Abdomen/Rectal/Prostate Exam Flashcards
Organs in the RUQ (6)
liver GB Pylorus Duodenum Hepatic flexure of colon Head of pancreas
Organs in LUQ (5)
Spleen Splenic flexure of colon stomach body and tail of pancreas transverse colon
Organs in LLQ (3)
Sigmoid colon
descending colon
left ovary
Organs in the RLQ (4)
Cecum
Appendix
Ascending colon
right ovary
are the GB and duodenum generally palpated?
no
abdominal aorta is usually palpable in which quadrant?
upper quadrants or EIPgastrum
spleen’s position to the stomach
later to and behind stomach
upper margin of spleen lies against?
diaphragm
a distended bladder may be palpable above the ?
symphysis pubis
cramping + colicky pain can suggest?
renal stones
sudden, knife like epigastric pain that radiates to the back suggests?
pancreatitis
visceral pain in the RUQ suggests?
liver distention against its capsule from the various causes of hepatitis,
list the DDs for epigastric pain (3)
GERD
Pancreatitis
Perf ulcers
List the DDs for RUQ pain (2)
cholecystitis
choleangitis
will asking about severity of pain helpful in IDing the cause?
not as helpful
Acute RLQ pain DDs? (3)
appendicitis
PID
Ectopic pregnancy
Acute LLQ pain DDs? (3)
Diverticulitis
bowel obstruction
peritonitis
List some Dz’s that cause chronic pain
IBS
Colon CA
intermittent pain, change in bowel habits and/or change in stool (pellet like) suggests?
IBS
Describe physical exam findings for IBS
- intermittent pain,
- change in bowel habits and/or change in stool (pellet like)
change in bowel habits + mass lesion warns of?
colon CA
visceral pericumbilical pain suggests?
early acute appendicitis
visceral pericumbilical pain that later, pain moves to parietal pain in the RLQ suggests
appendicitis
pain disproportionate to PA findings suggests?
intestinal mesenteric ischemia
describe visceral pain
when hollow organs contract forcefully or distend/stretch
or
solid organs w/ capsule or liver
Difficult to localize:
- gnawing
- burning
- aching
Described as difficult to localize pain
- gnawing
- burning
- aching
which pain?
visceral pain
describe parietal pain
originates from inflammation of the parietal peritoneum
-easier to localize, pain is usually worse than visceral and worse with movement
steady, aching pain
aggravated by moving or coughing
PT trying to move around–attempting to find a comfortable position suggests?
renal stones with peritonitis
ischemia causes which kind of pain
visceral pain
descr referred pain
felt more in distal sites
caused by which nerve fibers are at the same level of the structures
usually localized
pain of duodenal or pancreatic origin can refer to what areas?
back
biliary tree
right scapular region
right posterior thorax
pain from pleurisy or inferior wall MI can refer to?
epigastric area
define dyspepsia
chronic or recurrent discomfort
or
PAIN in the upper abdomen, characterized by postprandial fullness, early satiety, epigastric pain/burning
Define discomfort
subjective
negative feeling that is not painful
-can include symps: bloating, nausea, upper abdominal fullness, heartburn
list two Dz where bloating can ocur
lactose intolerance
ovarian CA
aerophagia
IBS
sudden knife like epigasric pain often radiating to the back is typical of?
pancreatitis
define aerophagia
swallowing air– can lead to bloating
Functional Dyspepsia define
3 MO hx of non-specific upper GI discomfort or nausea not attributable to structural abnormalities or PUD
diagnostic criteria for GERD
patient reporting heartburn and regurgitation TOGETHER for over 1 week….. 90% likely its gerd
Heartburn define
rising retrosternal burning pain/discomfort occurring weekly or more
heartburn can be a sign of?
Myocardial ischemia
non-GI signs
hoarseness
coughing
wheezing
GERD
dysphagia define
difficulty swallowing from impaired passage of solid foods or liquids from mouth to stomach
“i feel that food is getting stuck when i swallow”
dysphagia to solid food– list DZs
structural causes like stricture, webbing or neoplasm
Dysphagia to liquids list causes
motility disorder such as achalasia
Define globus sensation
FB/lump sensation in throat
unrelated to swallowing
Define odynophagia and list causes
pain with swallowing
causes: esophageal ulceration
list alarming symptoms that can present with odynophagia
wt loss
GI bleeding
palpable mass
difference b/w retching and vomiting
retching: involuntary spasm of stomach, dia and esophagus that LEADS to vomiting
vomiting: forceful expulsion of gastric contents out of the mouth
regurgitation define
raise of esophageal/gastric conents w/o nausea/retching
hematemesis define
*causes
coffee ground emesis or red blood
causes: esophageal/gastric varices, Mallory-Weise tears or PUD
anorexia define
loss of appetite
- fear of abdominal discomfort “food fear”
- self-image/body distortions or appendicitis
timing for acute diarrhea
can last up to 2 weeks
timing for chronic diarrhea
*causes
4 weeks or longer
*non-infectious like CD or UC
high volume and frequent watery stools likely coming from what part of colon
small intestine
steatorrhea
causes
fatty diarrheal stools from malabsoprtion
- oily residue + frothy + floating
- celiacl sprue, pancreatic insufficiency
tenesmus define
constant urge to defecate accompanied by pain, cramping, and involuntary straining
small volume stools + tenesmus =?
rectcal inflammatory conditions
pus/mucous/blood in stool occur in?
rectal inflammatory conditions
causes of tenesmus
recent use of ABX
recent hospitalization
recent travel
new diet
timing for constipation
3 months
with symptoms onset at least 6 months prior to diagnosis PLUS 2 of the following:
1. fewer than 3 BM/week
2. 25% or more BM associated with straining/sensation of incomplete evacuation/hard stool
3. manual facilitation
melena vs hematochezia
melena–upper GI bleed, black and tarry
hematochezia–lower GI bleed (rectal, colon anus), bright red stool
blood on surface or toilet paper points to
hemorrhoids
primary vs secondary contipation
primary: normal transit, slow transit, impaired expulsion
secondary: pregnancy, adv age, medications, underlying med condition
define obstipation
no passage of either feces or gas
cause of obstipation
intestinal obstruction
jaundice can signify issues with what organs
liver
GB
pancreas
acholic stool
MC w/?
other causes
stool without bile–>gray, light colored stoools
MC in obstrcutive jaundice
causes: ETOH, hep A, Hep B, Hep C, liver damage secondary to medications
what are caput medusae and what is the cause
dilated veins
*from portal HTN from cirrhosis
asymmetry on exam can suggest
hernia
enlarged organ
mass
do you asucultate before or after percuss/palpate
AUSCULTATE BEFORE
vascular sounds like heart murmur
bruits
grating sound corresponding to respirations
friction rub
continuous soft humming noise
venous hum
incr bowel sounds suggest
diarrhea
decr bowel sounds suggest
ileus
peritonitis
bruit in epigastric/renal artery suggests?
htn caused by renal artery stenosis
friction rubs are present in?
Hepatoma
Gonococcal infection around liver
splenic infarction
pancreatic CA
venous hum is heard in PTs with?
hepatic cirrhosis
tympany vs dull
tympany: hollow drum sound—AIR FILLED (GI tract, gas
Dull: heard over solid structures, or if fluid is beneath
what is castell’s sign
splenic percussion sign—lowest interspace on the left anterior axillary line
**should be tympanic
is castell’s sign tympanic or dull
tympanic
why do we palpate abdomen
to check for tenderness, guarding or masses
guarding can decrease if patient inhales or exhales
exhales—– bc the muscles are relaxed
signs of peritonitits– (4)
- coughing causes pain
- guarding
- rigidity
- rebound tenderness
with rebound tenderness, what hurts more.. pushing down or letting go?
letting go
define guarding
VOLNTARY contractions of abdominal wall
define rigidity
INVOL contraction of abdominal wall that persists over a few exams
why does liver go down when PT takes a deep breath
bc liver is attached to the underside of dia—
STEPS TO PALPATE LIVER:
- place ___(R/L) hand ____ (above/below) patient and press ____ (down/upward)
- ___(R/L) hand on abdomen ___(below/above) border of ____(dullness/tympany)
- gently push ___ (up/down) and in with the ___(R/L) hand as patient takes deep breath (in/out)
- place left hand under patient (11th and 12th rib) and press upward
- Right hand on abdomen below lower border of dullness
- gently push up and in with the right hand as patients takes a deep breath in
when do we use the hooking technique?
to palpate the liver in obese PT
at what age do we palpate the aorta
> 50
normal width of aorta
no more than 3 cm wide
list the special techniques
CVA tenderness
Test for ascites
Appendicitis test
Cholecystitis test
+CVA tenderness?
pylonephritis
testing for ascites– what will a + exam result look like
WILL BE a shift in dullness (move to dependent side) and tympany shifts to top
McBurney Point
junction of the middle and outer thirds of the line joining the umbilicus to the anterior superior illiac spine
Appendicitis is __times more likely when what is tender?
there is McBurney point tenderness
List the appendicitis tests
ROvsing sign
Psoas sign
Obturator sign
Rovsing sign
worsening RLQ pain with palpation to LLQ
AND
can check if referred rebound tenderness in the LLQ
Psoas Sign
worsening abdominal pain with right left extension at hip when patient is lying on their side
OR
place hand above the PT’s right knee, ask PT to raise thigh against hand
PAIN= + test
Obturator sign
RLQ pain on internal rotation of flexed right hip
- lower leg swings outward
- ***not as reliable
test for cholecytitis?
Murphy test
typical patient demographic for cholecystitis
Fat
Female
Forty
Fertile
non-tender RUQ pain perform what test
murphy test to chest GB
how to perform Murphy test
- deeply palpate the RUQ at location of pain
- ask PT to take deep breath in (forces GB and liver down toward fingers)
- sharp halting in inspiratory effort due to pain from palpation of the GB on exam—-POSITIVE MURPHY SIGN
+ murphy sign _____ likelihood of ____
triples likelihood for acute cholecystitis
prostate gland location
anterior rectal wall
below bladder
infront of rectum
normal length of prostate
2.5 cm
pencil thin stools?
colon CA
pain on defication, itching, bleeding/discharge from infection or rectcal abscess suggests?
proctitis
rectal intching in peds suggest?
pinworms
difficulty starting/stopping urine stream
and/or
frequency at night
benign prostate hypertrophy (BPH)
or
prostate CA
ESP >70 male
men: sudden onset of UTI symptoms with perineal and low back pain, malaise and fever chills
acute prostatitis
when is the DRE performed?
- when dz is suspected or already IDed
* screening when there is no suspicion or expectation of DZ
patient positioning for rectal exam
PT laying on L side with knee/hip flexed
*ask PT to beardown and then insert as the sphincter relaxes
tender purulent reddened mass with fever
anal abscess
abscesses that funnel from anus/rectum to surface of skin may form?
fistula
ooze blood, pus or feculent mucus can suggest?
fistula
laxity in sphincter tone could suggest?
neurologic dz (S2-S4 cord lesions)
normal prostate feels?
rubbery and non-tender
rotate fingers in what direction (towards PTs __ side) and then in what direction after?
FIRST rotate clockwise (PTs right) and then counterclockqise (to their left)
small tuft of hair surrounded by halo of erythema ?
Pilonidal cyst
list some abnormalities of rectum
external hemorrhoid
internal hem
prolapse of rectum
Abdomen is protuberant with active bowel sounds. It is soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.”
**what is this?
normal
Abdomen is flat. No bowel sounds heard. It is firm and board like, with increased tenderness, guarding, and rebound in the right mid-quadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses. No CVA tenderness
**what is this suggestive of?
appendicitis poss peritonitis
No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Prostate smooth and nontender with palpable median sulcus. (Or if female, uterine cervix nontender.) Stool brown; no fecal blood
*what is this?
normal
Perirectal area inflamed; no ulcerations, warts, or discharge. Unable to examine external sphincter, rectal vault, or prostate because of spasm of external sphincter and marked inflammation and tenderness of anal canal
prostitis
No perirectal lesions or fissures. External sphincter tone intact. Rectal vault without masses. Left lateral prostate lobe with 1 × 1 cm firm, hard nodule; right lateral lobe smooth; median sulcus obscured. Stool brown; no fecal blood
prostate CA
how is hep a transmitted
fecal-oral poor handwashing international travel sick contacts MSM homelessness illicit drug use shellfish
how is hep c transmitted
percutaneous exposures–needle sticks, IV drug users, blood transfusions b4 1992
how is hep B transmitted
sexual contacts, percutaneous, parenteral and perinatal
how to reduce tranmission for hep A
advice hand washing
clean surfaces with diluted bleach
when does CDC reccommend Hep A vaccination? (7)
> 1
indv with chronic liver disease
groups at incrs risk–travelers, MSM, IV drug users, ppl who work with non human primates, ppl with clotting disorder
a healthy PT is exposed to Hep A.. what is the next step
- Hep A vaccine
OR - single dose of immune globulin (>40) within 2 weeks of exposure
Immunocomp PT or Chronic liver Dz PT exposed to Hep A.. what to do next
HAV AND HAV immunoglobulin within 2 weeks of exposure
who is at risk for getting Hep B (6)
- born in countries with high endemic HBV infections
- person with HIV
- IV drug user
- MSM
- household contacts or sexual partners have HBV
- any kind of HC worker
which PT population ALWAYS gets Hep B screening
Pregnant–first tri
CDC reccomendations for Hep B vaccination (5)
- having sex with someone who has HBV, or person with many sexual partners
- ppl with percutanoues or mucosal exposure to blood
- travelers to endemic regions
- chornic liver dz
- HIV, correctional facilities,
Hep B scheduling for babies
birth
1-2 MO
6-18MO
Hep B scheduling for an adult w.o prior Hep B vaccine
3 doses total: 0, 1, 6 MO
Hep C becomes chronic illness in ___% of patients
75%
is there a vaccine for Hep C?
NO
prevention against Hep C?
avoic percutaneous exposures, blood exposures
who screening for Hep C?
high risk groups
all pregnant women (1st tri)
screen all adults 18-79 for chronic HCV infection
major RF for Hep C (3)
cirrhosis
hepatic CA
liver failure
RLQ pain or pain that migrates from the periumbilical region + abdominal wall rigidity on palpation
MC suggests?
-what also could it be suggestive of in a woman PT
appendicitis
WOMAN: PID, ruptured ovarian cyst, ectopic preg
cramping pain radiating to the right or LLQ or groin
renal stone
LLQ pain
+palpable mass
diverticulitis
diffuse abdominal pain with abdominal distention, hyperactive high pitched bowel sounds and tenderness on palpation
small or large bowel obstruction
pain with absent bowel sounds, rigidity, percussion tenderness and guarding
peritonitis
intermittent pain for 12 weeks with relief from defecation change in frequency of BMs or change in form of stool (loose, watery, pellet)
IBS
Regurgitation occurs with? (3)
GERD
esophageal stricture
esophageal CA
vomiting + pain can indicate?
SBO
fecal odor occurs with?
SBO and gastrocolic fistula
Hematemesis can occur with (3)
esophageal or gastric varices, Mallory-Weiss tears or PUD
abdominal pain, slight distended soft nontender abdomen and a fear of eating food bc it will hurt?
hallmark of mesenteric ischemia
fullness or early satiety (5)
diabetic gastroparesis antichoinergic meds gastric outlet obstruction gastric CA hepatits
drooling, nasopharyngeal regurgitation, cough from aspiration are indicators of?
oropharyngeal dysphagia
gurgling or regurgitation of undisgested food occurs in? (3)
GERD
motility disrodres
structural disroders (Zenkers diverticulum and esoph stricture)
PT points to where dysphagia occurs: below the sternoclavicular notch suggets?
Esophageal dysphagia
if solid food dysphagia consider?
structural causes: esoph stricutre, webing or Schatzki ring, neoplasm
if dysphagia to solid and liquid consider?
motility disorder like achalasia
flatus
causes?
define?
excessive gas
- aerophagia
- legumes
- intestinal lactase deficiency
- IBS
acute diarrhea MCC?
infectious
high volume, frequent and watery stools are coming from where in the colon?
small intestine
small volume stools with tenesmus
or
diarrhea with mucus pus or blood occur in?
rectal inflammatory conditions
diarrhea is comon with which drugs (4)
PNCs
macrolides
magnesium antacids
metformin
patient recently hospitalized + diarrhea.. consider what?
C Diff
list secondary caues of constipation (3)
amyloidosis
DM
CNS disorders
drugs tht cause constipation (4)
dz that cause it? (6)
anticholinergics
ccb
iron
opiates
dm hypothyroidism hypercalciemia MS PD systemic sclerosis
ostipation signifies?
obstruction
drugs that cause cholestasis (3)
OCPs
methyl testosterone
chlorpromazine
dark urine indicates?
impaired excretion of bilirubin into the GI tract
painless jaundice
malignant obstruction of bile ducts
painful jaundice
infectious in origin–hepatitis A and cholangitis
acholic stools
viral hep
obstrucitve jaundice***
pink tinged urine
myoglobin from rhabdo
protuberant abdomen that is tympanic thorughout suggests?
intestinal obstruction or paralytic ilius
dull areas on abdomen characterize?
pregnant uterus
ovarian tumor
distended bladder
large liver or spleen
dullness in both flanks suggests
ascities
air bubble on the right… liver dullness on left suggests?
sinus inversus
liver dullness is displaced downward by the low diaphragm if PT has what dz
COPD
*span stays normal
what can falsely increase liver size
dullness from a right pleural eff or consolidated lung if adjacent to the liver
what is a positive splenic percussion sign
change in percussion note from tympany to dullness on inspiration
causes of splenomegaly
portal HTN
hematologic malignancies
HIV
infiltrative dz–amyloidosis, splenic infarct or hematoma
enlarged left flank mass can be?
splenomegaly or an enlarged left kidney
palpating spleen area: palpable notch on medial border, the edge extends beyond the midline, percussion is dull and fingers can probe deep to the medial and lateral borders but not between the left flank mass and costal margin
splenomegaly
tympany in the LUQ + probe fingers b/w the mass and costal margin suggest
enlarged kidney
RF for AAA
> 65
smoking
male
first degree relative with hx of AAA
RUQ pain
-sharp increase in tenderness with inspiratory effort is a + ______ sign?
+ murphys sign
timing of GERD?
agrivating factors?
location of discomfrt
after meals esp spicy food
-lying down, bending over, exercise,
chest or epigastric
pain is whre for PUD
+radiation to?
epigastric
can radiatie to the baack
which ulcer is more likely to wake the PT in the night?
duodenal ulcer
which ulcer is more liley to occur intermittently over a few weeks and then disappers for months and then reappears
duodenal
persistent abdominal pain–slowly progressive–
Gastric carcinoma
pain in gastric carcinoma or PUD is shorter
gastric carcinoma
if pain subsides temporarily with acute appendiits.. what do you want to suspect?
perforation
where is the pain for small bowel obstruction vs large bowel obstruc
SBOO: periumbilical or upper abdom
LBO: lower abdmoinal or generlzed
time for acute diarrhea
<14 days
chronic diarrhea time
> 30 days
dz that cause melena (3)
BLACK TARRY STOOL
- GERD
- gastritis
- PUD
dz that cause hematochezia
BRIGHT RED BLOOD
- colon CA
- hyperplasia or adenomatous polyps
- diverticula of colon
- UC
- CD
- infectious diarr
- proctitis
- ischemic colitits
- hemorrhoids
- anal fissure
MCC of protuberant abdomen
fat
bulging flanks?
ascities
venous hum has both?
diastolic and systolic components
venous hum indicates
hepatic cirrhosis
