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GI and Renal Exam 3 > 41 - Primary Care Presentation > Flashcards

41 - Primary Care Presentation Flashcards

1
Q

Describe the history for a GI problem

A

What is the Chief Complaint?

HPI

  • Onset
  • Provoke
  • Palliate
  • Progression
  • Prior episodes
  • Quality/quantity
  • Region/radiation
  • Severity
  • Timing
  • Treatment
  • Associated symptoms
  • Anyone at home sick
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2
Q

Additional history

A
  • Medications (arythromycin, antidepressants)
  • Allergies
  • Past history
  • Past Surgical history
  • Family history
  • Social history
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3
Q

Describe the GI ROS

A
  • Dyspepsia
  • Nausea
  • Vomiting
  • Diarrhea
  • Constipation
  • Bloating
  • Hematemesis
  • Hematochezia
  • Pain
  • Change in stool
  • Bleeding, color
  • Food intolerance
  • Eructation
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4
Q

Describe the physical exam inspection portion

A

Look for….

  • General contour
  • Asymmetry
  • Masses
  • Lesions
  • Scars
  • Umbilicus
  • Venous pattern
  • Hernias
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5
Q

Describe the auscultation in the physical exam

A

Listen for…

  • Prior to percussion and palpation
  • Four quadrants
  • Identify bowel sound frequency – normal, hypo or hyper
  • Sound character: borborygmi, tinkling
  • Arterial bruits
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6
Q

Describe the percussion of the abdomen

A

Percuss for…

  • Tone in 4 quadrants
  • Liver span
  • Spleen
  • Bladder
  • Gastric bubble
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7
Q

Describe the palpation of the physical exam

A

Palpate for…

  • Watch facial expression
  • Light – skin and subcutaneous tissues
  • Deep – visceral structures – tenderness – masses
  • Hepatomegaly
  • Splenomegaly
  • Bladder
  • Aorta size
  • Uterine height
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8
Q

Describe an acute abdomen

A

Acute Abdomen…

  • Look at position of patient
  • Look for guarding
  • Rigidity
  • Rebound testing (Rovsing’ s sign, Psoas sign)
  • Murphy’s sign
  • Shifting dullness
  • Rectal exam
  • Pelvic exam
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9
Q

Define nausea

A

Nausea – the unpleasant sensation of being about to vomit

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10
Q

Define vomiting

A

Vomiting - the forceful expulsion of gastric contents

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11
Q

Define retching

A

Retching – absence of expulsion of gastric content (after you vomit, everything is out but they still have the urge to vomit)

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12
Q

Define regurgitation

A

Regurgitation – the return of esophageal contents to the hypopharynx with little effort

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13
Q

Define reflux

A

Reflux – heartburn, regurgitation and dysphagia , laryngitis and chronic cough

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14
Q

Describe nausea and vomiting history

A
  • An initial careful history and physical exam in most cases will elicit the cause and additional testing is usually not required
  • Be specific when asking about symptom duration, frequency, and severity, characteristics of vomiting episodes and associated symptoms
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15
Q

Describe identifying the etiology

A

Identify and correct – Always look for etiology

  • Fluid loss
  • Hypokalemia
  • Metabolic alkalosis

When there is a chronic problem
- Chronic problem should think about imaging or scope evaluation

Targeted therapy
- Antiemetics

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16
Q

Give the clinical pearls of diagnosing GI concerns

A
  • Abdominal pain with vomiting – often an organic etiology (cholelithiasis)
  • Abdominal distension and tenderness – suggest bowel obstruction
  • Vomiting of food eaten several hours earlier – think of a possible gastric obstruction
  • Heartburn with nausea – GERD
  • Early AM vomiting - pregnancy
  • Neurogenic vomiting - may be positional or projectile (Very classically when young people get a blow to the head, they have very projectile vomiting)
  • Quick vomiting after food - think food poisoning
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17
Q

What is Cullen’s sign?

A

A sign of subcutaneous intraperitoneal bleed, usually from acute hemorrhagic pancreatitis – ruptured ectopic pregnancy, a periumbilical ecchymosis

18
Q

What is Grey Turner’s sign?

A

A bilateral reddish – purplish discoloration of the flanks – hemorrhagic pancreatitis

19
Q

What should you recognize about Cullen’s and Grey Turner’s sign?

A

Both of these are rare -

20
Q

What is the Kehr sign?

A

Abdominal pain radiating to the left shoulder. Classic for pain associated with an insult to the spleen

21
Q

What is the costovertebral angle tenderness sign (Lloyd’s sign)

A

Pain is usually in the region of the 12th rib – caused by kidney problem

22
Q

What is a peritoneal sign?

A

Obturator, Iliopsoas, Rebound, Heel jar test, Rovsing’ s sign, don’t forget the hx

23
Q

Describe ulcerative colitis

A
  • Recurring episodes of inflammation limited to the mucosal layer of the colon
  • Diarrhea with blood, frequent small volume bowel movements, colicky abdominal pain, urgency, tenesmus and incontinence
  • Patient may have systemic symptoms – fever, fatigue, weight loss, dyspnea due to anemia (check CBC regularly)
  • Attacks of bloody diarrhea that may last for weeks to months
  • Non typhoid Salmonella or Campylobacter infections
  • Diet high in refined sugar, fat, meat
  • Diet rich in vegetables reduces the risk
  • Hygiene hypothesis
24
Q

Describe Crohn’s disease

A
  • Transmural inflammation of the GI tract – 80% of patients have small bowel involvement
  • Fatigue, prolonged diarrhea with abdominal pain, weight loss, fever , with or without gross bleeding
  • Crampy abdominal pain, diarrhea fluctuates over time without bleeding, other features suggesting inflammatory bowel disease may involve the eyes, skin, joints
  • Perianal disease (fissures, abscess)
  • Fibrotic strictures – small bowel obstruction (causes a lot of pain for these patients)
  • Fistula formation – intestine to bladder, intestine to skin, intestine to bowel, intestine to the vagina
25
Q

What are the possible causes of a GI bleed?

A
  • May occur anywhere from oral cavity to anorectum
  • 20 -30% have a colorectal source – colon cancer, colon polyps, colitis, vascular ectasias
  • 29-56% have a upper GI tract source – esophagitis, ulcers, vascular ectasias, cancer
  • 29-52% no source found
  • A small bowel source is likely with recurrent bleeding and negative findings on EGD and colonoscopy studies
26
Q

Describe GI pain

*** KNOW THIS ***

A

The evaluation and treatment of pain remains suboptimal

Chronic pain – persists beyond the ordinary time that an insult or injury needs to heal

***** Nociceptive pain – originating in damaged tissues outside the nervous system, inside the gut (visceral pain) - mesenteric pain falls into this category (can be out of proportion to what you see on physical exam)

***** Neuropathic pain – from abnormal neural activity

27
Q

Describe abdominal pain in adults

A
  • The clinician must decide if the complaint is an accelerating process, one that has leveled out, or one that is chronic and longstanding
  • Possible surgical problem – think of obstruction and peritonitis
28
Q

Describe pain due to an obstruciton

A

Obstruction – pain with anorexia, bloating, nausea, vomiting, high pitched or absent bowel sounds

29
Q

Describe pain due to peritonitis

A

Peritonitis – these patients look sick, lie very still, abdominal wall rigidity, diminished bowel sounds

30
Q

Describe RUQ pain (right upper quadrant pain)

A

RUQ pain – think liver or biliary tree, pain may radiate to the back, liver capsule needs to be stretched for pain, viral drug induced hepatitis

Dissecting aneurysm - pain that radiates to the back

31
Q

Describe epigastric pain

A

Epigastric pain – sudden onset think of pancreatitis*** esp. with pain in the back, dyspepsia – ulcers, GERD

32
Q

Describe upper abdominal pain

A

Upper abdominal pain – is it cardiac?, pneumonia?, PE?, empyema?

Need to also think cardiac or lung - do these exams too

33
Q

Describe lower abdominal pain

A

Lower abdominal pain – can be distal GI tract or radiation from upper structures or from pelvis

34
Q

Describe pain on both the R and L side

A

Pain from both R and L side can be colitis or an ileitis

35
Q

Describe left sided pain

A

Left sided pain usually diverticulitis (this is the case in 99% cases of men)

In women could be ovary, uterus, other pelvic pain

36
Q

Describe abdominal pain in women

A

In Women – ask about regularity and timing of menstrual periods, pregnancy, vaginal discharge or bleeding

37
Q

Describe severe generalized abdominal pain

A

Severe generalized abdominal pain think about evaluating for possible surgical intervention

38
Q

Describe pain out of proportion

A

Pain out of proportion to physical findings suspect acute mesenteric ischemia or infarction

39
Q

Describe self-limiting GI illness

A

Self-limiting illness – viral or bacterial enteritis or toxin mediated food poisoning – 24 to 48 hours for bacterial onset – family members or co-workers with similar symptoms

40
Q

What’s really important here?

A

HISTORY

  • Don’t be afraid to go back and ask again or think of more possibilities
  • Replacement of fluids is sometimes the best treatment
  • Small sips of pedialite, gatorade, do small amounts, ice chips
  • Monitor urine output or measure diapers to assess hydration (little kids)
  • Color of urine (small amount of very concentrated urine is bad - sign of dehydration)
  • Jello or pudding works for kids
  • Then try crackers, toast, etc. but stay away from dairy products
  • Look at pulse and BP for fluids in the body
  • Take the temperature and watch that
  • ** In the elderly, they aren’t going to mount a high temperature like others would
  • ** A very high fever in elderly usually means sepsis or another severe condition
  • If someone really looks sick, they probably are
  • Do not miss some of these big things

GI and Renal Exam 3 (15 decks)

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