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anatomy & diagnostics (phase 1b) > (CPA) gastrointestinal & genitourinary exam > Flashcards

(CPA) gastrointestinal & genitourinary exam Flashcards

1
Q

what position should the patient be in for the GI/GU exam?

A

supine position (lying flat)

exposed from xiphisternum to pubic symphysis

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2
Q

why is the supine position preferred for an abdominal exam?

A

allows relaxation of abdominal musculature

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3
Q

what is the abdomen visually inspected for?

A

skin abnormalities

surgical scars

abdominal masses

hernias

asymmetry

movement of the abdominal wall

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4
Q

upon inspection, what do previous abdominal scars indicate?

A

previous abdominal pathology (perhaps addressed w surgery?)

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5
Q

which pathology does a sunken umbilicus indicate?

A

obesity

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6
Q

which pathology does a everted or distended umbilicus indicate?

A

umbilical hernia

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7
Q

which pathology do enlarged veins on the anterior umbilical wall indicate?

A

portal hypertension or obstructed inferior vena cava

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8
Q

which pathology does a swollen/distended abdomen indicate?

A

ascites

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9
Q

which pathology does asymmetry indicate?

A

abdominal mass

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10
Q

name the nine abdominal regions

A 
right hypochondriac
right lumbar
right iliac fossa
epigastric
umbilical 
hypogastric/suprapubic
left hypochondriac
left lumbar
left iliac fossa
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11
Q

which organ(s) mainly occupies the right hypochondriac region?

A

gallbladder, liver

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12
Q

what are the parts to palpation in an abdominal exam?

A

light palpation

deep palpation

palpation of the liver

palpation of the spleen

bimanual palpation of the kidney (balloting the kidneys)

palpation of the abdominal aorta

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13
Q

explain how light palpation is carried out

A

lightly palpate the nine abdominal regions

assess for tenderness

while closely monitoring the face for any signs of pain

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14
Q

which organ(s) mainly occupies the epigastric region?

A

stomach, duodenum, head & body of pancreas

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15
Q

which abdominal region is associated with the left and right kidney?

A

left and right lumbar regions respectively

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16
Q

which organ(s) mainly occupies the left hypochondriac region?

A

pancreas tail

spleen

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17
Q

which organ(s) mainly occupies the umbilical region?

A

transverse colon
small bowel (ileum)
part of the stomach

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18
Q

which organ(s) mainly occupies the right iliac region?

A

appendix
caecum
part of the ascending colon

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19
Q

which organ(s) mainly occupies the left iliac region?

A

sigmoid colon

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20
Q

which organ(s) mainly occupies the suprapubic/hypogastric region?

A

bladder

uterus in females

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21
Q

explain how deep palpation is carried out

A

palpate the nine abdominal regions in an S shape

apply greater pressure

  • warn the patient that they may feel more pain and discomfort
  • tell them they can let you know if they want you to stop
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22
Q

what is the difference between light and deep palpation?

A

deep palpation requires greater pressure

= both types of palpation happen in an S shape, on inspiration

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23
Q

where does liver palpation begin?

A

right iliac fossa, starting at the edge of the superior iliac spine

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24
Q

how is the liver palpated?

A

begin in the right iliac fossa, starting at the edge of the superior iliac spine

use flat edge of hand and fingers

ask the patient to take a deep breath, and on inspiration, palpate the abdomen to the right costal margin upwards

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25
Q

what does it mean if you can feel the liver during inspiration?

A

a palpable liver indicates hepatomegaly

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26
Q

what must you do before you palpate the liver?

A

ask the patient to take a deep breath

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27
Q

where does spleen palpation begin?

A

begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine

= using the flat edge of your hand

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28
Q

how is the spleen palpated?

A

ask the patient to take a deep breath and on inspiration, begin palpation of the abdomen

begin at the right iliac fossa and palpate to the left costal margin

repeat the process of palpation moving 1-2cm superiorly each time (but still palpating to the left costal margin)

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29
Q

what happens if you can palpate the spleen below your hand during inspiration?

A

a palpable spleen indicates splenomegaly

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30
Q

what type of organ is the spleen?

A

intraperitoneal organ

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31
Q

where is the spleen located?

A

residing within the left hypochondrium at the height or ribs 9-11

left mid-axillary line

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32
Q

list the causes of splenomegaly

A 
C - congestive heart failure
H - haemolytic anaemia
P - portal hypertension secondary to liver cirrhosis
S - splenic metastases
G - glandular fever
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33
Q

how is kidney balloting carried out?

A

left hand = behind patient’s back, below the ribs and underneath the right flank

right hand = anterior abdominal wall, below the right costal margin in the right flank

push fingers together (left hand upwards and right hand downwards)

deep breath and palpate

repeat with left kidney

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34
Q

what causes a bilaterally enlarged kidney?

A

polycystic kidney disease

amyloidosis

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35
Q

what causes a unilaterally enlarged kidney?

A

renal tumour

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36
Q

what does abdominal tenderness indicate?

A

peritonitis and sometimes anxiety

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37
Q

what is abdominal guarding?

A

tends to contract voluntarily when palpation causes pain

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38
Q

what is abdominal rigidity?

A

reflex contraction –
involuntary guarding

= when the abdomen is rigid

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39
Q

what is abdominal rebound tenderness?

A

sharp, stabbing pain experienced when the abdominal wall is compressed slowly and then released quickly

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40
Q

what does abdominal rigidity indicate?

A

inflammation of the parietal peritoneum

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41
Q

what does abdominal rebound tenderness indicate?

A

generalised or localised peritonitis

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42
Q

how is the abdominal aortic pulse palpated?

A

perform deep palpation superior to the umbilicus in the midline, noting the movement with your fingers

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43
Q

what should the abdominal aortic pulse be in healthy individuals?

A

pulsatile

= hands begin to move superiorly with each pulsation

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44
Q

an expansile mass when palpating the abdominal aorta suggests which pathology?

A

abdominal aortic aneurysm

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45
Q

at which splenic level does the abdominal aorta bifurcate and into what?

A

at the level of L4

into the right and left common iliac arteries

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46
Q

at which vertebral level is the transpyloric plane?

A

L1

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47
Q

which organs are associated with the transpyloric plane?

A

pylorus of the stomach

neck of the pancreas

fundus of the gallbladder

duodenojejunal flexure

renal hilum

end of the spinal cord

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48
Q

at which vertebral level is the subcostal plane?

A

L3

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49
Q

which organs are associated with the subcostal plane?

A

origin of the inferior mesenteric artery

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50
Q

at which vertebral level is the supracristal plane?

A

L4

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51
Q

which organs are associated with the supracristal plane?

A

bifurcation of the abdominal aorta

into the left and right common iliac arteries

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52
Q

at which vertebral level is the intertubercular plane?

A

L5

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53
Q

which organs are associated with the intertubercular plane?

A

tubercles of the right and left ilium

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54
Q

at which vertebral level is the interspinous plane?

A

S2

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55
Q

which organs are associated with the interspinous plane?

A

horizontal plane through the anterior superior iliac spines

marks the boundary between the umbilical region and the hypogastric region

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56
Q

what is the normal percussion note described as?

A

resonant (normal)

57
Q

what causes a dull percussion note?

A

presence of fluid

58
Q

what causes a hyper-resonant percussion note?

A

presence of air

59
Q

how is the liver percussed from the 4th rib?

A

begin at the right 4th rib in the mid-clavicular line and percuss downwards until the note changes from resonant to dull = indicates the upper border (usually right 5th ICS)

continue to percuss downward until you reach the end of liver dullness (lower border)

60
Q

how is the liver percussed from the right iliac fossa?

A

percuss upwards 1-2cm at a time from the right iliac fossa to the right costal margin until the percussion notes changes from resonant to dull = lower liver border

continue to percuss upwards 1-2cm at a time until the percussion note changes from dull to resonant = upper liver border

61
Q

what are the surface markings of the liver?

A
  • right 5th rib at the mid-clavicular line
  • left 5th rib at the mid-clavicular line
  • lower end of the sternum
  • costal margin at the right mid-axillary line
62
Q

how is the spleen percussed?

A

percuss upwards 1-2cm from the left iliac fossa, upwards towards the left costal margin

(noting the change from resonant to dull at the anterior axillary line)

63
Q

where do you percuss for splenic enlargement?

A

at the 10th intercostal space (between 10th and 11th ribs) percuss for splenic enlargement

(both during expiration and full inspiration)

64
Q

how do you percuss for shifting dullness?

A

percuss from the midline out to the flanks, noting where the change from resonant to dull occurs

mark the spot, ask patient to turn on to the opposite side

wait 10 seconds for the fluid, if present, to shift

percuss the marked spot and if area of dullness is now resonant = ascites is present

65
Q

why do we auscultate in a GU/GI exam?

A

to detect bowel sounds and vascular bruits

66
Q

how is auscultation carried out to hear bowel sounds?

A

apply the diaphragm of the stethoscope to the abdominal wall

listen in two places on the abdomen (30/60 seconds)

67
Q

why do we hear bowel sounds on auscultation?

A

normal bowel sounds are heard as gurgling noises due to the peristalsis of the gastrointestinal tract

68
Q

how long must you listen for bowel sounds before concluding that they are absent?

A

should listen for at least 3-4 minutes before coming to any conclusion that bowel sounds are absent

69
Q

absent bowel sounds are indicative of which pathologies?

A

paralytic ileus or peritonitis

70
Q

which pathology do high-pitched and frequent bowel sounds indicate?

A

intestinal obstruction

71
Q

what are the three regions where ureteric stones are most likely to reside and why?

A

across the sacroiliac joint

the pelvic–ureteric junction

vesicoureteric junction

= regions where the ureter is narrowest

72
Q

what is the gold standard imaging for the diagnosis of a ureteric stone?

A

ultrasound scan (USS)

73
Q

what does the management of ureteric stones depend on?

A

ureteric stone size (i.e. > or < 5mm)

74
Q

how are ureteric stones <5mm managed?

A

small stones so leave them to pass independently

75
Q

how are ureteric stones >5mm managed?

A

larger stones so lithotripsy OR stenting

76
Q

what pathology can be caused due to ureteric stones?

A

hydronephrosis (swelling of the kidneys)

77
Q

what is a vascular bruit?

A

an audible vascular sound associated with turbulent blood flow through an artery due to an aneurysm OR obstruction

78
Q

which arteries are auscultated in the abdominal exam?

A

abdominal aorta

superior mesenteric or coeliac arteries

renal arteries

(liver tumours)

iliac arteries

79
Q

where is the abdominal aorta auscultated in the abdominal exam?

A

just above and left of the umbilicus

80
Q

where are the superior mesenteric and coeliac arteries auscultated in the abdominal exam?

A

epigastrium

81
Q

where are the renal arteries auscultated in the abdominal exam?

A

approx 2-3cm superior and lateral to the umbilicus

82
Q

where are liver tumours auscultated in the abdominal exam?

A

over the liver

83
Q

where are the iliac arteries auscultated in the abdominal exam?

A

in the iliac fossa

84
Q

what are the three borders of the liver?

A

upper
oblique
right

85
Q

describe the upper border of the liver

A

(right dome of the diaphragm) f

rom the right 5th rib and costal cartilage which extends across the lower end of the sternum

86
Q

describe the oblique border of the liver

A

follows the right costal margin

from the right mid-axillary line through the tip of RIGHT 9th costal cartilage through the tip of LEFT 8th costal cartilage to the LEFT 5th intercostal space in the mid clavicular line.

87
Q

describe the right border of the liver

A

ascends from right costal margin (right mid-axillary line) to the right 5th rib at the mid-clavicular line

88
Q

where does the gallbladder reside?

A

at the tip of the 9th costal cartilage

89
Q

what is the gallbladder the intersect of?

A

intersect of the transpyloric line and the right mid-clavicular line

90
Q

at which junction does the gallbladder reside?

A

lateral border of the rectus abdominis muscle and the right costal margin

91
Q

which part of the ribs does the transpyloric plane run through?

A

tips of the 9th costal cartilages

92
Q

what is the surface marking of the spleen?

A

ribs 9-11

left mid-axillary line

lateral border of the erector spinae muscles

93
Q

what are the surface markings of the liver?

A

right 5th rib, MCL

left 5th ICS, MCL

lower end of sternum

costal margin at right mid-axillary line

94
Q

what are the surface markings of the gallbladder?

A

tip of the right 9th costal cartilage

95
Q

how are the kidneys surface marked?

A

trasnpyloric plane - extrapolate backwards to the posterior abdominal wall

mark T12 as a result (midpoint between scapula inferior angle and highest point of iliac crest in the specular line)

back down to L1 = mark the

1) hila of kidneys (4-5cm away from posterior median line)
2) superior poles = 12th ribs
3) inferior poles = below 12th rib, 3-4cm above iliac crests

96
Q

what is the size of the kidneys?

A

9-12cm long and 5-7cm broad

97
Q

how are the ureters surface marked?

A

1) 5cm lateral to the PML (posterior median line) at L1
TO
2) PSIS (posterior superior iliac spine - skin dimple)

98
Q

how far is the renal hilum from the PML?

A

4-5cm

99
Q

how far away is the inferior pole of the kidney from the supracristal (L4) plane?

A

approx 3-4 cm

100
Q

when is spelenomegaly suspected in percussion?

A

if you find the percussion note becomes dull on full inspiration

101
Q

which organs occupy the right lumbar region?

A

right kidney
ascending colon
(part of the transverse colon)

102
Q

which organs occupy the left lumbar region?

A

left kidney
descending colon
(part of the transverse colon)

103
Q

what does colicky abdominal pain suggest?

A

obstruction

104
Q

what does constant abdominal pain suggest?

A

inflammation

105
Q

what does abdominal pain on movement suggest?

A

musculoskeletal problem

106
Q

what are four possible causes of colicky abdominal pain?

A

cholelithiasis
choledolithiasis
urinary tract canaliculi
small/large bowel obstruction

107
Q

what are the possible causes for constant abdominal pain?

based on abdominal region

A

(RH)
hepatitis
cholangitis
cholescystitis

(EG)
pancreatitis
gastritis

(RL)
nephritis
pyelonephritis

(RIF)
appendicits
Crohn’s disease

(HG)
cystitis

(LIF)
diverticulitis
ulcerative colitis

108
Q

differentiate between cholangitis and cholecystitis

A

cholecystits is an inflammation of the gallbladder wall

cholangitis is inflammation of the bile ducts

109
Q

differentiate between cholelithiasis and choledolithiasis

A

cholelithiasis is the presence of gallstones in the gallbladder

choledocholithiasis is the presence of one or more gallstones in the common bile duct (CBD)

110
Q

which condition does not present with colicky pain despite its name?

A

bilary colic

= stone in the cystic duct or CBD which blocks bile that is secreted when the gallbladder contracts after a meal is eaten (constant, not colicky pain)

(dull RUQ, post-prandial, resolves in 6 hours)

111
Q

which surface marking is the transpyloric plane linked to?

A

tip of the ninth costal cartilage

112
Q

which surface marking is the subcostal plane linked to?

A

lower end of the tenth costal cartilage

113
Q

which marking is the supracristal plane linked to?

A

umbilicus or highest point of iliac crests

114
Q

which surface marking is the intertubercular plane linked to?

A

tubercles of the iliac crests

115
Q

which surface marking is the interspinous plane linked to?

A

ASIS

116
Q

where does gallbladder pain radiate to?

A

through to the back and right

117
Q

where does kidney pain radiate to?

A

‘loin to groin’

118
Q

where does stomach/pancreatic/duodenal pain radiate to?

A

straight through to the back

119
Q

where does appendix pain radiate to?

A

general right lower quadrant

120
Q

where does small bowel, caecum, transverse + sigmoid colon, uterus pain radiate to?

A

lower abdominal pain does not normally radiate

if rarely it does then to the lower back or perineum BUT RARE

121
Q

how is the transpyloric plane located?

A

lies midway between the superior border of manubrium of sternum and symphysis pubis.

122
Q

how are the four abdominal quadrants made?

A

a vertical (mid-sagittal) plane and a transverse plane (transumbilical plane)

123
Q

why is palpation only possible on inspiration?

A

during inspiration, the abdominal wall moves out and the liver, spleen and kidneys move downwards

124
Q

what can cause diffuse abdominal swelling? (2)

A

ascites (fluid collection in peritoneal cavity)

intestinal obstruction

125
Q

when do you normally auscultate in a GU/GI exam and why?

A

before you do any palpation or percussion = will help the bowels to remain undisturbed

126
Q

why do we lightly palpate?

A

look for tender areas and any lumps

127
Q

what happens if the patient already has pre-existing abdominal pain?

A

if you know any tender areas in advance from the patient’s history, then you will palpate these areas very last

128
Q

what are percussion sounds like?

A

hollow, drum-like sound = air-filled spaces such as stomach and colon

dull sound = solid organs liver, spleen or over liquids

129
Q

define ascites

A

excess fluid accumulation in the peritoneal cavity

130
Q

what are the five causes of ascites?

A

fluid, fat, faeces, fetus & flatus

131
Q

how much peritoneal fluid is present on the abdomen normally?

A

normally approx 50-75ml

132
Q

what are the most common causes of peritoneal fluid accumulation?

A

hepatic cirrhosis w portal hypertension

liver and peritoneal malignancies

cardiac failure

peritonitis

malnutrition

pancreatitis

hypoproteinaemia

renal dialysis

133
Q

why is bowel percussion usually resonant?

A

due to presence of gas in the bowels

134
Q

what happens to bowel percussion in ascites?

A

when fluid collects in the peritoneal cavity = percussion note becomes dull

135
Q

what is a fluid thrill?

A

the ripple felt when the fluid in the abdomen is flicked

136
Q

when is a fluid thrill felt for?

A

severely distended abdomen

if you cannot detect ascites by the shifting dullness test

137
Q

describe how you feel for a fluid thrill

A

place the palm of your left hand over the left side of patient’s abdomen

flick a finger of your right hand on the right side of the abdomen

feel a ripple = fluid thrill present

138
Q

differentiate between bimanual palpation of the kidneys and balloting

A

bimanual palpation = normal deep palpation but w both hands

balloting = flexing the posteriorly placed index finger and middle fingers to push to lower pole to strike the right palpating hand

139
Q

what is the surface marking of the abdominal aorta?

A

line drawn between

1) xiphisternal joint (T8/T9)
2) umbilicus/supracristal plane (L3/L4)

anatomy & diagnostics (phase 1b) (7 decks)

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