is pressure exerted in LLQ

Smoking Cessation

Stats:

480,000 Premature deaths per year with 3-5 times increase in all-cause mortality in smokers vs non-smokers

$289 billion in extra costs

17.8% of adults smoke

Quitting smoking before 40 years old reduced smoking-related mortality by 90%.

Cancer patients who quit at time of diagnosis reduce their risk of dying by 30-40%

 

Nicotine and addiction:

Physiologic withdrawal can last for 6 weeks

The physicians role- Ask, Advise, Assess (motivational interviewing), Assist (behavioral therapies, nicotine replacement, pharmacologic therapies), Arrange (bringing the patient back)

Endocarditis

Definition: Infection involving the inner lining of the heart, often involving the valves.

TUH In-Hospital Mortality- ~23%

5-Year Mortality- 40%

Risk Factors: Prosthetic valve, history of IE, intracardiac devices, rheumatic heart disease, age, hemodialysis, IV drug abuse, HIV (?), diabetes

Valves affected (TUH): Aortic 34%,Mitral 36%, Tricuspid 33%, Pulmonic 2%

Microbiology (TUH): S. aureus 58%, Viridans strep 9%, Coag. neg staph 5.5%, Enterococcus 6%

Clinical and Laboratory Findings on Admission (most common): Fever >38C, Elevated ESR/CRP, Worsening of old murmur, New murmur, Vascular embolic event, Hematuria

Complications: Cerebral (CVA, TIA, brain abscess, meningitis), Intracardiac abscess, CHF, conduction abnormalities, Osteomyelitis/Distant abscesses

Modified Duke Criteria:

Major-

  • Positive blood culture for typical IE
  • Echo with intracardiac mass, abscess, prosthetic valve dehiscence, new valvular regurgitation

Minor-

  • Predisposing heart condition
  • IV drug abuse
  • Temp >100.4
  • Vascular phenomena: arterial emboli, pulm infarcts, Janeway lesion
  • Immunologic phenomena: Osler nodes, Roth spots
  • Other positive blood cultures

Diagnosis:

  • Blood cultures (2 sets)
  • CXR
  • ECG
  • Echo (TTE vs. TEE)
    • Especially with S. aureus
  • CBC, Basic met, Coags
  • ID consult, +/- CT surgery and cardiology

Treatment:

Empiric coverage- Vancomycin

MRSA-

  • Vancomycin 30mg/kg BID x 4 weeks

Viridans strep-

  • Penicillin G q4h x 4 weeks
  • Ceftriaxone 2g daily x 4 weeks
  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Pen-Allergic Patients: Vancomycin 30mg/kg BID x 4 weeks

MSSA-

  • Oxacillin 2g q4h x 4-6 weeks
  • Cefazolin 2g q8h x 4-6 weeks
  • Pen-Allergic Patients: Cefazolin 2g q8h x 4-6 hour OR Vancomycin 30mg/kg BID x 4-6 weeks

Enterococcus-

  • Penicillin G q4h PLUS Gentamicin q8h x 2 weeks
  • Ampicillin 2mg q4h PLUS Gentamicin q8h x 4 weeks
  • Vancomycin 30mg/kg BID x 4 weeks PLUS Gentamicin q8h x 4 weeks
  • Ampicillin PLUS Ceftriaxone

HACEK-

  • Ceftriaxone 2g IV daily x 4 weeks
  • Ampicillin 2g q6h PLUS Gentamicin q8h x 4 weeks

Prosthetic Valve Endocarditis- Viridans Strep

  • Penicillin G x 6 weeks +/- Gentamicin x 2 weeks
  • Ampicillin x 6 weeks +/- Gentamicin x 2 weeks
  • Vancomycin 30mg/kg BID x 6 weeks

Prosthetic Valve Endocarditis- S. aureus

  • MSSA
    • Oxacillin 2g q6h x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks
  • MRSA
    • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 2 weeks PLUS Rifampin 300mg q8h x 6 weeks

Prosthetic Valve Endocarditis- Enterococcus

  • Ampicillin 2g q6h x 6 weeks PLUS Gentamicin x 6 weeks
  • Penicillin G x 6 weeks PLUS Gentamicin x 6 weeks
  • Vancomycin 30mg/kg BID x 6 weeks PLUS Gentamicin x 6 weeks

Valve Replacement Indications

  • Major
    • Heart Failure
    • Uncontrolled Infection
    • Prevention of Embolic Events
  • Other Indications
    • Fungal
    • Pseudomonas species
    • Perivalvular abscess
    • Valve Dehiscence

Prophylaxis

  • Prosthetic cardiac valve
  • Previous episode of IE
  • Unrepaired cyanotic congential heart disease
  • Heart transplant recipients with cardiac valvulopathy

GLP1 Receptor Agonists & DPP4 Inhibitors

Thank you to our pharmacists for a very informative lecture!

Lecture Video: see Class Capture

Lecture Powerpoints: GLP1 Receptor Agonists & DPP4 Inhibitors

When Do I Start These Medications?

Check out: AACE Algorithm for Adding/Intensifying Diabetes Medications

GLP1 Receptor Agonists

Ex: Liraglutide (Victoza®), Exenatide, Dulaglutide (Trulicity®), Abliglutide

Pros

  • Target multiple organs, not just the pancreas.
  • Improve HTN, HLD and can lead to weight loss!
  • Low risk of hypoglycemia
  • LEADER trial: Liraglutide significantly reduces MACE
  • Decrease A1C by 0.5-1.8% on average.
  • Long-acting, once weekly versions available
    • These versions affect both prandial and basal glucose levels
  • Dulaglutide is covered by Health Partners!

Cons

  • Requires subcutaneous injection
  • Can cause mild-moderate nausea (main side effect and the reason you uptitrate the medication)
    • Ex: with Liraglutide, if patient misses 3 days, then must restart titration
  • Exenatide injector is extremely confusing to use (go for Liraglutide or Dulaglutide instead)
    • Contraindicated in patients with h/o pancreatitis, thyroid C cell tumors, significantly renal impairment (varies by drug), severe GI disease
  • Expensive if not covered by insurance

DPP4 Inhibitors (the “gliptins”)

Ex: Sitagliptin (Januvia®), Saxagliptin, Linagliptin, Alogliptin

Pros

  • Oral
  • Well tolerated, weight neutral, low risk of hypoglycemia

Cons

  • Daily administration
  • Lack the systemic effects seen by GLP1 RA
  • Only decrease A1C by 0.5-0.9% on average
  • Warning for patients with h/o CHF, pancreatitis. May also cause hepatotoxicity, joint pain, hypersensitivity
  • Expensive (even the generic alogliptan is $3/dose)

Obesity & Weight Loss

Thank you to Dr Sharon Herring for a very informative lecture!

Weight Loss Apps to recommend for your patients:

  • My Fitness Pal (iOS and Android)

FDA Approved Medications for the Treatment of Obesity – click here for the detailed pdf

  • Phentermine Hydrochloride (Adipex)
  • Phentermine Hydrochloride + Topiramate XR (Qysmia)
  • Lorcaserin (Belviq)
  • Buproprion + Naltrexone (Contrave)
  • Orlistat (Alli, Xenical)
  • Liraglutide (Saxenda, Victoza)