Clinical Features Flashcards by Kristin Shaw

bulge in the groin that may be tender to palpate but generally has no pain
heavy/discomfort in groin
slight pelvic pain in women
worst at end of day/ prolonged sitting
radiating twinge of pain with sitting/standing

Groin hernia

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bulge in the groin that may be tender to palpate but generally has no pain
can be moved in and out
asymptomatic

Reducable groin hernia

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bulge in the groin
+/- N/V, pain, block
tenderness, bowels may not move due to obstruction
fever

Incarcaerated groin hernia

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bulge in groin
painful
+/- N/V, pain, block
ischemia–> pain out of proportion

Strangulated groin hernia

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swelling lateral to the rectus muscle

- pain is dull/ constant

Spigelian hernia

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local inflammation initially

- overtime ischemia, gangrene, perforation

Richter’s Hernia

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bowels and intestine protrude out of stoma
skin is clean and normal looking
patient comfortable

Parastomal hernia

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Asymptomatic
painless bleeding; bright red blood per rectum
anal pruritis
prolapse
pain due to thrombosis

Hemorrhoids

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sudden onset of severe pain and swelling
fluctuant mass that feels like fluid inside
fever
cellulitis possible

Rectal abscess

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pain
purulent drainage
perirectal skin lesion

rectal fistula

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straining
lumpy hard stools
sensation of incomplete evacuation
use of digital maneuvers
sensation of anorectal obstruction/ blockage
decreased frequency
abdominal discomfort or pain
abdominal distention
nausea

constipation

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Hematochezia
obstructive symptoms
acute onset of constipation
severe persistent constipation that is unresponsive to tx
weight loss more than 10 pounds
change in stool caliber- pencil thin stool
family hx of colon cancer or IBD

alarming sx of constipation

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abdominal cramping & bloating
leakage of liquid or sudden episodes of watery diarrhea when normally constipated
rectal bleeding
small, semi-formed stools
straining when trying to pass stools
bladder pressure/ loss of control
lower back pain
fluid leaks out but no evacuation of bowels
pressure on bladder and urethra–> can’t void

fecal impact

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painless cyst or sinus opening at the top of the natal cleft
acute abscess can form
chronic cyst can form

pilonidal disease

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sudden onset of severe pain and swelling
acutely inflamed and fluctuant mass overlying the sacrum or coccyx
fever if cellulitis

pilonidal disease with acute abscess

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painless cyst or sinus opening at the top of the natal cleft
persistent drainage from a sinus track connected to the cyst
mucoid/ purulent material

pilonidal disease with cyst

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crampy abdominal pain
nausea
vomit a lot and feel better afterwards
no passage of flatus/ stool
more belching/hiccups
abdominal distention
abdominal tenderness

SBO

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vomit
abdomen distended
not passing gas
Xray/CT show the whole bowel is dilated without a transition pt

ileus

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Crampy abdominal pain
N/V
low grade fever
anorexia
malaise

appendicitis

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abdominal distention and acute/chronic diarrhea
radiographic evidence of colonic distention
3 of the following: fever over 38C, HR over 120, WBC over 10,500, anemia
1 of the following: dehydration, altered sensorium, electrolyte disturbances, hypotension

toxic megacolon

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rapid onset of severe, unrelenting periumbilical pain
patient is writhing on bed, screaming in agony but stomach is soft and normal
N/V
forceful/urgent bowel evacuation

ischemic bowel disease

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fever

- person is writhing around and all of a sudden they are pain free due to bowel dieing

ischemic bowel disease to infarct

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crampy and tender abdominal pain
nausea
vomiting
bloody diarrhea
blood per rectum

colonic ischemia

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painless jaundice
unintentional weight loss
recent onset of atypical DM
palpable mass (late stage)
ascites (late stage)
courvoisier’s sign

pancreatic cancer

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What is courvoisier’s sign

non-tender palpable gallbladder with jaundice

- Asymptomatic - Biliary colic RUQ- Post-prandial after fatty meal; Steady pain that lasts at 30 min peaks at an hour and trends down and is gone at 6 hrs - Non-specific abdominal pain - Midepigastric pain - Chest pain - Fullness after meals - Abdominal distention/bloating - Nausea - Vomiting - Diaphoresis

Cholelithiasis

- RUQ pain or epigastric sudden onset; Typically post prandial fatty meal, but not always; Pain can be for 12-15hrs - Typically sit still because movement aggravates pain - Nausea/ Vomiting - Murphy’s sign- push RUQ and breather and gall bladder touches the physician hand and they stop bleeding - Fever - Jaundice - Courvoisier's sign

Cholecystitis

What is Courvoisier's sign?

palpable gallbladder on PE due to extreme dilation

``` Biliary-type pain RUQ, midepigastric or shoulder pain Afebrile  Nausea  Vomiting Complicated (pancreatitis, cholangitis, etc)- jaundice and/or fever ```

Choledocolithiasis

- Abdominal pain - Fever - Yellow skin - Weakness - Charcot Triad - Reynold’s Pentad

Acute Cholangitis

Charcot triad

Fever, abdominal pain and jaundice

Reynold's Pentad

``` Fever Abdominal pain Jaundice Confusion Hypotension ```

- Symptoms range from none to fatigue or pruritus - asymptomatic - jaundice - splenomegaly

PSC

- Midepigastric pain; Patient laying forward and worsening when laying back - Pain radiating to the back - Nausea  - Vomiting - Dyspnea - Epigastric tenderness - Jaundice - N/V

Acute pancreatitis

- Midepigastric pain; Patient laying forward and worsening when laying back - Pain radiating to the back - Nausea  - Vomiting - Dyspnea - Epigastric tenderness - Jaundice - N/V - Tachypnea  - Hypoxemia  - Hypotension - ARDS  - Cullen’s Sign - Grey Turner Sign

Severe sx acute pancreatitis

Cullen Sign

- Exomotic discoloration in periumbilical region due to bleeding intrabdominally - Most likely have necrotizing pancreatitis

Grey Turner Sign

- Exomotic discoloration along the flanks due to hemorrhage | - Most likely have necrotizing pancreatitis

- Abdominal pain - Anorexia - Maldigestion - Weight loss - Nausea - Vomiting - Steatorrhea- fatty, fowl smelling stools - Tenderness over pancreas during attacks

Chronic pancreatitis

- Typically Asymptomatic - GI bleeding- polyp opens and lets loose - Intestinal Obstruction- distended abdomen; rare - Bright red blood per rectum - Rectal Tenesmus - Change in bowel habits- only if large polyp

Polyps

- Presenting at young age - History of rectal bleeding, bowel  obstruction, perforation - Family history   - Asymptomatic - Occasionally abdominal pain or  mass - Poorly differentiated tumors in the right colon

Lynch syndrome

- Presenting at young age - History of rectal bleeding, bowel obstruction, perforation - Family history - Asymptomatic - >100adenomas on colonoscopy - Extracolonic Manifestations

FAP

- Asymptomatic - Painless rectal bleeding - Rectal Prolapse - Failure to Thrive - Family history

Familial Juvenile Polyposis

- vague abdominal pain - iron deficient anemia - fatigue - GI bleeding - Weakness from chronic blood loss - Rectal Bleeding - Abdominal Pain - Cachexia, weight loss, back pain, urine or bowel changes, ascites, pallor indicative of progressive disease

R. side colon cancer

- obstructive symptoms - colicky abdominal pain - change in bowel habits - constipation alternating with loose stools - stool streaked with blood - Rectal Bleeding - Abdominal Pain - Cachexia, weight loss, back pain, urine or bowel changes, ascites, pallor indicative of progressive disease

L. side colon cancer

- rectal tenesmus - urgency - recurrent hematochezia - narrow caliber stools - Rectal Bleeding - Abdominal Pain - Cachexia, weight loss, back pain, urine or bowel changes, ascites, pallor indicative of progressive disease

Rectal cancer

- RECTAL BLEEDING - Anorectal pain - Rectal mass sensation - No symptoms Physical Exam - Rectal mass on Digital Rectal Exam (DRE) - Condylomata - Bleeding

Anal cancer

- Abdominal pain –LLQ - Constant, several days - Nausea/vomiting - Fever - Change in bowel habits - Constipation to diarrhea or vice versa - Dysuria - Guarding, rigidity, rebound - Tender palpable mass

Diverticulitis

- Painless hematochezia - Painless maroon-color blood mixed with stool - Bloating, cramping, urge to defecate - Hemodynamically unstable: syncope, lightheadedness, postural dizziness - Due to bleeding significantly Signs - Abdomen – benign; soft and non-tender -BRBPR or dark - Hemodynamically unstable: Hypotension, tachycardia, pallor

Diverticular bleed

- Rectal bleeding* - Diarrhea (hallmark bloody diarrhea)* - Fecal urgency - Tenesmus- crampy, rectal pain; urgency to go to the bathroom all the time - Abdominal pain* - LLQ and suprapubic pain - More rarely can see fistulas, weight loss, more common in CD - In severe or advanced cases, patients may present with fever   Physical exam - Abdominal tenderness ?peritonitis - DRE = BRB (bright red blood)

Ulcerative colitis general

- Gradual onset diarrhea (<4/day) and intermittent bloody mucoid stool - Urgency and tenesmus - No significant abdominal pain but LLQ cramping normal often relieved by BM (bowel movement) - Mild fever, anemia, hypoalbunemia possible  

Ulcerative colitis mild

- Gradual onset diarrhea (<6/day) and intermittent bloody mucoid stool - Urgency and tenesmus - No significant abdominal pain but LLQ cramping normal often relieved by BM (bowel movement) - Mild fever, anemia, hypoalbunemia possible  

ulcerative colitis moderate

- >6 bloody diarrhea stools/day - Severe anemia, hypovolemia, hypoalbunemia with nutritional deficit (marker for malnutrition) - Abdominal pain/tenderness - Fulminant colitis = subset of severe disease which is rapidly worsening sx’s with toxicity - Distended abdomen, tender leukocytosis, severe diarrhea, fever 

Severe ulcerative colitis

- Aphthous oral ulcers, - Iritis/uveitis/episcleritis- severe eye pain, photophobia - Seronegative arthritis, ankylosing spondylitis, sacroiliitis; As the GI flares up, so does the arthritis - Erythema nodosum, pyoderma gangrenosum; firm nodular raised areas located in lower extremities on extensor surfaces - Autoimmune hemolytic anemias - Primary sclerosing cholangitis

Ulcerative colitis

- can affect any portion of the GI tract - Abdominal pain (intermittent and often RLQ /periumbilical) - Diarrhea (watery/nonbloody typically and ?# per day) – not bloody - Incontinence due to so much diarrhea - Low grade fevers - Weight loss/anorexia/malnutrition - Weakness/fatigue/malaise (anemia) - Bone loss - SBO presentation (Nausea and vomiting with abd pain) w/ active disease or later in disease w/ strictures and chronic fibrosis - Abscess or fistula presentation (perianal disease) - Anal fissure/skin tag/abscess/fistula (perianal presentation) - Dermatologic, ophthalmologic, orthopedic manifestation

Crohn Disease

- <2 yrs malabsorption presentation - can be severe- growth retardation, weight loss, distention - Diarrhea - 45-85% - Flatulence - 28% - Borborygmus - 35-72% - Weight loss - 45% of patients; in infants and young children with untreated celiac disease,  failure to thrive and growth retardation are common (classic malabsorption) - Weakness and fatigue - 78-80% usually related to general poor nutrition - Severe abdominal pain - 34-64% - Fatigue, depression, Fe-deficiency anemia - Anemia - 10-15% of patients - Osteopenia and osteoporosis - 1-34% of patients - Neurologic symptoms - 8-14% of patients; include motor weakness, paresthesias with sensory  loss, and ataxia; seizures may develop - Skin disorders - 10-20% of patients; including dermatitis herpetiformis, a condition with  pruritic, papulovesicular skin lesions involving the extensor surfaces of the extremities, trunk,  buttocks, scalp, and neck - Hormonal disorders - Including amenorrhea, delayed puberty, and infertility in women and impotence and infertility in men

Celiac disease

- A protuberant and tympanic abdomen - Evidence of weight loss (loss of muscle mass or subcutaneous fat) - Orthostatic hypotension - Peripheral edema (protein malabsorption) - Ecchymoses (vit K deficiency) - Hyperkeratosis (vit A deficiency) or dermatitis herpetiformis - Cheilosis and glossitis (Fe-defcy) - Evidence of peripheral neuropathy or ataxia (vit  B12 or E defcy) - Chvostek or Trousseau sign, tetany (Ca++ deficiency

Malabsorption

- Abdominal bloating - Abdominal cramping - Flatulence - Diarrhea/loose stool (with higher intake of lactose) - Nausea - Borborygmi - Severity of symptoms depends on quantity ingested and severity of deficiency  Lactose intolerance diagnosis and management

lactose intolerance

- Watery  - Large volume  - Abdominal cramping  - Bloating  - Gas  - Weight loss with persistent diarrhea  - Rarely occurs with fever, occult blood or inflammatory cells in stool

diarrhea of the small bowel

- Frequent, regular  - Small volume  - Painful bowel movements - Fever - Bloody or mucoid stools common - Inflammatory and red blood cells seen on microscopy

diarrhea of the large bowel

- Symptoms develop within 12-48 hours after being exposed - Acute onset nausea and vomiting, watery, non-bloody diarrhea with abdominal cramps - Symptoms of gastroenteritis last 24-72 hours

norovirus

- Symptoms may develop while still on abx therapy or 5-10 days after - Watery diarrhea

C. diff

- Incubation period is about 3 days (1-7) - Abrupt onset abdominal pain and diarrhea (bloody or mucoid) - Pain goes around the intestines as the bacteria goes trough the intestines - Prodrome of fever, chills, aches in 30% - Can mimic appendicitis - recently ate chicken

Camphylobacter

- Nausea, - Vomiting  - Diarrhea (pea soup) not grossly bloody but may have blood - Abdominal cramping - Fever - Fever resolves in 48-72 hours - Gastroenteritis is self-limiting 4-10 days

salmonella

- High fever  - Diarrhea (small volume, bloody and mucoid) initially may be watery - Abdominal cramping  - Tenesmus- frequent desire to go to the bathroom - daycare center, MSM

shigella

- Onset of symptoms 12-36 hours - Nausea, vomiting, diarrhea  - Abdominal pain and cramping  - Dry mouth and sore throat  - Bilateral cranial nerve involvement/palsies - home canning of fruits, veggies and fish

Botulism

- abdominal pain - borborygmi (rumbling/gurgling of intestines) - vomiting - diarrhea is profuse watery “rice-water” stool-mucous, fishy smell

cholera

- diarrhea to severe dysentery - abdominal pain - weight loss - fever - Complication includes fulminant colitis with bowel necrosis leading to perforation and peritonitis

intestinal entomoeba

- Malaise, anorexia, abdominal cramps and watery diarrhea | - diarrhea that develops during or within 10 days of returning from travel

travelers diarrhea

- Chronic abdominal pain and altered bowel habits in absence of any organic cause

IBS

- Asymptomatic - Abdominal Pain - Weight Loss - Nausea and Vomiting - Gastrointestinal Bleeding - Intestinal Obstruction

Small Bowel Cancer

- Watery diarrhea - flushing - sweating - wheezing - dyspnea - abdominal pain - hypotension - Urinary excretion of 5-HIAA

carcinoid syndrome

``` Orthostatic dizziness confusion angina palpitations cold/clammy extremities. ```

UGIB- severe bleed

Epigastric or RUQ pain

UGIB- PUD

odynophagia GERD dysphagia

UGIB- Esophageal ulcer

emesis retching coughing prior to hematemesis

UGIB- Mallory- Weiss tear

``` Jaundice weakness fatigue anorexia abdominal distention ```

UGIB- variceal hemorrhage or portal HTN gastropathy

Dysphagia early satiety involuntary weight loss cachexia

UGIB-Malignancy

- Painless bleeding most common - May sense abdominal fullness and urge to pass stool - Hematochezia - Clots per rectum - Maroon colored or mixed blood with stool - Melena (rare, may occur with right sided bleeds)

LGIB

- resting tachycardia - orthostatic hypotension (HR increase 20pts and systolic BP decrease 10-20mmHg) - pale conjunctiva - pale oral mucosa - dry mucosa - pale, grey, clammy, cool extremities - Abdomen: normal ->distention->caput medusa->ascites - >tenderness->rebound - guaic + melena

GIB

- Fatigue - Sleep disturbance - Muscle cramps - Weight loss/wasting - Skin - Spider telangiectasias - caput medusa - Palmar erythema - Dupuytren contracture - Abdominal pain - Liver enlargement or Stetch of Glisson capsule - Ascites - Anorexia, nausea/vomiting (more advanced) - Hematemesis - Amenorrhea - Erectile dysfunction - Loss of libido - Gynecomastia - Jaundice - icteric sclera - pruritis without a rash - Confusion/altered mental - Thenar wasting

cirrhosis

- Appearance of chronic illness - Palpable/firm liver (hard sharp nodular edge) -70% - Hepatomegaly - Splenomegaly – 35-50% - Abdominal and thoracic superficial veins are dilated - Ascites - Pleural effusion - Peripheral edema - signs of right sided failure - Jaundice/Icterus - palmar erythema - Esophageal/gastric varices – hematemesis, melena

cirrhosis

``` - need abt 1500ml for PE dx so relatively inaccurate – Abdominal distension – Bulging flanks – Shifting dullness to percussion – Fluid wave ```

ascites

- Symptoms range from alert w/ minor impairment memory, coordination, cognition  to coma - asterixis - twitchiness

hepatic encephalopathy

- Hematemesis/melena/hematochezia - Pale, hypotensive, lightheaded, syncope, orthostatic, tachycardic, any signs/symptoms of hemorrhagic shock - Liver disease/Cirrhosis signs

GI varicies

- Fatigue/Malaise - Anorexia - Nausea and vomiting - Fever - Enlarged tender liver - Jaundice - Normal to low WBC - Markedly elevated aminotransferase (>1000U/L) - Hyperbilirubinemia - Elevated PT? INR? (>1.5) - Encephalopathy

Acute hepatitis

Anti-HAV appears early

Hep A

- asymptomatic or mild clinical illness w/ 6-7 wk incubation - Anti-HCV ELISA - HCV RNA PCR serology

Hep C

anti-HDV

Hep D

- Aminotransferase >1000 - Positive ANA and/or smooth muscle Ab most common type - IgG elevated

Autoimmune hepatitis

- Macrocytic anemia - Thrombocytopenia - AST/ALT ratio 2/1 and mildly elevated (not greater than 300) - TB elevated - PT/INR elevated

Alcoholic hepatitis

HBsAg and anti-HBc IgG

Chronic Hep B

- Insidious until perhaps cirrhotic pt deteriorates - Weakness, weight loss, anorexia - Ascites - Jaundice, Icterus, pruritis - Tender enlarged liver +/-mass

HCC

- associated with illnesses where the body is in a hypermetabolic state, i.e. trauma, sepsis, burns - progressive muscle loss - organ dysfunction

Kwashiorkor-like deficiency

- results from chronic diseases like heart failure, cancer, COPD, AIDS - organ dysfunction - Progressive muscle wasting in setting of early weight loss to severe cachexia - Temporal wasting

Marasmus-like deficiency

- Weight loss leading to body weight 15% below expected - In female patients, amenorrhea is almost always present - Constipation - Cold intolerance - Bradycardia - Hypotension - Loss of body fat - Dry and scaly skin

anorexia

- Body weight fluctuations but generally within 20% of normal body weight - Commonly describe family and psychological issues - Impulsive or antisocial behavior may be present - Menstruation is typically preserved - Gastric dilatation, pancreatitis after binges - Poor dentition, esophagitis secondary to vomiting - Electrolyte abnormalities, dehydration secondary to diuretics and cathartics - Constipation

Bulimia Nervosa

- Fatigue - Tachycardia - Palpitations - Dyspnea on exertion - Skin and mucosal changes - Smooth tongue - Brittle nails - Spooning of nails - Cheilosis - Many patients develop pica, a craving for specific foods

iron-deficient

- Anorexia - Muscle cramps - Paresthesias - Irritability - Cardiovascular dysfunction – wet beriberi - Neurological dysfunction – dry beriberi

Thiamine deficient

Wet beriberi

- Marked peripheral vasodilation caused high output heart failure - Dyspnea, tachycardia, cardiomegaly, edema

Dry beriberi

Peripheral nerve involvement causing motor and sensory neuropathy,  paresthesias and loss of reflexes

- megaloblastic anemia - Glossitis occurs and vague GI symptoms occur - Paresthesias - Balance difficulty - Cerebral dysfunction: dementia   - low B12

B12 deficiency

- GI symptoms  - Swollen, painful tongue - Neurologic symptoms such as cognitive impairment, dementia, depression - low folic acid - megaloblastic anemia

folic acid deficiency

osteomalacia

Vitamin D deficiency

- Asymptomatic - Epigastric pain o Gastric – while eating o Duodenal – hours after eating or middle of the night - Early satiety - Nausea +/- vomiting - Belching, bloating, distention - Chest pain/heartburn - GI bleed– hematemesis, melena - Guaic + stools - Perforation – sudden onset of pain +/- peritoneal signs

PUD

- Epigastric pain - Burning sensation - Gnawing Sensation - Nausea +/- vomiting - +/- Hematemesis (BR or coffee ground)

gastritis

- retrosternal pain - heart burn - odynophagia - dysphagia WATER BRUSH - globus densation - food impaction LARYNGITIS - chronic cough - hematemesis - abdominal pain - weight loss

GERD

odynophagia Immunocompromised ptn Thrush

candida esophagitis

- retrosternal pain - heart burn - odynophagia - dysphagia - water bursh - globus densation - food impaction - laryngitis - chronic cough - hematemesis - abdominal pain - weight loss

esophagitis

- Hematemesis - melena - hematochezia - Pale, hypotensive, lightheaded, syncope, orthostatic, tachycardic - Liver disease/Cirrhosis signs : jaundice, pruritus, ascites, encephalopathy/MS changes, muscle cramps, anorexia, spontaneous bleeding/easy bruising, abdominal pain, nausea/vomiting

esophageal varicies

- repeated episodes of retching and vomiting - severe chest pain lower thorax and upper abdomen radiating to the back or left shoulder. - Swallowing aggravates the pain - Shortness of breath - Mackler triad - Neck pain, upper chest pain, epigastric pain - rales (pleural effusion)

Boerhaave syndrome

Hematemesis 85% o Vomit/retch then hematemesis classic- blood streaked vomit Melena Hematochezia Syncope/Assoc GI hemorrhagic hypovolemia Guaic stool positive

Mallory Weiss tear

halitosis regurgitation of undigested food gurgling in throat

Zenker diverticulum

- Dysphagia*- intermittent, non-progressive, solids only - Odynophagia - Heartburn - Food impaction - Chest pain - Chronic cough, asthma

Schatzki ring

* Dysphagia*- slow onset, solid to liquid * Odynophagia * Heartburn * Food impaction * Chest pain * Chronic cough, asthma

esophageal strictures

``` dysphagia - progressive solid to liquid - regurg at night and supine - long duration of sx Chest pain - sudden, squeezing in the retrosternal exacerbated by food and stress ```

dysmotility disorder

- Dysphagia*- Progression from solid food to liquids; Rapid - Weight loss >50% - Regurgitate food- Epigastric pain/retrosternal pain/bone pain from mets - Chronic cough - Hoarseness/dysphonia - Virschow node- lymph node in left supraclavicular fossa - Cachectic

esophageal carcinoma

- Insidious presentation - Indigestion - Nausea/Vomiting - Dysphagia - Early satiety/Anorexia - Weight loss - Melena/Hematemesis - Local spread to omenta, pancreas, diaphragm, mesocolon, transverse colon, duodenum - GOO- gastric outlet obstruction - SBO - Palpable enlarged stomach - Hematogenous spread liver - Sister Mary Joseph Node- periumbilical lymph node - Virchow Node- supraclavicular node - Hepatomegaly

gastric cancer