(11) Abdomen tables Flashcards
GERD:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or excess relaxations of the lower esophageal sphincter; Helicobacter pylori may be present
Location: chest or epigastric
Quality: heartburn, regurgitation
Timing: After meals, especially spicy
foods
Aggravating Factors: Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
Relieving Factors: Antacids, proton pump inhibitors;
avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers
Associating Symptoms/Setting: Wheezing, chronic cough, shortness of breath, hoarseness, choking
sensation, dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and esophageal cancer
Peptic Ulcer Disease:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Mucosal ulcer in stomach or duodenum >5 mm, covered with fibrin, extending through the muscularis mucosa; H. pylori infection present in 90% of peptic ulcers
Location: epigastric, may radiate straight to the back
Quality: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike; No symptoms in up to 20%
Timing: Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs
Aggravating Factors: variable
Relieving Factors: Food and antacids may bring relief
(less likely in gastric ulcers)
Associating Symptoms/Setting: Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer); dyspepsia is more common in the young (20–29 yrs), gastric ulcer in those over 50 yrs, and duodenal ulcer in those 30–60 yrs
Gastric Cancer:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Adenocarcinoma in 90%–95%, either
intestinal (older adults) or diffuse
(younger adults, worse prognosis)
Location: increasingly in “cardia” and GE junction; also in distal stomach
Quality: variable
Timing: Pain is persistent, slowly progressive;
duration of pain is typically
shorter than in peptic ulcer
Aggravating Factors: Often food; H. pylori infection
Relieving Factors: Not relieved by food or antacids
Associating Symptoms/Setting: Anorexia, nausea, early satiety, weight
loss, and sometimes bleeding; most
common in ages 50–70 yrs
Acute Appendicitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Acute inflammation of the appendix
with distention or obstruction
Location: Poorly localized periumbilical pain,
usually migrates to the right lower
quadrant
Quality: Mild but increasing, possibly
cramping; Steady and more severe
Timing: Lasts roughly 4–6 hrs, depending
on intervention
Aggravating Factors: Movement or cough
Relieving Factors: If it subsides temporarily,
suspect perforation of the
appendix.
Associating Symptoms/Setting: Anorexia, nausea, possibly vomiting,
which typically follow the onset of
pain; low fever
Acute Cholecystitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Acute inflammation of the gallbladder with distention or obstruction
Location: Right upper quadrant or epigastrium; may radiate to right shoulder or interscapular
area
Quality: steady, aching
Timing: Gradual onset; course longer
than in biliary colic
Aggravating Factors: Jarring, deep breathing
Relieving Factors: none
Associating Symptoms/Setting: Anorexia, nausea, vomiting, fever;
no jaundice
Biliary Colic:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Sudden obstruction of the cystic duct
or common bile duct by a gallstone
Location: Epigastric or right upper quadrant;
may radiate to the right scapula and
shoulder
Quality: Steady, aching; not colicky;
Usually last longer than 3 hrs
Timing: Rapid onset over a few min, lasts
one to several hrs and subsides
gradually; often recurrent
Aggravating Factors: Fatty meals but also fasting;
often precedes cholecystitis,
cholangitis, pancreatitis
Relieving Factors: none
Associating Symptoms/Setting: Anorexia, nausea, vomiting, restlessness
Acute Pancreatitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process:Intrapancreatic trypsinogen activation
to trypsin and other enzymes, resulting
in autodigestion and inflammation
of the pancreas
Location: Epigastric, may radiate straight to the back or other areas of the abdomen;
20% with severe sequelae of organ
failure
Quality: usually steady
Timing: Acute onset, persistent pain
Aggravating Factors: Lying supine; dyspnea if pleural
effusions from capillary leak syndrome;
selected medications,
high triglycerides may exacerbate
Relieving Factors: Leaning forward with trunk
flexed
Associating Symptoms/Setting: Nausea, vomiting, abdominal distention,
fever; often recurrent; 80%
with history of alcohol abuse or
gallstones
Chronic Pancreatitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Irreversible destruction of the pancreatic
parenchyma from recurrent inflammation
of either large ducts or small ducts
Location: epigastric, radiating to back
Quality: severe, persistent, deep
Timing: Chronic or recurrent course
Aggravating Factors: Alcohol, heavy or fatty meals
Relieving Factors: Possibly leaning forward with
trunk flexed; often intractable
Associating Symptoms/Setting: Pancreatic enzyme insufficiency,
diarrhea with fatty stools (steatorrhea)
and diabetes mellitus
Acute Diverticulitis:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Acute inflammation of colonic diverticula,
outpouchings 5–10 mm in diameter,
usually in sigmoid or descending
colon
Location: LLQ
Quality: may be cramping at 1st then steady
Timing: often gradual onset
Aggravating Factors: none
Relieving Factors: analgesia, bowel rest, antibiotics
Associating Symptoms/Setting: Fever, constipation. Also nausea,
vomiting, abdominal mass with
rebound tenderness
Acute Bowel Obstruction:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Obstruction of the bowel lumen, most
commonly caused by (1) adhesions or
hernias (small bowel), or (2) cancer or
diverticulitis (colon)
Location: Small bowel: periumbilical or upper abdominal; Colon: lower abdominal or generalized
Quality: cramping
Timing: Paroxysmal; may decrease as
bowel mobility is impaired
Paroxysmal, though typically
milder
Aggravating Factors: Ingestion of food or liquids
Relieving Factors: none
Associating Symptoms/Setting: Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction); obstipation develops (early); vomiting late if at all; prior symptoms of underlying cause
Mesenteric Ischemia:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Occlusion of blood flow to small
bowel, from arterial or venous thrombosis
(especially superior mesenteric
artery), cardiac embolus, or hypoperfusion;
can be colonic
Location: May be periumbilical at first, then diffuse; may be postprandial,
classically inducing “food fear”
Quality: Cramping at first, then
steady; pain disproportionate
to examination findings
Timing: Usually abrupt in onset, then
persistent
Aggravating Factors: underlying cardiac disease
Relieving Factors: none
Associating Symptoms/Setting: Vomiting, bloody stool, soft distended
abdomen with peritoneal
signs, shock; age >50 yrs
Pancreatic Cancer:
Process Location Quality Timing Aggravating Factors Relieving Factors Associating Symptoms/Setting
Process: Predominantly adenocarcinoma (95%); 5% 5-yr survival
Location: If cancer in body or tail, epigastric, in either upper quadrant, often radiates to the back
Quality: steady, deep
Timing: Persistent pain; relentlessly progressive illness
Aggravating Factors: smoking, chronic pancreatitis
Relieving Factors: Possibly leaning forward with trunk flexed; often intractable
Associating Symptoms/Setting: Painless jaundice, anorexia, weight loss; glucose intolerance, depression
Oropharngeal Dysphagia:
Timing
Aggravating Factors
Associated Symptoms/Conditions
Timing: acute or gradual onset & variable course, depending on underlying disorder
Aggravating Factors: attempts to start swallowing process
Associated Symptoms/Conditions: aspiration into the lungs or regurgitation into the nose w/ attempts to swallow; from motor disorders affecting the pharyngeal muscles such as stroke, bulbar palsy, or other neuromuscular conditions
Esophageal Dysphagia (mechanical narrowing): Mucosal rings and webs
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent
Aggravating Factors: solid food
Relieving Factors: regurgitation of the bolus of food
Associated Symptoms/Conditions: usually none
Esophageal Dysphagia (mechanical narrowing): Esophageal stricture
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent, may become slowly progressive
Aggravating Factors: solid foods
Relieving Factors: regurgitation of the food bolus
Associated Symptoms/Conditions: long history of heartburn and regurgitation
Esophageal Dysphagia (mechanical narrowing): Esophageal cancer
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: may be intermittent at first, progressive over months
Aggravating Factors: solid foods w/ progression to liquids
Relieving Factors: regurgitation of food bolus
Associated Symptoms/Conditions: pain in chest and back, weight loss - especially late in course of illness
Motor Disorders: Diffuse esophageal spasm
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent
Aggravating Factors: solids or liquids
Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver, sometimes nitroglycerin
Associated Symptoms/Conditions: chest pain that mimics angina pectoris or MI and lasts min to hrs, possibly heartburn
Motor Disorders: Scleroderma
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent, may progress slowly
Aggravating Factors: solids or liquids
Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver
Associated Symptoms/Conditions: heartburn, other manifestations of scleroderma
Motor Disorders: Achalasia
Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions
Timing: intermittent, may progress
Aggravating Factors: solids or liquids
Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver
Associated Symptoms/Conditions: regurgitation often at night when lying down with nocturnal cough, possibly chest pain precipitated by eating
Acute Diarrhea: Secretory Infection (non-inflammatory)
process characteristics of stool timing associated symptoms setting/person @ risk
process: infection by virus, preformed bacterial toxins, cryptosporidium, rotavirus, Giardia lamblia
characteristics of stool: watery, w/o blood, pus, mucus
timing: few days
associated symptoms: N/V, periumbilical pain, temp normal or slightly elevated
setting/person @ risk: travel, food source, epidemic
Acute Diarrhea: Inflammatory Infection
process characteristics of stool timing associated symptoms setting/person @ risk
process: colonization of invasion of intentional mucosa
characteristics of stool: loose to watery, often w/ blood, pus, or mucus
timing: acute illness of varying duration
associated symptoms: lower abd cramping pain and often rectal urgency, tenesmus, fever
setting/person @ risk: travel, contaminated food or water, frequent anal intercourse
Drug-induced Diarrhea
process characteristics of stool timing associated symptoms setting/person @ risk
process: action of many drugs (Mg antacids, Abs, chemo, laxatives)
characteristics of stool: loose to watery
timing: actor, recurrent, chronic
associated symptoms: nausea, usually little to no pain
setting/person @ risk: prescribed or OTC meds
Chronic Diarrhea: Irritable Bowel Syndrome
process characteristics of stool timing associated symptoms setting/person @ risk
process: altered motility ot secretion from liminal and mucosal irritants that change mucosal permeability; immune activation, and colonic transit, including maldigested carbs, fats, excess bile acids, gluten intolerance, enteroendocrine signaling, and changes in microbiomes
characteristics of stool: loose, 50% w/ mucus; small-moderate volume; small hard stools w/ constipation; may be mixed patten
timing: worse in am, rarely at night
associated symptoms: cramps lower abdominal pain, abd distention, flatulence, nausea; urgency, pain relieved w/ defecation
setting/person @ risk: young-middle aged, women
Chronic Diarrhea: fecal impaction/motility disorders
process characteristics of stool timing associated symptoms setting/person @ risk
process: partial obstruction by impacted stool only allowing passage of loose feces
characteristics of stool: loose, small volume
timing: variable
associated symptoms: campy abd pain, incomplete evacuation
setting/person @ risk: older adults, immobilized/institutionalized pts, medications
Chronic Diarrhea: cancer of sigmoid colon
process characteristics of stool timing associated symptoms setting/person @ risk
process: partial obstruction by malignant neoplasm
characteristics of stool: may be blood streaked
timing: variable
associated symptoms: change in usual bowel habits, cramps lower abd pain, constipation
setting/person @ risk: >55y/o
Ulcerative Colitis
process characteristics of stool timing associated symptoms setting/person @ risk
process: mucosa; inflammation typically extending proximally from rectum to varying lengths of colon, w/ microulcerations and if chronic inflammatory polyps
characteristics of stool: frequent, eatery, often contain blood
timing:onset typically abrupt, often recurrent, persistent, may awaken at night
associated symptoms: cramping w/ urgency, tenesmus, fever, fatigue, weakness, abd pain if complicated by toxic megacolon; may include episcleritis, uveitis, arthritis, erythema nodosum
setting/person @ risk: young adults, Ashkenazi Jew, altered CD+ T cell Th2 response (increased colon CA risk)
Crohn Disease of small bowel or colon
process characteristics of stool timing associated symptoms setting/person @ risk
process: Chronic transmural inflammation of the bowel wall, with skip pattern involving the terminal ileum and/ or proximal colon (and rectal sparing); may cause strictures
characteristics of stool: Small, soft to loose or
watery, with bleeding
if colitis, obstructive
symptoms, if enteritis
timing: More insidious
onset; chronic or
recurrent
associated symptoms: Crampy periumbilical, right lower quadrant (enteritis) or diffuse (colitis) pain, with anorexia, fever, and/ or weight loss; perianal or perirectal abscesses and fistulas; may cause small or large bowel obstruction
setting/person @ risk: Often teens or young adults, but also adults of middle age; more common in Ashkenazi Jewish descendants; linked to altered CD4+ Tcell helper Th1 and 17 response; increases risk of colon cancer
Chronic Diarrhea: malabsorption syndrome
process characteristics of stool timing associated symptoms setting/person @ risk
process: Defective membrane transport or absorption of intestinal epithelium (Crohn, celiac disease, surgical resection); impaired luminal digestion (pancreatic insufficiency); epithelial defects at brush border (lactose intolerance)
characteristics of stool: Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in toilet (steatorrhea)
timing: Onset of illness
typically insidious
associated symptoms: Anorexia, weight loss, fatigue, abdominal distention, often crampy lower abdominal pain. Symptoms of nutritional deficiencies such as bleeding (vitamin K), bone pain and fractures (vitamin D), glossitis (vitamin B), and edema (protein)
setting/person @ risk: Variable, depending
on
cause
Chronic Diarrhea: osmotic - lactose intolerance
process characteristics of stool timing associated symptoms setting/person @ risk
process: intestinal lactase deficiency
characteristics of stool: watery diarrhea of large volume
timing: follow the ingestion of milk and milk products; relieved by fasting
associated symptoms: crampy abd pain, abd distention, flatulence
setting/person @ risk: African Americans, native Americans, Hispanics (lower risk in Caucasians)
Chronic Diarrhea: abuse of osmotic purgatives
process characteristics of stool timing associated symptoms setting/person @ risk
process: laxative habit, often surreptitious
characteristics of stool: watery diarrhea of large volume
timing: variable
associated symptoms: often none
setting/person @ risk: persons w/ anorexia or bulimia
Chronic Diarrhea: secretory diarrhea
process characteristics of stool timing associated symptoms setting/person @ risk
process: Variable: bacterial infection, secreting
villous adenoma, fat or bile salt malabsorption,
hormone-mediated conditions (gastrin in Zollinger–Ellison syndrome, vasoactive intestinal peptide)
characteristics of stool: watery diarrhea of large volume
timing: variable
associated symptoms: Weight loss, dehydration, nausea, vomiting, and cramping, abdominal pain
setting/person @ risk: Variable
depending on cause
Constipation: inadequate time or setting for the defecation reflex
Process
Associated Setting/Symptoms
Process: Ignoring the sensation of a full rectum
inhibits the defecation reflex
Associated Setting/Symptoms: Hectic schedules, unfamiliar
surroundings, bed rest
Constipation: False Expectations of Bowel Habits
Process
Associated Setting/Symptoms
Process: Expectations of “regularity” or more
frequent stools than a person’s norm
Associated Setting/Symptoms: Beliefs, treatments, and advertisements
that promote the use of laxatives
Constipation: Diet Deficient in Fiber
Process
Associated Setting/Symptoms
Process: decreased fecal bulk
Associated Setting/Symptoms: Other factors such as debilitation and
constipating drugs may contribute
Irritable Bowel Syndrome:
Process
Associated Setting/Symptoms
Process: Functional change in frequency or form
of bowel movement without known
pathology; possibly from change in
intestinal bacteria.
Associated Setting/Symptoms: Three patterns: diarrhea—predominant, constipation—predominant, or mixed. Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance)
Cancer of Rectum or Sigmoid Colon:
Process
Associated Setting/Symptoms
Process: Progressive narrowing of the bowel
lumen from adenocarcinoma
Associated Setting/Symptoms: Change in bowel habits; often diarrhea,
abdominal pain, bleeding, occult blood
in stool; in rectal cancer, tenesmus and
pencil-shaped stools; weight loss
Fecal Impaction:
Process
Associated Setting/Symptoms
Process: A large, firm, immovable fecal mass,
most often in the rectum
Associated Setting/Symptoms: Rectal fullness, abdominal pain, and diarrhea around the impaction; common in debilitated, bedridden, and often elderly and institutionalized patients
Constipation causing obstructing lesions - diverticulitis, volvulus, intussusception, hernia:
Process
Associated Setting/Symptoms
Process: Narrowing or complete obstruction of
the bowel
Associated Setting/Symptoms: Colicky abdominal pain, abdominal
distention, and in intussusception, often
“currant jelly” stools (red blood and
mucus)
Constipation: Painful Anal Lesions
Process
Associated Setting/Symptoms
Process: Pain may cause spasm of the external
sphincter and voluntary inhibition of
the defecation reflex
Associated Setting/Symptoms: Anal fissures, painful hemorrhoids,
perirectal abscesses
Constipation:drugs
Process
Associated Setting/Symptoms
Process: A variety of mechanisms
Associated Setting/Symptoms: Opiates, anticholinergics, antacids
containing calcium or aluminum, and
many others
Constipation: depression
Process
Associated Setting/Symptoms
Process: a disorder of mood
Associated Setting/Symptoms: Fatigue, anhedonia, sleep disturbance,
weight loss
Constipation: Neurologic Disorders
Process
Associated Setting/Symptoms
Process: Interference with the autonomic
innervation of the bowel
Associated Setting/Symptoms: Spinal cord injuries, multiple sclerosis,
Hirschsprung disease, and other
conditions
Constipation: metabolic conditions
Process
Associated Setting/Symptoms
Process: Interference with bowel motility
Associated Setting/Symptoms: Pregnancy, hypothyroidism,
hypercalcemia
Melena:
problem
selected causes w/ associated symptoms/setting
Problem: Refers to passage of black tarry stool
Fecal blood tests are positive
Involves loss ≥60 mL of blood into the
gastrointestinal tract (less in children),
usually from the esophagus, stomach, or
duodenum with transit time of 7–14 hrs
Less commonly, if slow transit, blood loss
originates in the jejunum, ileum, or
ascending colon
In infants, melena may result from
swallowing blood during the birth
Gastritis, GERD, peptic ulcer (gastric or duodenal) - Usually epigastric discomfort from
heartburn, dysmotility; if peptic ulcer, pain after meals delay of 2–3 hrs if duodenal ulcer; may be asymptomatic
Gastritis or stress ulcers - Recent ingestion of alcohol, aspirin, or
other anti-inflammatory drugs; recent
bodily trauma, severe burns, surgery, or
increased intracranial pressure
Esophageal or gastric varices - Cirrhosis of the liver or other causes of portal hypertension
Reflux esophagitis, Mallory-Weiss tear in esophageal mucosa due to retching and vomiting - Retching, vomiting, often recent ingestion of alcohol
Black Stool:
problem
selected causes w/ associated symptoms/setting
Problem: Black stool from other causes with
negative fecal blood tests; stool change
has no pathologic significance
Selected Causes: ingestions of iron, bismuth salts, licorice, or even chocolate cookies - asymptomatic
Stool with Red Blood (Hematochezia)
problem
selected causes w/ associated symptoms/setting
Problem: Usually originates in the colon, rectum, or anus; much less frequently from the jejunum or ileum Upper gastrointestinal hemorrhage may also cause red stool, usually with large blood loss ≥1 L Rapid transit leaves insufficient time for the blood to turn black from oxidation of iron in hemoglobin
Colon cancer - Often a change in bowel habits, weight loss
Hyperplasia or adenomatous polyps - Often no other symptoms
Diverticula of the colon - Often no symptoms unless inflammation causes diverticulitis
Proctitis (various causes including anal intercourse) - rectal urgency, tenesmus
ischemic colitis - lower abdominal pain, sometimes fever or shock on older adults, abdomen typically soft to palpation
hemmorhoids - blood on toilet paper, on surface of the stool, dripping into toilet
anal fissure - blood on toilet paper or on surface of stool, anal pain
Reddish but non bloody stool: causes & symptoms
ingestion of beets - pink urine usually pecans reddish stool, from poor metabolism of betacyanin
Urinary Frequency: mechanisms
- decreased bladder capacity
- impaired bladder emptying w/ residual urine in the bladder
urinary frequency - decreased bladder capacity
mechanism-cause-symptoms (3)
- increased bladder sensitivity to stretch b/c of inflammation - infection, stones, tumor, foreign body in bladder - burning on urination, urinary urgency, sometimes gross hematuria
- decreased elasticity of the bladder wall - infiltration by scar tissue or tumor - burning on urination, urinary urgency, sometimes gross hematuria
- decreased cortical inhibition of bladder contractions - motor disorders of the CNS (stroke) - urinary urgency, near sx: weakness, paralysis
urinary frequency - impaired bladder emptying w/ residual urine in the bladder
mechanism-cause-symptoms (2)
- partial mechanism obstruction of the bladder neck/proximal urethra - BPH, urethral stricture, obstructive lesion of bladder/prostate - hesitancy in starting stream, strain to void, reduced size/force of stream, dribbling during or at end of urination
- loss of S2-S4 innervation to the bladder - near dz affecting sacral nerves or nerve roots, diabetic neuropathy - weakness or sensory deficits
Nocturia w/ high volumes:
mechanisms/causes/symptoms (3)
- decreased concentrating ability of he kidney w/ loss of normal drop in nocturnal urine output - chronic renal insufficiency - other sx of renal insufficiency
- excessive fluid intake before bed - habit, esp. ETOH/coffee
- fluid-retaining, edematous states, daytime accumulation of dependent edema that is excreted when pt supine - heart failure, nephrotic syndrome, hepatic cirrhosis w/ ascites, chronic venous insufficiency - edema, reduced UOP during day
Nocturia w/ low volumes
mechanisms/causes/symptoms
urinary frequency, voiding while up at night w/o real urge “pseudo frequency”
- insomnia
- variable symptoms
Polyuria
mechanisms/causes/symptoms
- deficiency of ADH (DI) - disorder of posterior pituitary and hypothalamus - thirst, polydipsia (severe, persistent), nocturne
- renal unresponsiveness to ADH (nephrogenic DI) - kidney diseases (hypoercalcemic and hypokalemic nephropathy), drug toxicity (lithium) - thirst, polydipsia, (severe, persistent), nocturne
- solute diuresis:
- electrolytes (Na) - large saline infusions, potent diuretics, kidney diseases - variable sx
- non electrolytes (glucose) - uncontrolled DM - thirst, polydipsia, nocturne - excessive water intake - primary polydipsia - polydipsia episodic, thirst may not be present, nocturne usually absent
Stress Incontinence
urethral sphincter is weakened so that transient increased in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance
Stress incontinence: mechanisms
women:
- pelvic floor weakness
- inadequate muscular and ligamentous support of bladder neck and proximal urethra change the angle between bladder and urethra
- causes: childbirth and surgery
- local conditions affecting the internal urethral sphincter (postmenopausal atrophy of mucosa and urethral infection)
men: prostate surgery
stress incontinence: symptoms
momentary leakage of small amounts of urine w/ coughing, laughing, sneezing while person is upright
-urine loss unrelated to conscious urge to urinate
stress incontinence: physical signs
may be demonstrable if examined before voiding and in standing position
- atrophic vaginitis may be evident
- bladder distention is absent
Urge incontinence
detrusor muscles are stronger than normal and overcome the normal urethral resistance
-bladder is typically small
urge incontinence: mechanisms/symptoms/physical signs (3)
- decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, lesions of spinal cord above sacral level - involuntary urine loss proceeded by urge to void, moderate volume - small bladder not detectable on abd exam
- hyper excitability of sensory pathways (bladder infections, tumors, fecal impaction) - urgency, frequency, nocturne w/ small to moderate volumes (if acute inflammation present: pain on urination) - when cortical inhibition decreased, mental deficits or motor signs of CNS dz present
- reconditioning of voiding reflexes as in frequent voluntary voiding at low bladder volumes - “pseudo-stress incontinence”: voiding 10-21 sec after stresses such as position change, stairs, cough/laugh/sneeze - when sensory pathways are hyper excitable signs of local pelvic problems or fecal impaction present
urinary overflow incontinence
detrusor contractions are insufficient to overcome urethral resistance causing urinary retention
- bladder typically flaccid and large even after effort to void
urinary overflow incontinence: mechanisms/symptoms/physical signs (3)
- obstruction of bladder outlet (BPH, tumor) - intravascular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues
- weakness of detrusor muscle associated w/ peripheral nerve dz at S2-S4 level - decreased force of urinary stream
- impaired bladder sensation that interrupts reflex arc (diabetic neuropathy) - prior sx of partial urinary obstruction or other symptoms of peripheral nerve disease may be present
Physical signs: enlarged, tender bladder, prostate enlargement, motor signs of peripheral nerve disease, decrease in perineal sensation, diminished/absent reflexes
Functional Urinary Incontinence
patient is functionally unable to reach toilet in time b/c of impaired health or environmental conditions
Functional urinary Incontinence: mechanisms/symptoms/physical signs
mechanisms:
- problems in mobility resulting from weakness, arthritis, poor vision, or other conditions
- environmental factors such as unfamiliar setting, distant bathroom facilities, bed rails, physical restraints
symptoms: incontinence on the way to toilet or only in the early morning
physical signs: bladder not detectable on exam, look for environmental causes
Urinary Incontinence s/t medications
drugs may contribute to any type of incontinence
-sedatives, tranquilizers, sympathetic blockers, potent diuretics
Umbilical Hernia
protrusion through a defective umbilical ring
-most common in infants (usually closes spontaneously in 1-2 years) but occurs in adults
Incisional Hernia
protrusion through an operative scare
- palpate to detect length and width of defect in abdominal wall
- small defect, through which a large hernia has passed, has a greater risk for complications than a large defect
Epigastric Hernia
small midline protrusion through a defect in the lines alba occurs between the diploid process and the umbilicus
- w/ pt coughing or performing valsalva maneuver palpate by running fingered down line laba
Diastasis Recti
separation of 2 rectus abdomens muscles through which abdominal contents form a midline ridge typically extending from the xiphoid to the umbilicus and seen only when pt raises head and shoulders
- often present w/ repeated pregnancies, obesity, chronic lung disease
- clinically benign
Abdominal Lipoma
common, benign, fatty tumors usually in SQ tissues anywhere on body including abdominal wall
-small or large
-soft and lobulated
press finger down on edge, tumor usually slips out from under finger and is well demarcated, nonreducible, nontender
Types of Protuberant Abdomens
- Fat - most common, thickens abdominal wall, mesentery, omentum, umbilicus sunken, pannus (apron of fatty tissue) may extend below inguinal ligaments - lift to look for skin inflammation or hidden hernia
- Gas - distention may be localized or generalized, tympanic percussion, caused by foods, obstruction, paralytic ileum, note location (more marked in colon than small bowel)
- Tumor - usually rising out of pelvis, dull to percussion, airfilled bowel displaced to periphery (ovarian tumor, uterine fibroids), don’t mistake for distended bladder
- Pregnancy - listen for fetal heart
- Ascites - seeks lowest point in abdomen producing bulging flanks that are dull to percussion, umbilicus may protrude, turn pt to side to look for shift
increased bowel sounds
diarrhea, early intestinal obstruction
decreased then absent bowel sounds
dynamic ileum and peritonitis
listen at least 2 min
high pitched tinkling bowel sounds
intestinal fluid
air under tension in dilated bowel
rushes of high pitched bowel sounds w/ abdominal cramp
intestinal obstruction
hepatic bruit suggests
carcinoma of liver
cirrhosis
arterial bruits w/ both systolic and diastolic components suggest
partial obstruction of aorta or large arteries
epigastrium bruits suggest
renal artery stenosis or renovascular hypertension
abdominal venous hum
rare soft humming noise w/ both systolic and diastolic components
- points to increased collateral circulation between portal and systemic system as in hepatic cirrhosis
abdominal friction rubs
area grating sounds w/ respiratory variation
- indicate inflammation of peritoneal surface of an organ as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct
- when systolic bruit accompanies hepatic friction rub, suspect carcinoma of liver
abdominal wall tenderness
may originate in abdominal wall
when pt raised head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion protected by the tightened muscles) decreases
visceral tenderness
usually the discomfort is dull w/ no muscular rigidity or rebound tenderness
may be tender to deep palpation: enlarged liver, normal aorta, normal cecum, normal or spastic colon
tenderness from disease in chest and pelvis: acute pleurisy
may cause abdominal pain and tenderness
- when unilateral can mimic acute cholecystitis or appendicitis
- chest signs usually present, rebound tenderness and rigidity less common
tenderness from disease in chest and pelvis: acute salpingitis
frequently bilateral, the tenderness of inflamed Fallopian tubes is usually maximal just above inguinal ligaments
- rebound tenderness and rigidity may be present
- on pelvic exam: motion of cervix and uterus causes pain
tenderness of peritoneal inflammation
tenderness more sever than visceral tenderness
- muscular rigidity and rebound tenderness are frequently but not necessarily present
- generalized peritonitis causes exquisite tenderness throughout the abdomen w/ board-like muscular rigidity
local causes of peritoneal inflammation:
acute cholecystitis (Murphy’s sign, signs maximal in RUQ)
acute pancreatitis (epigastric tenderness and rebound tenderness present, soft abdominal wall)
acute appendicitis (RLQ but may be absent early, McBurney’s point)
acute diverticulitis (confined inflammatory process, LLQ sigmoid colon, may have suprapubic or right sided pain, localized peritoneal signs and tender underlying mass, micro perforation, access, obstruction may occur)
Downward displacement of liver by low diaphragm
common when diaphragm flattened and low (COPD)
- liver edge may be palpable well below costal margin
- percussion reveals low upper edge, vertical span of liver normal
Normal variations in liver shape
right lobe may be elongated and easily palpable as it projects downward toward the iliac crest (Riedel lobe)
Smooth large liver
- cirrhosis may produce enlarged liver w/ firm, nontender edge (may also be scarred and contracted), also seen w/ hemochromatosis, amyloidosis, lymphoma
- suggests inflammation (hepatitis, venous congestion: right heart failure)
Irregular large liver
- enlarged liver that is firm or hard w/ irregular edge or surface suggests hepatocellular carcinoma
- may be one or more nodules
- liver may/may not be tender
