41 - Primary Care Presentation Flashcards
Describe the history for a GI problem
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
Additional history
- Medications (arythromycin, antidepressants)
- Allergies
- Past history
- Past Surgical history
- Family history
- Social history
Describe the GI ROS
- Dyspepsia
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Bloating
- Hematemesis
- Hematochezia
- Pain
- Change in stool
- Bleeding, color
- Food intolerance
- Eructation
Describe the physical exam inspection portion
Look for….
- General contour
- Asymmetry
- Masses
- Lesions
- Scars
- Umbilicus
- Venous pattern
- Hernias
Describe the auscultation in the physical exam
Listen for…
- Prior to percussion and palpation
- Four quadrants
- Identify bowel sound frequency – normal, hypo or hyper
- Sound character: borborygmi, tinkling
- Arterial bruits
Describe the percussion of the abdomen
Percuss for…
- Tone in 4 quadrants
- Liver span
- Spleen
- Bladder
- Gastric bubble
Describe the palpation of the physical exam
Palpate for…
- Watch facial expression
- Light – skin and subcutaneous tissues
- Deep – visceral structures – tenderness – masses
- Hepatomegaly
- Splenomegaly
- Bladder
- Aorta size
- Uterine height
Describe an acute abdomen
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
Define nausea
Nausea – the unpleasant sensation of being about to vomit
Define vomiting
Vomiting - the forceful expulsion of gastric contents
Define retching
Retching – absence of expulsion of gastric content (after you vomit, everything is out but they still have the urge to vomit)
Define regurgitation
Regurgitation – the return of esophageal contents to the hypopharynx with little effort
Define reflux
Reflux – heartburn, regurgitation and dysphagia , laryngitis and chronic cough
Describe nausea and vomiting history
- 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
Describe identifying the etiology
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
Give the clinical pearls of diagnosing GI concerns
- 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
What is Cullen’s sign?
A sign of subcutaneous intraperitoneal bleed, usually from acute hemorrhagic pancreatitis – ruptured ectopic pregnancy, a periumbilical ecchymosis
What is Grey Turner’s sign?
A bilateral reddish – purplish discoloration of the flanks – hemorrhagic pancreatitis
What should you recognize about Cullen’s and Grey Turner’s sign?
Both of these are rare -
What is the Kehr sign?
Abdominal pain radiating to the left shoulder. Classic for pain associated with an insult to the spleen
What is the costovertebral angle tenderness sign (Lloyd’s sign)
Pain is usually in the region of the 12th rib – caused by kidney problem
What is a peritoneal sign?
Obturator, Iliopsoas, Rebound, Heel jar test, Rovsing’ s sign, don’t forget the hx
Describe ulcerative colitis
- 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
Describe Crohn’s disease
- 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
