(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
2
Q
why is the supine position preferred for an abdominal exam?
A
allows relaxation of abdominal musculature
3
Q
what is the abdomen visually inspected for?
A
skin abnormalities
surgical scars
abdominal masses
hernias
asymmetry
movement of the abdominal wall
4
Q
upon inspection, what do previous abdominal scars indicate?
A
previous abdominal pathology (perhaps addressed w surgery?)
5
Q
which pathology does a sunken umbilicus indicate?
A
obesity
6
Q
which pathology does a everted or distended umbilicus indicate?
A
umbilical hernia
7
Q
which pathology do enlarged veins on the anterior umbilical wall indicate?
A
portal hypertension or obstructed inferior vena cava
8
Q
which pathology does a swollen/distended abdomen indicate?
A
ascites
9
Q
which pathology does asymmetry indicate?
A
abdominal mass
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
11
Q
which organ(s) mainly occupies the right hypochondriac region?
A
gallbladder, liver
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
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
14
Q
which organ(s) mainly occupies the epigastric region?
A
stomach, duodenum, head & body of pancreas
15
Q
which abdominal region is associated with the left and right kidney?
A
left and right lumbar regions respectively
16
Q
which organ(s) mainly occupies the left hypochondriac region?
A
pancreas tail
spleen
17
Q
which organ(s) mainly occupies the umbilical region?
A
transverse colon
small bowel (ileum)
part of the stomach
18
Q
which organ(s) mainly occupies the right iliac region?
A
appendix
caecum
part of the ascending colon
19
Q
which organ(s) mainly occupies the left iliac region?
A
sigmoid colon
20
Q
which organ(s) mainly occupies the suprapubic/hypogastric region?
A
bladder
uterus in females
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
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
23
Q
where does liver palpation begin?
A
right iliac fossa, starting at the edge of the superior iliac spine
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
25
what does it mean if you can feel the liver during inspiration?
a palpable liver indicates hepatomegaly
26
what must you do before you palpate the liver?
ask the patient to take a deep breath
27
where does spleen palpation begin?
begin palpation in the right iliac fossa, starting at the edge of the superior iliac spine
= using the flat edge of your hand
28
how is the spleen palpated?
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)
29
what happens if you can palpate the spleen below your hand during inspiration?
a palpable spleen indicates splenomegaly
30
what type of organ is the spleen?
intraperitoneal organ
31
where is the spleen located?
residing within the left hypochondrium at the height or ribs 9-11
left mid-axillary line
32
list the causes of splenomegaly
```
C - congestive heart failure
H - haemolytic anaemia
P - portal hypertension secondary to liver cirrhosis
S - splenic metastases
G - glandular fever
```
33
how is kidney balloting carried out?
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
34
what causes a bilaterally enlarged kidney?
polycystic kidney disease
amyloidosis
35
what causes a unilaterally enlarged kidney?
renal tumour
36
what does abdominal tenderness indicate?
peritonitis and sometimes anxiety
37
what is abdominal guarding?
tends to contract voluntarily when palpation causes pain
38
what is abdominal rigidity?
reflex contraction –
involuntary guarding
= when the abdomen is rigid
39
what is abdominal rebound tenderness?
sharp, stabbing pain experienced when the abdominal wall is compressed slowly and then released quickly
40
what does abdominal rigidity indicate?
inflammation of the parietal peritoneum
41
what does abdominal rebound tenderness indicate?
generalised or localised peritonitis
42
how is the abdominal aortic pulse palpated?
perform deep palpation superior to the umbilicus in the midline, noting the movement with your fingers
43
what should the abdominal aortic pulse be in healthy individuals?
pulsatile
= hands begin to move superiorly with each pulsation
44
an expansile mass when palpating the abdominal aorta suggests which pathology?
abdominal aortic aneurysm
45
at which splenic level does the abdominal aorta bifurcate and into what?
at the level of L4
into the right and left common iliac arteries
46
at which vertebral level is the transpyloric plane?
L1
47
which organs are associated with the transpyloric plane?
pylorus of the stomach
neck of the pancreas
fundus of the gallbladder
duodenojejunal flexure
renal hilum
end of the spinal cord
48
at which vertebral level is the subcostal plane?
L3
49
which organs are associated with the subcostal plane?
origin of the inferior mesenteric artery
50
at which vertebral level is the supracristal plane?
L4
51
which organs are associated with the supracristal plane?
bifurcation of the abdominal aorta
| into the left and right common iliac arteries
52
at which vertebral level is the intertubercular plane?
L5
53
which organs are associated with the intertubercular plane?
tubercles of the right and left ilium
54
at which vertebral level is the interspinous plane?
S2
55
which organs are associated with the interspinous plane?
horizontal plane through the anterior superior iliac spines
| marks the boundary between the umbilical region and the hypogastric region
56
what is the normal percussion note described as?
resonant (normal)
57
what causes a dull percussion note?
presence of fluid
58
what causes a hyper-resonant percussion note?
presence of air
59
how is the liver percussed from the 4th rib?
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
how is the liver percussed from the right iliac fossa?
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
what are the surface markings of the liver?
- 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
how is the spleen percussed?
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
where do you percuss for splenic enlargement?
at the 10th intercostal space (between 10th and 11th ribs) percuss for splenic enlargement
(both during expiration and full inspiration)
64
how do you percuss for shifting dullness?
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
why do we auscultate in a GU/GI exam?
to detect bowel sounds and vascular bruits
66
how is auscultation carried out to hear bowel sounds?
apply the diaphragm of the stethoscope to the abdominal wall
listen in two places on the abdomen (30/60 seconds)
67
why do we hear bowel sounds on auscultation?
normal bowel sounds are heard as gurgling noises due to the peristalsis of the gastrointestinal tract
68
how long must you listen for bowel sounds before concluding that they are absent?
should listen for at least 3-4 minutes before coming to any conclusion that bowel sounds are absent
69
absent bowel sounds are indicative of which pathologies?
paralytic ileus or peritonitis
70
which pathology do high-pitched and frequent bowel sounds indicate?
intestinal obstruction
71
what are the three regions where ureteric stones are most likely to reside and why?
across the sacroiliac joint
the pelvic--ureteric junction
vesicoureteric junction
= regions where the ureter is narrowest
72
what is the gold standard imaging for the diagnosis of a ureteric stone?
ultrasound scan (USS)
73
what does the management of ureteric stones depend on?
ureteric stone size (i.e. > or < 5mm)
74
how are ureteric stones <5mm managed?
small stones so leave them to pass independently
75
how are ureteric stones >5mm managed?
larger stones so lithotripsy OR stenting
76
what pathology can be caused due to ureteric stones?
hydronephrosis (swelling of the kidneys)
77
what is a vascular bruit?
an audible vascular sound associated with turbulent blood flow through an artery due to an aneurysm OR obstruction
78
which arteries are auscultated in the abdominal exam?
abdominal aorta
superior mesenteric or coeliac arteries
renal arteries
(liver tumours)
iliac arteries
79
where is the abdominal aorta auscultated in the abdominal exam?
just above and left of the umbilicus
80
where are the superior mesenteric and coeliac arteries auscultated in the abdominal exam?
epigastrium
81
where are the renal arteries auscultated in the abdominal exam?
approx 2-3cm superior and lateral to the umbilicus
82
where are liver tumours auscultated in the abdominal exam?
over the liver
83
where are the iliac arteries auscultated in the abdominal exam?
in the iliac fossa
84
what are the three borders of the liver?
upper
oblique
right
85
describe the upper border of the liver
(right dome of the diaphragm) f
rom the right 5th rib and costal cartilage which extends across the lower end of the sternum
86
describe the oblique border of the liver
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
describe the right border of the liver
ascends from right costal margin (right mid-axillary line) to the right 5th rib at the mid-clavicular line
88
where does the gallbladder reside?
at the tip of the 9th costal cartilage
89
what is the gallbladder the intersect of?
intersect of the transpyloric line and the right mid-clavicular line
90
at which junction does the gallbladder reside?
lateral border of the rectus abdominis muscle and the right costal margin
91
which part of the ribs does the transpyloric plane run through?
tips of the 9th costal cartilages
92
what is the surface marking of the spleen?
ribs 9-11
left mid-axillary line
lateral border of the erector spinae muscles
93
what are the surface markings of the liver?
right 5th rib, MCL
left 5th ICS, MCL
lower end of sternum
costal margin at right mid-axillary line
94
what are the surface markings of the gallbladder?
tip of the right 9th costal cartilage
95
how are the kidneys surface marked?
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
what is the size of the kidneys?
9-12cm long and 5-7cm broad
97
how are the ureters surface marked?
1) 5cm lateral to the PML (posterior median line) at L1
TO
2) PSIS (posterior superior iliac spine - skin dimple)
98
how far is the renal hilum from the PML?
4-5cm
99
how far away is the inferior pole of the kidney from the supracristal (L4) plane?
approx 3-4 cm
100
when is spelenomegaly suspected in percussion?
if you find the percussion note becomes dull on full inspiration
101
which organs occupy the right lumbar region?
right kidney
ascending colon
(part of the transverse colon)
102
which organs occupy the left lumbar region?
left kidney
descending colon
(part of the transverse colon)
103
what does colicky abdominal pain suggest?
obstruction
104
what does constant abdominal pain suggest?
inflammation
105
what does abdominal pain on movement suggest?
musculoskeletal problem
106
what are four possible causes of colicky abdominal pain?
cholelithiasis
choledolithiasis
urinary tract canaliculi
small/large bowel obstruction
107
what are the possible causes for constant abdominal pain?
| based on abdominal region
(RH)
hepatitis
cholangitis
cholescystitis
(EG)
pancreatitis
gastritis
(RL)
nephritis
pyelonephritis
(RIF)
appendicits
Crohn's disease
(HG)
cystitis
(LIF)
diverticulitis
ulcerative colitis
108
differentiate between cholangitis and cholecystitis
cholecystits is an inflammation of the gallbladder wall
cholangitis is inflammation of the bile ducts
109
differentiate between cholelithiasis and choledolithiasis
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
which condition does not present with colicky pain despite its name?
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
which surface marking is the transpyloric plane linked to?
tip of the ninth costal cartilage
112
which surface marking is the subcostal plane linked to?
lower end of the tenth costal cartilage
113
which marking is the supracristal plane linked to?
umbilicus or highest point of iliac crests
114
which surface marking is the intertubercular plane linked to?
tubercles of the iliac crests
115
which surface marking is the interspinous plane linked to?
ASIS
116
where does gallbladder pain radiate to?
through to the back and right
117
where does kidney pain radiate to?
'loin to groin'
118
where does stomach/pancreatic/duodenal pain radiate to?
straight through to the back
119
where does appendix pain radiate to?
general right lower quadrant
120
where does small bowel, caecum, transverse + sigmoid colon, uterus pain radiate to?
lower abdominal pain does not normally radiate
| if rarely it does then to the lower back or perineum BUT RARE
121
how is the transpyloric plane located?
lies midway between the superior border of manubrium of sternum and symphysis pubis.
122
how are the four abdominal quadrants made?
a vertical (mid-sagittal) plane and a transverse plane (transumbilical plane)
123
why is palpation only possible on inspiration?
during inspiration, the abdominal wall moves out and the liver, spleen and kidneys move downwards
124
what can cause diffuse abdominal swelling? (2)
ascites (fluid collection in peritoneal cavity)
| intestinal obstruction
125
when do you normally auscultate in a GU/GI exam and why?
before you do any palpation or percussion = will help the bowels to remain undisturbed
126
why do we lightly palpate?
look for tender areas and any lumps
127
what happens if the patient already has pre-existing abdominal pain?
if you know any tender areas in advance from the patient’s history, then you will palpate these areas very last
128
what are percussion sounds like?
hollow, drum-like sound = air-filled spaces such as stomach and colon
dull sound = solid organs liver, spleen or over liquids
129
define ascites
excess fluid accumulation in the peritoneal cavity
130
what are the five causes of ascites?
fluid, fat, faeces, fetus & flatus
131
how much peritoneal fluid is present on the abdomen normally?
normally approx 50-75ml
132
what are the most common causes of peritoneal fluid accumulation?
hepatic cirrhosis w portal hypertension
liver and peritoneal malignancies
cardiac failure
peritonitis
malnutrition
pancreatitis
hypoproteinaemia
renal dialysis
133
why is bowel percussion usually resonant?
due to presence of gas in the bowels
134
what happens to bowel percussion in ascites?
when fluid collects in the peritoneal cavity = percussion note becomes dull
135
what is a fluid thrill?
the ripple felt when the fluid in the abdomen is flicked
136
when is a fluid thrill felt for?
severely distended abdomen
if you cannot detect ascites by the shifting dullness test
137
describe how you feel for a fluid thrill
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
differentiate between bimanual palpation of the kidneys and balloting
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
what is the surface marking of the abdominal aorta?
line drawn between
1) xiphisternal joint (T8/T9)
2) umbilicus/supracristal plane (L3/L4)
