Bates

Question 1

Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or lower esophageal sphincter action. Helicobacter pylori may be present.

Answer 1

process of Gastroesophageal reflux disease (GERD)

Question 2

location of Gastroesophageal reflux disease (GERD)

Answer 2

Chest or epigastric

Question 3

what does Gastroesophageal reflux disease (GERD) feel like

Answer 3

Burning (heartburn) Also regurgitation

Question 4

when does GERD occur

Answer 4

After meals, specifically fatty foods

Question 5

Lying down, bending over. Physical activity

Answer 5

aggravating factors of GERD

Question 6

What relieves gerd

Answer 6

Antacids; avoiding alcohol, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers

Question 7

associated symptoms with GERD

Answer 7

Wheezing, chronic cough, shortness of breath, hoarseness, choking sensation, halitosis, sore throat. Increases risk of Barrett’s esophagus and esophageal cancer

Question 8

Peptic Ulcer and Dyspepsia

Process

Location

Quality

Timing

Aggravating factors

Relieving factors

Associated symp

Answer 8

Process: Demonstrated ulcer usually in duodenum or stomach; dyspepsia causes similar symptoms but no ulceration. H. pylori infection often present.

Location: Epigastric, may radiate to the back

Quality: Variable: gnawing burning, boring, aching, pressing, or hungerlike

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 weeks, disappears for months, then recurs.

Aggravating factors: Variable

Relieving factors: Food and antacids may bring relief, least commonly in gastric ulcer.

Associated symp: 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 years), gastric ulcer in those over 50 years, and duodenal ulcer in those 30–60 years.

Question 9

Cancer of the Stomach

Process

Location

Quality

Timing

Aggravating factors

Relieving factors

Associated symp

Answer 9

Process: Predominantly adenocarcinoma (90%–95%)

Location: Increasingly in “cardia” and GE junction; also in distal stomach

Quality: Variable

Timing: The history of pain is typically shorter than in peptic ulcer. Pain is persistent, slowly progressive.

Aggravating factors: Often food

Relieving factors: Not relieved by food or antacids

Associated symp: Anorexia, nausea, early satiety, weight loss, and sometimes bleeding. Most common in ages 50–70

Question 10

Acute Appendicitis

Process

Location

Quality

Timing

Aggravating factors

Relieving factors

Associated symp

Answer 10

Process: Acute inflammation of the appendix with distention or obstruction OR Right lower quadrant pain

Location: Poorly localized periumbilical pain, followed usually by OR Right lower quadrant pain

Quality: Mild but increasing, possibly cramping OR Steady and more severe

Timing: Lasts roughly 4–6 hours OR Depends on intervention

Aggravating factors: Movement or cough

Relieving factors: If it subsides temporarily, suspect perforation of the appendix.

Associated symp: Anorexia, nausea, possibly vomiting, which typically follow the onset of pain; low fever

Question 11

Acute Cholecystitis

Process

Location

Quality

Timing

Aggravating factors

Associated symp

Answer 11

Process: Inflammation of the gallbladder, usually from obstruction of the cystic duct by gallstone

Location: Right upper quadrant or upper abdominal; may radiate to the right scapular area

Quality: Steady, aching

Timing: Gradual onset; course longer than in biliary colic

Aggravating factors: Jarring, deep breathing

Associated symp: Anorexia, nausea, vomiting, fever

Question 12

Biliary Colic

Process

Location

Quality

Timing

Associated symp

Answer 12

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

Timing: Rapid onset over a few minutes, lasts one to several hours and subsides gradually. Often recurrent

Associated symp: Anorexia, nausea, vomiting, restlessness

Question 13

Acute Pancreatitis

Process Location Quality Timing Aggravating factors Relieving factors Associated symp

Answer 13

Process: Acute inflammation of the pancreas

Location: Epigastric, may radiate to the back or other parts of the abdomen; may be poorly localized

Quality: Usually steady

Timing: Acute onset, persistent pain

Aggravating factors: Lying supine

Relieving factors: Leaning forward with trunk flexed

Associated symp: Nausea, vomiting, abdominal distention, fever. Often a history of previous attacks and alcohol abuse or gallstones

Question 14

Chronic Pancreatitis

Process Location Quality Timing Aggravating factors Relieving factors Associated symp

Answer 14

Process: Fibrosis of the pancreas secondary to recurrent inflammation

Location: Epigastric, radiating through to the back

Quality: Steady, deep

Timing: Chronic or recurrent course

Aggravating factors: Alcohol, heavy or fatty meals

Relieving factors: Possibly leaning forward with trunk flexed; often intractable

Associated symp: Pancreatic enzyme insufficiency, diarrhea with fatty stools (steatorrhea) and diabetes mellitus.

Question 15

Acute Diverticulitis

Process Location Quality Timing Associated symp

Answer 15

Process: Acute inflammation of a colonic diverticulum, a saclike mucosal outpouching through the colonic muscle

Location: Left lower quadrant

Quality: May be cramping at first, but becomes steady

Timing: Often a gradual onset

Associated symp: Fever, constipation. There may be initial brief diarrhea.

Question 16

Cancer of the Pancreas

Process

Location

Quality

Timing

Relieving factors

Associated symp

Answer 16

Process: Predominantly adenocarcinoma (95%)

Location: Epigastric and in either upper quadrant; often radiates to the back

Quality: Steady, deep

Timing: Persistent pain; relentlessly progressive illness

Relieving factors: Possibly leaning forward with trunk flexed; often intractable

Associated symp: Anorexia, nausea, vomiting, weight loss, and jaundice; depression

Question 17

Acute Bowel Obstruction process

Answer 17

Obstruction of the bowel lumen, most commonly caused by (1) adhesions or hernias (small bowel), or (2) cancer or diverticulitis (colon)

Question 18

acute Bowel obstruction

SMALL BOWEL

Location

Quality

Timing

Associated symp

Answer 18

Location: Small bowel: periumbilical or upper abdominal

Quality: Cramping

Timing: Paroxysmal; may decrease as bowel mobility is impaired

Associated symp: Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction). Obstipation develops.

Question 19

acute Bowel obstruction

COLON

Location

Quality

Timing

Associated symp

Answer 19

Location: Colon: lower abdominal or generalized

Quality: Cramping

Timing: Paroxysmal, though typically milder

Associated symp: Obstipation early. Vomiting late if at all. Prior symptoms of underlying cause.

Question 20

Mesenteric Ischemia

Process

Location

Quality

Timing

Associated symp

Answer 20

Process: Blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion), or reduced from hypoperfusion

Location: May be periumbilical at first, then diffuse

Quality: Cramping at first, then steady

Timing: Usually abrupt in onset, then persistent

Associated symp: Vomiting, diarrhea (sometimes bloody), constipation, shock; older age

Question 21

Oropharyngeal Dysphagia,

due to motor disorders affecting the pharyngeal muscles

Timing

Factors that aggravate

Associated symptoms and conditions

Answer 21

Timing: Acute or gradual onset and a variable course, depending on the underlying disorder

Factors that aggravate: Attempts to start the swallowing process

Associated symptoms and conditions: Aspiration into the lungs or regurgitation into the nose with attempts to swallow. From stroke, bulbar palsy, or other neuromuscular conditions

Question 22

Esophageal Dysphagia what are the mechanical narrowing issues (3)

Answer 22

Mucosal rings and webs Esophageal stricture Esophageal cancer

Question 23

Mucosal rings and webs

timing

aggravating factors

relieving factors associated symp/conditions

Answer 23

timing : Intermittent

aggravating factors: Solid foods

relieving factors: Regurgitation of the bolus of food

associated symp/conditions: none

Question 24

Esophageal stricture

timing

aggravating factors

relieving factors

associated symp/conditions

Answer 24

timing : Intermittent; may become slowly progressive

aggravating factors: solid foods

relieving factors: Regurgitation of the bolus of food

associated symp/conditions: A long history of heartburn and regurgitation

Question 25

Esophageal cancer timing aggravating factors relieving factors associated symp/conditions

Answer 25

timing : May be intermittent at first; progressive over months aggravating factors: Solid foods, with progression to liquids relieving factors: Regurgitation of the bolus of food associated symp/conditions: Pain in the chest and back and weight loss, especially late in the course of illness

Question 26

Esophageal Dysphagia what are the motor disorders (3)

Answer 26

Diffuse esophageal spasm Scleroderma Achalasia

Question 27

Scleroderma timing aggravating factors relieving factors associated symp/conditions

Answer 27

timing : Intermittent; may progress slowly aggravating factors: Solids or liquids relieving factors: Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis) associated symp/conditions: Heartburn; other manifestations of scleroderma Regurgitation, often at night when lying down, with nocturnal cough; possibly chest pain precipitated by eating

Question 28

Achalasia timing aggravating factors relieving factors associated symp/conditions

Answer 28

timing : Intermittent; may progress aggravating factors: Solids or liquids relieving factors: Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis) associated symp/conditions: Heartburn; other manifestations of scleroderma Regurgitation, often at night when lying down, with nocturnal cough; possibly chest pain precipitated by eating

Question 29

Diffuse esophageal spasm timing aggravating factors relieving factors associated symp/conditions

Answer 29

timing : Intermittent aggravating factors: Solids or liquids relieving factors: sometimes nitrogylcerin. Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis) associated symp/conditions: Chest pain that mimics angina pectoris or myocardial infarction and lasts minutes to hours; possibly heartburn

Question 30

constipation can happen from what 2 types of things

Answer 30

life activities and habits mechanical obstruction

Question 31

life activities and habits Irritable Bowel Syndrome process associated symp. and setting

Answer 31

process: Functional change in frequency or form of bowel movement without known pathology; possibly from change in intestinal bacteria. associated symp. and setting: Three patterns: diarrhea—predominant, constipation—predominant, or mixed. Symptoms present ≥6 months and abdominal pain for ≥3 months plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance)

Question 32

life activities and habits Inadequate Time or Setting for the Defecation Reflex process associated symp. and setting

Answer 32

process: Ignoring the sensation of a full rectum inhibits the defecation reflex. associated symp. and setting: Hectic schedules, unfamiliar surroundings, bed rest

Question 33

life activities and habits False Expectations of Bowel Habits process associated symp. and setting

Answer 33

process: Expectations of “regularity” or more frequent stools than a person’s norm associated symp. and setting: Beliefs, treatments, and advertisements that promote the use of laxatives

Question 34

life activities and habits Diet Deficient in Fiber process associated symp. and setting

Answer 34

process: Decreased fecal bulk associated symp. and setting: Other factors such as debilitation and constipating drugs may contribute.

Question 35

Mechanical obstruction Cancer of the Rectum or Sigmoid Colon process associated symp. and setting

Answer 35

process: Progressive narrowing of the bowel lumen from adenocarcinoma associated symp. and setting: Change in bowel habits; often diarrhea, abdominal pain, bleeding, occult blood in stool. In rectal cancer, tenesmus and pencil-shaped stools. Weight loss.

Question 36

Mechanical obstruction Fecal Impaction process associated symp. and setting

Answer 36

process: A large, firm, immovable fecal mass, most often in the rectum associated symp. and setting: Rectal fullness, abdominal pain, and diarrhea around the impaction; common in debilitated, bedridden, and often elderly patients

Question 37

Mechanical obstruction Other Obstructing Lesions (such as diverticulitis, volvulus, intussusception, or hernia) process associated symp. and setting

Answer 37

process: Narrowing or complete obstruction of the bowel associated symp. and setting: Colicky abdominal pain, abdominal distention, and in intussusception, often “currant jelly” stools (red blood and mucus)

Question 38

Mechanical obstruction Painful Anal Lesions process associated symp. and setting

Answer 38

process: Pain may cause spasm of the external sphincter and voluntary inhibition of the defecation reflex. associated symp. and setting: Anal fissures, painful hemorrhoids, perirectal abscesses

Question 39

Mechanical obstruction Drugs process associated symp. and setting

Answer 39

process: A variety of mechanisms associated symp. and setting: Opiates, anticholinergics, antacids containing calcium or aluminum, and many others

Question 40

Mechanical obstruction Depression process associated symp. and setting

Answer 40

process: A disorder of mood. associated symp. and setting: Fatigue, anhedonia, sleep disturbance, weight loss

Question 41

Mechanical obstruction Neurologic Disorders process associated symp. and setting

Answer 41

process: Interference with the autonomic innervation of the bowel associated symp. and setting: Spinal cord injuries, multiple sclerosis, Hirschsprung’s disease, and other conditions

Question 42

Mechanical obstruction Metabolic Conditions process associated symp. and setting

Answer 42

process: Interference with bowel motility associated symp. and setting: Pregnancy, hypothyroidism, hypercalcemia

Question 43

less then how many days to be considered acute diarrhea?

Answer 43

≤14 days

Question 44

what are the three kinds of acute diarrhea

Answer 44

Secretory Infection (non-inflammatory) Inflammatory Infection Drug-Induced Diarrhea

Question 45

Secretory Infection (non-inflammatory) process characteristics of stool timing associated symp. setting, persons at risk

Answer 45

process: Infection by viruses, preformed bacterial toxins (such as S. aureus, B. cereus, C. perfringens, toxigenic E. coli, Vibrio cholerae), cryptosporidium, Giardia lamblia, rotavirus characteristics of stool: Watery, without blood, pus, or mucus timing: Duration of a few days, possibly longer. Lactase deficiency may lead to a longer course. associated symp.: Nausea, vomiting, periumbilical cramping pain. Temperature normal or slightly elevated setting, persons at risk: Often travel, a common food source, or an epidemic

Question 46

Inflammatory Infection process characteristics of stool timing associated symp. setting, persons at risk

Answer 46

process: Colonization or invasion of intestinal mucosa (nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica, C. difficile) characteristics of stool: Loose to watery, often with blood, pus, or mucus timing: An acute illness of varying duration associated symp.: Lower abdominal cramping pain and often rectal urgency, tenesmus; fever setting, persons at risk: Travel, contaminated food or water. Frequent anal intercourse.

Question 47

Drug-Induced Diarrhea process characteristics of stool timing associated symp. setting, persons at risk

Answer 47

process: Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives characteristics of stool timing: Loose to watery timing.: Acute, recurrent, or chronic Associated symp: Possibly nausea; usually little if any pain setting, persons at risk: Prescribed or over-the-counter medications

Question 48

how many days to be considered chronic diarrhea?

Answer 48

≥30 days

Question 49

3 types of chronic diarrhea

Answer 49

1. diarrheal syndrome 2. Inflammatory Bowel Disease 3. voluminous Diarrhea (osmotic/secretory diarrhea)

Question 50

diarrheal syndrome Irritable bowel syndrome process characteristics of stool timing associated symp. setting, persons at risk

Answer 50

process: Change in frequency and form of bowel movements without chemical or structural abnormality characteristics of stool: Loose; ~50% with mucus; small to moderate volume. Small, hard stools with constipation. May be mixed pattern. timing: Worse in the morning; rarely at night. associated symp.: Crampy lower abdominal pain, abdominal distention, flatulence, nausea. Urgency, pain relieved with defecation. setting, persons at risk: Young and middle-aged adults, especially women

Question 51

diarrheal syndrome Cancer of the sigmoid colon process characteristics of stool timing associated symp. setting, persons at risk

Answer 51

process:Partial obstruction by a malignant neoplasm characteristics of stool: May be blood-streaked timing: Variable associated symp.: Change in usual bowel habits, crampy lower abdominal pain, constipation setting, persons at risk: Middle-aged and older adults, especially older than 55 years

Question 52

Inflammatory Bowel Disease Ulcerative colitis process characteristics of stool timing associated symp. setting, persons at risk

Answer 52

process: Inflammation of the mucosa and submucosa of the rectum and colon with ulceration; typically extends proximally from the rectum characteristics of stool: Soft to watery, often containing blood timing: Onset ranges from insidious to acute. Typically recurrent; may be persistent. May awaken at night. associated symp.: Milder cramping, lower or generalized abdominal pain, anorexia, weakness; fever if severe. May include episcleritis, uveitis, arthritis, erythema nodosum. setting, persons at risk: Often young people. Increases risk of colon cancer.

Question 53

Inflammatory Bowel Disease Crohn’s disease of the small bowel (regional enteritis) or colon (granulomatous colitis) process characteristics of stool timing associated symp. setting, persons at risk

Answer 53

process: Chronic transmural inflammation of the bowel wall, in a skip pattern typically involving the terminal ileum and/or proximal colon characteristics of stool: Small, soft to loose or watery, usually free of gross blood (enteritis) or with less bleeding than ulcerative colitis (colitis) timing: Insidious onset; chronic or recurrent. Diarrhea may wake the patient at night. associated symp.: Crampy periumbilical or right lower quadrant (enteritis) or diffuse (colitis) pain, with anorexia, low fever, and/or weight loss. Perianal or perirectal abscesses and fistulas. May cause small or large bowel obstruction setting, persons at risk: Often young people, especially in late teens, but also in middle age. More common in people of Jewish descent. Increases risk of colon cancer

Question 54

Voluminous Diarrhea Malabsorption syndrome process characteristics of stool timing associated symp. setting, persons at risk

Answer 54

process: Defective membrane transport or absorption of intestinal epithelium (Crohn’s, 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 timing: Onset of illness typically insidious associated symp.: 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, persons at risk: Variable, depending on cause

Question 55

Voluminous Diarrhea - osmotic diarrhea Lactose intolerance process characteristics of stool timing associated symp. setting, persons at risk

Answer 55

process: Deficiency in intestinal lactase characteristics of stool: Watery diarrhea of large volume timing: Follows the ingestion of milk and milk products; relieved by fasting associated symp.: Crampy abdominal pain, abdominal distention, flatulence setting, persons at risk: In \>50% of African Americans, Asians, Native Americans, Hispanics; in 5%–20% of Caucasians

Question 56

Voluminous Diarrhea - osmotic diarrhea Abuse of osmotic purgatives process characteristics of stool timing associated symp. setting, persons at risk

Answer 56

process: Laxative habit, often surreptitious characteristics of stool: Watery diarrhea of large volume timing: Variable associated symp.: Often none setting, persons at risk:Persons with anorexia nervosa or bulimia nervosa

Question 57

Voluminous Diarrhea Secretory diarrhea process characteristics of stool timing associated symp. setting, persons at risk

Answer 57

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 symp.: Weight loss, dehydration, nausea, vomiting, and cramping abdominal pain setting, persons at risk: Variable depending on cause

Question 58

Refers to passage of black, tarry (sticky and shiny) stools. Occult blood tests are positive. Involves loss of at least 60 mL of blood into the gastrointestinal tract (less in children), usually from the esophagus, stomach, or duodenum and transit time of 7–14 hours. Less commonly, when transit is slow, blood loss originates in the jejunum, ileum, or ascending colon. In infants, melena may result from swallowing blood during the birth.

Answer 58

Melena

Question 59

selected causes of Melena (4)

Answer 59

1. Gastritis, GERD, peptic ulcer (gastric or duodenal) 2. Gastritis or stress ulcers 3. Esophageal or gastric varices 4. Reflux esophagitis Mallory-Weiss tear in esophageal mucosa due to retching and vomiting

Question 60

Usually epigastric discomfort from heartburn, dysmotility; if peptic ulcer, pain after meals (delayed, 2–3 hours if duodenal ulcer). May be silent.

Answer 60

Gastritis, GERD, peptic ulcer (gastric or duodenal)

Question 61

Recent ingestion of alcohol, aspirin, or other anti-inflammatory drugs; recent bodily trauma, severe burns, surgery, or increased intracranial pressure

Answer 61

Gastritis or stress ulcers

Question 62

Cirrhosis of the liver or other causes of portal hypertension

Answer 62

Esophageal or gastric varices

Question 63

Retching, vomiting, often recent ingestion of alcohol

Answer 63

Reflux esophagitis Mallory-Weiss tear in esophageal mucosa due to retching and vomiting

Question 64

May result from other causes, with negative occult blood tests. These stools have no pathologic significance.

Answer 64

Black, Nonsticky Stools

Question 65

causes of Black, Nonsticky Stools

Answer 65

Ingestion of iron, bismuth salts, licorice, or even chocolate cookies

Question 66

Usually originates in the colon, rectum, or anus; much less frequently from the jejunum or ileum. Upper gastrointestinal hemorrhage may also cause red stools; blood loss is then usually large (more than a liter). Rapid transit through the intestinal tract leaves insufficient time for the blood to turn black from oxidation of iron in hemoglobin.

Answer 66

Red Blood in the Stools (hematochezia)

Question 67

causes of Red Blood in the Stools (hematochezia)

Answer 67

1. Colon cancer 2. Hyperplasia or adenomatous polyps 3. Diverticula of the colon 4. Inflammatory conditions of the colon and rectum a. Ulcerative colitis, Crohn’s disease b. Infectious diarrhea c. Proctitis (various causes including frequent anal intercourse) 5. Ischemic colitis 6. Hemorrhoids 7. Anal fissure

Question 68

Often a change in bowel habits, weight loss

Answer 68

Colon cancer

Question 69

Often no symptoms unless inflammation causes diverticulitis

Answer 69

Diverticula of the colon

Question 70

Rectal urgency, tenesmus

Answer 70

Proctitis (various causes including frequent anal intercourse)

Question 71

Lower abdominal pain, sometimes fever or shock in older adults. Abdomen typically soft to palpation

Answer 71

Ischemic colitis

Question 72

Blood on the toilet paper, on the surface of the stool, or dripping into the toilet

Answer 72

Hemorrhoids

Question 73

Blood on the toilet paper or on the surface of the stool; anal pain

Answer 73

Anal fissure

Question 74

Ingestion of beets causes

Answer 74

Reddish but Nonbloody Stools

Question 75

Pink urine, which usually precedes the reddish stool; from poor metabolism of betacyanin

Answer 75

Ingestion of beets

Question 76

Localized bulges in the abdominal wall include

Answer 76

ventral hernias (defects in the wall through which tissue protrudes) and subcutaneous tumors such as lipomas. The more common ventral hernias are umbilical, incisional, and epigastric. Hernias and a rectus diastasis usually become more evident when the patient raises head and shoulders from a supine position.

Question 77

2 local bulges in abdominal wall of infant

Answer 77

1. Umbilical Hernia 2. Diastasis Recti

Question 78

A protrusion through a defective umbilical ring is most common in infants but also occurs in adults. In infants, it usually closes spontaneously within 1 to 2 years.

Answer 78

Umbilical Hernia

Question 79

Separation of the two rectus abdominis muscles, through which abdominal contents form a midline ridge when the patient raises head and shoulders. Often seen in repeated pregnancies, obesity, and chronic lung disease. It has no clinical consequences.

Answer 79

Diastasis Recti

Question 80

This is a protrusion through an operative scar. Palpate to detect the length and width of the defect in the abdominal wall. A small defect, through which a large hernia has passed, has a greater risk for complications than a large defect.

Answer 80

Incisional Hernia

Question 81

A small midline protrusion through a defect in the linea alba occurs between the xiphoid process and the umbilicus. With the patient’s head and shoulders raised (or with the patient standing), run your fingerpad down the linea alba to feel it.

Answer 81

Epigastric Hernia

Question 82

Common, benign, fatty tumors usually in the subcutaneous tissues almost anywhere in the body, including the abdominal wall. Small or large, they are usually soft and often lobulated. Press your finger down on the edge of a lipoma. The tumor typically slips out from under it.

Answer 82

Lipoma

Question 83

Protuberant Abdomens causes (5)

Answer 83

1. Fat 2. Gas 3. Tumor 4. Pregnancy 5. Ascitic Fluid

Question 84

is the most common cause of a protuberant abdomen. thickens the abdominal wall, the mesentery, and omentum. The umbilicus may appear sunken. A pannus, or apron of fatty tissue, may extend below the inguinal ligaments. Lift it to look for inflammation in the skin folds or even for a hidden hernia.

Answer 84

Fat

Question 85

\_\_\_\_\_ distention may be localized or generalized. It causes a tympanitic percussion note. Increased production from certain foods may cause mild distention. More serious are intestinal obstruction and adynamic (paralytic) ileus. Note the location of the distention. Distention becomes more marked in colonic than in small bowel obstruction.

Answer 85

Gas

Question 86

A large, solid \_\_\_\_\_\_\_, usually rising out of the pelvis, is dull to percussion. Air-filled bowel is displaced to the periphery. Causes include ovarian tumors and uterine myomata. Occasionally a markedly distended bladder may be mistaken for such a tumor.

Answer 86

Tumor

Question 87

is a common cause of a pelvic “mass.” Listen for the fetal heart

Answer 87

Pregnancy

Question 88

seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness)

Answer 88

Ascitic Fluid

Question 89

Bowel Sounds Bowel sounds may be: Increased:

Answer 89

as in diarrhea or early intestinal obstruction

Question 90

Bowel Sounds Bowel sounds may be: decreased:

Answer 90

Decreased, then absent, as in adynamic ileus and peritonitis. Before deciding that bowel sounds are absent, sit down and listen where shown for 2 minutes or even longer.

Question 91

High-pitched tinkling sounds suggest

Answer 91

intestinal fluid and air under tension in a dilated bowel

Question 92

Rushes of high-pitched sounds coinciding with an abdominal cramp indicate

Answer 92

intestinal obstruction.

Question 93

suggests carcinoma of the liver or alcoholic hepatitis.

Answer 93

hepatic bruit

Question 94

with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries.

Answer 94

Arterial bruits

Question 95

Partial occlusion of a renal artery may explain

Answer 95

hypertension

Question 96

is rare. It is a soft humming noise with both systolic and diastolic components. It indicates increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis.

Answer 96

Venous Hum

Question 97

are rare. They are grating sounds with respiratory variation. They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct.

Answer 97

Friction Rubs

Question 98

When a systolic bruit accompanies a hepatic friction rub, suspect

Answer 98

carcinoma of the liver.

Question 99

2 Types of Tender Abdomens

Answer 99

1. abdominal wall tenderness 2. Visceral Tenderness

Question 100

When the patient raises the head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion (protected by the tightened muscles) decreases.

Answer 100

Abdominal wall Tenderness

Question 101

The structures (enlarges liver, normal aorta, normal cecum, normal or spastic sigmoid colon) may be tender to deep palpation. Usually the discomfort is dull with no muscular rigidity or rebound tenderness. A reassuring explanation to the patient may prove quite helpful.

Answer 101

Visceral Tenderness

Question 102

Tenderness From Disease in the Chest and Pelvis 2 types

Answer 102

1. Acute Pleurisy 2. Acute Salpingitis

Question 103

Abdominal pain and tenderness may result from acute pleural inflammation. When unilateral, it may mimic acute cholecystitis or appendicitis. Rebound tenderness and rigidity are less common; chest signs are usually present.

Answer 103

Acute Pleurisy

Question 104

Frequently bilateral, the tenderness of ____________ (inflammation of the fallopian tubes) is usually maximal just above the inguinal ligaments. Rebound tenderness and rigidity may be present. On pelvic examination, motion of the uterus causes pain.

Answer 104

Acute Salpingitis

Question 105

is more severe than visceral tenderness. Muscular rigidity and rebound tenderness are frequently but not necessarily present. Generalized peritonitis causes exquisite tenderness throughout the abdomen, together with boardlike muscular rigidity. These signs on palpation, especially abdominal rigidity, double the likelihood of peritonitis

Answer 105

Tenderness of Peritoneal Inflammation

Question 106

Local causes of peritoneal inflammation include:

Answer 106

1. Acute Cholecystitis 2. Acute Pancreatitis 3. Acute Appendicitis 4. Acute Diverticulitis

Question 107

Signs are maximal in the right upper quadrant. Check for Murphy’s sign

Answer 107

Acute Cholecystitis

Question 108

epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft.

Answer 108

Acute Pancreatitis

Question 109

Right lower quadrant signs are typical of acute appendicitis but may be absent early in the course (McBurney’s point). Explore other portions of the right lower quadrant as well as the right flank.

Answer 109

Acute Appendicitis

Question 110

most often involves the sigmoid colon and then resembles a left-sided appendicitis.

Answer 110

Acute Diverticulitis

Question 111

T OR F A palpable liver does not necessarily indicate hepatomegaly (an enlarged liver), but more often results from a change in consistency—from the normal softness to an abnormal firmness or hardness, as in cirrhosis.

Answer 111

TRUE

Question 112

Clinical estimates of liver size should be based on both ______ AND _______ although even these techniques are far from perfect

Answer 112

percussion and palpation

Question 113

This finding is common when the diaphragm is low (e.g., in COPD). The liver edge may be palpable well below the costal margin. Percussion, however, reveals a low upper edge, and the vertical span of the liver is normal.

Answer 113

Downward Displacement of the Liver by a Low Diaphragm

Question 114

In some people, especially those with a lanky build, the liver tends to be elongated so that its right lobe is easily palpable as it projects downward toward the iliac crest. Such an elongation, sometimes called Riedel’s lobe, represents a variation in shape, not an increase in liver volume or size. Examiners can only estimate the upper and lower borders of an organ with three dimensions and differing shapes. Some error is unavoidable.

Answer 114

Normal Variations in Liver Shape

Question 115

Cirrhosis may produce an enlarged liver with a firm, nontender edge. The cirrhotic liver may also be scarred and contracted. Many other diseases may produce similar findings such as hemochromatosis, amyloidosis, and lymphoma. An enlarged liver with a ________ tender edge suggests inflammation, as in hepatitis, or venous congestion, as in right-sided heart failure.

Answer 115

Smooth Large Liver blank line is: SMOOTH

Question 116

An enlarged liver that is firm or hard and has an ______ edge or surface suggests hepatocellular carcinoma. There may be one or more nodules. The liver may or may not be tender.

Answer 116

Irregular Large Liver blank line is: IRREGULAR

Question 117

Screening for colorectal cancer assess risk:

Answer 117

Begin screening at age 20 years. If high risk, refer for more complex management. If average risk at age 50 (high-risk conditions absent), offer the screening options listed in the next cards

Question 118

Personal history of colorectal cancer or adenoma First-degree relative with colorectal cancer or adenomatous polyps Personal history of breast, ovarian, or endometrial cancer Personal history of ulcerative or Crohn’s colitis

Answer 118

Common high-risk conditions (25% of colorectal cancers)

Question 119

Familial adenomatous polyposis Hereditary nonpolyposis colorectal cancer

Answer 119

Hereditary high-risk conditions (6% of colorectal cancers)

Question 120

COLORECTAL CANCER Screening recommendations—U.S. Preventive Services Task Force 2008 Adults age 50 to 75 years—options:

Answer 120

High-sensitivity fecal occult blood testing (FOBT) annually Sigmoidoscopy every 5 years with FOBT every 3 years Screening colonoscopy every 10 years

Question 121

COLORECTAL CANCER Screening recommendations—U.S. Preventive Services Task Force 2008 Adults age 76 to 85 years

Answer 121

do not screen routinely, as gain in life-years is small compared to colonoscopy risks, and screening benefits not seen for 7 years; use individual decision making if screening for the first time

Question 122

COLORECTAL CANCER Screening recommendations—U.S. Preventive Services Task Force 2008 Adults older than age 85

Answer 122

do not screen, as “competing causes of mortality preclude a mortality benefit that outweighs harms”

Question 123

third most common cancer in both men and women, and it causes almost 10% of deaths from cancer.

Answer 123

Colorectal cancer

Question 124

More than \_\_\_\_\_\_% of cases occur after age 50, primarily from neoplastic changes in adenomatous polyps; only about a third of cases have identifiable high-risk factors.

Answer 124

90%

Question 125

Incidence rates are \_\_\_\_\_\_\_\_\_\_\_, except in adults younger than 50 years who fall outside the current age threshold for screening.

Answer 125

decreasing

Question 126

mortality rates in ____________ are double those of other ethnic groups.

Answer 126

african americans

Question 127

order of abdomen exam

Answer 127

1. inspection 2. Auscultation 3. Percussion 4. Palpation (light then deep)

Question 128

increased peristaltic waves

Answer 128

intestinal obstruction

Question 129

bruits suggest

Answer 129

vascular occlusion

Question 130

Bruits with both systolic and diastolic components suggest

Answer 130

the turbulent blood flow from atherosclerotic arterial disease.

Question 131

A protuberant abdomen that is tympanitic throughout suggests

Answer 131

intestinal obstruction

Question 132

Dull areas can indicate

Answer 132

a pregnant uterus, an ovarian tumor, a distended bladder, or a large liver or spleen.

Question 133

Dullness in both flanks prompts further assessment for

Answer 133

ascites

Question 134

rare condition organs are reversed—air bubble on the right, liver dullness on the left.

Answer 134

Situs inversus

Question 135

Involuntary rigidity (muscular spasm) typically persists despite these maneuvers, suggesting

Answer 135

Peritoneal inflammation

Question 136

Abdominal masses may be categorized in several ways: (5)

Answer 136

1. physiologic (pregnant uterus) 2. inflammatory (diverticulitis of the colon) 3. vascular (an abdominal aortic aneurysm) 4. neoplastic (colon cancer) 5. obstructive (a distended bladder or dilated loop of bowel) .

Question 137

is twice as likely in the presence of guarding, Rosving’s sign, and the psoas sign; it is three times more likely if rigidity and McBurney’s point tenderness are present

Answer 137

Appendicitis

Question 138

begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it. Older patients report this pattern less frequently than younger ones.

Answer 138

Appendicitis

Question 139

Localized tenderness anywhere in the right lower quadrant, even in the right flank, may indicate

Answer 139

appendicitis

Question 140

Pain in the right lower quadrant during left-sided pressure is a positive

Answer 140

Rovsing’s sign.

Question 141

Increased abdominal pain on either maneuver constitutes a positive \_\_\_\_\_\_\_\_\_, suggesting irritation of the psoas muscle by an inflamed appendix.

Answer 141

psoas sign

Question 142

Right hypogastric pain constitutes a positive \_\_\_\_\_\_\_\_\_, from irritation of the obturator muscle by an inflamed appendix.

Answer 142

obturator sign

Question 143

A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive ___________ of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.

Answer 143

Murphy’s sign