Abdominal, Gastrointestinal, and Urologic Assessment Flashcards
Where are the abdominal contents specifically located in the body?
inferior to the diaphragm and superior to the pelvic floor
What bony landmarks outline the inferior aspect of the abdomen?
Right and left iliac crests
pubic tubercle
What are the posterior bony structures overlying the abdomen?
The T10 spinal vertebrae and articulating ribs, and bilateral iliac crests
What are the innermost abdominal muscles?
internal obliques and transverse abdominas muscles
What are the external abdominal muscles?
external obliques and rectus abdominus
Why is it important to know the internal and external abdominal muscles?
To understand light and deep palpation techniques.
Why is it difficult to determine cause of abdominal pain?
Due to the nonspecific neuro recepters within the visceral cavity that are only sensitive to stretch and chemical irritation.
Common causes of abdominal pain
"nonspecific"- 43% of patients acute appendicitis- 4-20% acute cholecystitis- 3-9% small bowel obstruction- 4% gastroenteritis gastritis peptic ulcer disease reflux esophagitis GERD IBS diverticulitis
What is imperative to consider when assessing the origin of abdominal pain?
referred pain
What are the two general causes of abdominal pain?
functional and/or organic
What is the general nature of abdominal pain?
acute or chronic
What is the juncture that separates the esophagus from the stomach?
Lower esophageal sphincter (LES)
What marks the beginning of the duodenum?
pyloric sphincter
Where is the stomach located?
left upper abdomen
What is the term for digested food?
chyme
What is the primary function of the small intestine?
facilitation of further digestion and absorption of nutrients
What are the three segments of the small intestine?
duodenum, jejunum, and ileum
What is the most striking aspect of the small intestine?
Its length of 21 feet
What are the primary digestive actions that occur in the ileum?
absorption of vitamin b12 and bile salts
How many segments is the large intestine composed of?
Seven
What are the segments of the large intestine?
cecum, ascending colon, transverse colon, descending colon, sigmoid colon, rectum, and anus
What are the main functions of the large intestine?
To absorb water and electrolytes from the chyme and facilitate elimination of the residual, undigested food as feces.
Ileocecal valve
A sphincter muscle that prevents backflow of chyme from the cecum to the ileum.
What marks the beginning of the ascending colon?
Cecum
Where are 30% of cancerous tumors found in the colon?
Ascending colon
What are the accessory organs of the digestive system?
liver, gallbladder, pancreas
Where is the liver located?
RUQ
What are the main functional cells of the liver?
hepatocytes
What are three main functions of hepatocytes?
metabolic, endocrine, and secretory functions
All blood that leaves the ____ and ____ passes through and is processed by the ____.
stomach, intestines, liver
Key functions of the liver
metabolizing nutrients to produce energy for the body, bile production, immune factors, cholesterol, protein synthesis, breaking down toxins and bacteria, converting ammonia to urea, removing bilirubin, clotting factor regulation, hemoglobin processing to extract iron, amino acid regulation
About __% of bile secreted from the liver passes from the ___ ____ duct into the ____ via the ____ duct.
75, common hepatic, gallbladder, cystic
Function of bile
to promote emulsification of fats
Where is the pancreas located?
just below the stomach
What are the two main functions of the pancreas?
exocrine digestive enzyme secretion and endocrine hormone secretion
What is the primary function of the urologic system?
filter wastes, toxins, and foreign matter from the bloodstream
Where are the kidneys located?
Anterior to the 11th and 12th ribs at the costovertebral angle between T12 and L3 of the vertebral column. The left slightly higher than the right.
What is the main function of the spleen?
It is an immune system organ that filters the blood by removing old or damaged RBCs and platelets, stores breakdown products of RBCs and lymphocytes, and returns the RBC breakdown products to the bone marrow, stores blood that can be released in case of significant blood loss, and fights infections.
What are some age-related changes that occur within the urinary system?
decreased perfusion
reduced urine concentrating ability
decreased effectiveness of ADH
Red Flags of GI/GU systems
arthritis bilious emesis delayed puberty dysphagia hematuria, hematemesis hepatospleenomegaly nighttime pain or diarrhea oral ulcers perianal skin tags persistent RUQ or RLQ pain melena unintentional weight loss
List some differential diagnoses for abdominal pain
functional GI disorder, celiac disease, IBD, cholelithiasis, pancreatitis, gastritis, PUD, UTI pyelonephritis, appendicitis, SBO, hepatitis, AAA, GERD, reproductive disorder, diverticulitis
Questions for history of present illness of abdominal pain
Onset Location Quality Intensity Duration Associated symptoms Aggravating/Alleviating factors Attempted treatment
Medical history concerns for GI
chronic diseases food allergies abdominal surgeries growth/development recent illness/trauma CV disease mental health condition (eating disorder) H. Pylori
Family history concerns for GI
family history of GI disease CA autoimmune disorders cystic fibrosis migraines mental health disorders
Social history concerns for GI
impact on daily living family dynamic/environment socioeconomic factors stress emotional/behavioral symptoms recent travel exposure to lakes/streams animal or food contact smoking/tobacco substance abuse/alocohol abuse
Medical history concerns for GU
UTI/pyelonephritis incontinence recent vaginal childbirth obesity pelvic prolapse neurological disease dementia/confusion DM/HTN BPH mobility issues medications: diuretics, antibiotics hematuria
Family history concerns for GU
chronic diseases
obesity
renal/bladder CA
DM
Social history concerns for GU
caffeine intake sexual activity water/fluid intake impact on daily living family dynamic stressors smoking/etoh/substance abuse
In what ethnic group are gallstones and gallbladder CA more prevelant?
Mexican and Native Americans
In what ethnic group is gastric or stomach CA more prevelant?
Individuals from Japan, China, and Southern and Eastern Europe, and South and Central America
What is the appropriate order for the physical exam of the abdomen?
inspection
auscultation
percussion
palpation
What is a technique that helps lower the diaphragm and move abdominal organs downward?
Asking the patient to take a deep breath and hold it
Then asking the patient to raise their head from the exam table
What are Grey Turner’s sign and Cullen’s sign?
Flank ecchymosis and umbilical ecchymosis
Clues to abdominal hemorrhage, acute pancreatitis, or ectopic pregnancy
controversy regarding sensitivity and specificity
What is a sister Mary Joseph nodule?
An protruding deep purple umbilical nodule that often signifies malignancy or metastatic cancer
What does the majority of evidence recommend for assessing bowel sounds?
The majority of available evidence does not exist to recommend auscultating bowel sounds.
What should be auscultated on the abdomen?
Bruits over the aorta, iliac, renal, and femoral arteries
Friction rubs over the liver and spleen
What type of bruit is abnormal?
continuous across systole and diastole
What other type of sound is abnormal when auscultating abdominal sounds?
Friction rubs: may signify inflammation of the peritoneal surface from a mass or tumor
What is the purpose of percussing the abdomen?
to assess size, density, and location of abdominal organs and structures which can detect fluid or air in the abdomen
How is percussing performed?
by placing the distal joint and tip of the middle finger of the non dominant hand firmly on the area and using the middle finger of the dominant hand to strike the distal interphalangeal joint of the stationary finger on the area. Using short, quick motions.
Where is the liver typically percussed?
mid-clavicular line and fifth intercostal space
What is the typical liver span?
6-12 cm (2-5 inches)
Where is the spleen percussed?
posterior to the left mid-axillary line from the sixth to tenth rib (Traube’s space)
How is percussion of the kidneys performed and why?
By striking costovertebral angle using the ulnar surface of the fist or left hand to assess for pain/inflammation
What is the scratch test utilized for?
to detect liver size
How is the scratch test performed?
By placing a stethoscope on the xiphoid process while using a finger to scratch the abdominal surface. There will be a difference in sound transmission over solid and hollow organs.
Should you be able to palpate the gallbladder?
No
Is the spleen normally palpable?
Only in 3% of the population, otherwise the exam is considered abnormal, splenomegaly may be present
When should special tests for the abdomen be completed?
LAST
What does rebound tenderness indicate?
appendicitis
What is McBurney’s point?
pain with palpation of the RLQ which indicates appendicitis
What is Rovsings’s sign?
pain in the right iliac fossa with palpation of the left iliac fossa which often indicates appendicitis
What is Psoas test?
An indication of an inflammed appendix.
While the patient raises their right leg the provider pushes down on the knee causing irritation of the psoas muscle.
What is Murphy’s sign?
Indication of cholecystitis when the provider deeply palpates the RUQ.
What are some laboratory considerations for the GI and GU conditions?
Antibody tests to r/o celiac disease CBC with diff electrolytes LFTs hemoccult stool test ESR CRP CMP (liver function/IBS) AST/ALT/GGT (often elevated in acute hepatitis) amylase/lipase (pancreatitis)
When is a CT abdomen indicated?
when the amylase/lipase are not elevated and there is no certain diagnosis
At what age does the USPSTF recommend colorectal screening?
50-75 years of age
What are the most reliable methods for detecting hepatomegaly?
CT and MRI
What should be the first imaging test for a suspected appendicitis?
ultrasound in conjunction with scoring system
When should an abdominal aortic aneurysm be considered?
When abdominal pain is in the epigastric area
