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PCM III Exam 2 > Eval PT with abdominal complaint > Flashcards

Eval PT with abdominal complaint Flashcards

1
Q

Acute Abdomen

A

medical jargon that refers to any acute condition within the abdomen that requires immediate medical or surgical attention

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2
Q

Types of Abdominal Pain

A

Visceral Pain (colic pain): source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. Cramping not well localized.

Parietal Pain: Caused by inflammation of the peritoneum. Steady aching pain that is usually well localized.

Referred Pain: From a distant sight. Right shoulder – gallbladder, left shoulder – spleen, back – pancreas or aorta.

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3
Q

RUQ pain

A 
acute cholecystitis
duodenal ulcer
hepatitis
congestive hepatomegaly
pyelonephritis
appendicitis
(R) pneumonia
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4
Q

LUQ

A 
ruptured spleen
gastric ulcer
aortic aneurysm
perforated colon
pyelonephritis
(L) pneumonia
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5
Q

Between LUQ and LLQ

A 
intestinal obstruction
acute pancreatitis
early appendicitis
mesenteric thrombosis
aortic aneurysm
diverticulitis
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6
Q

LLQ

A 
sigmoid diverticulitis
salpingitis
tubo-ovarian abscess
ruptured ectopic pregnancy
incarcerated hernia
perforated colon
crohn's disease
ulcerative colitis
renal/ ureteral stone
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7
Q

RLQ

A 
appendicitis
salpingitis
tubo-ovarian abscess
ruptured ectopic pregnancy
renal/ ureteric stone
incarcerated hernia
mesenteric adenitis
meckel's diverticulitis
crohn's disease
perforated caecum
psoas abscess
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8
Q

Diagnostic Work Up for a Patient with Abdominal Pain/Complaint

A 
Endoscopy			Plain x-ray
Colonoscopy			U/A and C & S
Ultrasound			IVP
CT Scan				Pregnancy test
CBC				Laparoscopy
LFTs				MRI
Amylase/lipase		Electrolytes
Serum gastrin			Bilirubin
HIDA Scan			ERCP
Hemocult			Stool C & S / O & P / WBC
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9
Q

Blood in the Stool

A

Melena:
Black tarry stools
50-60 ml of blood in the stomach can produce melena
Above the “Ligament of Treitz” (very general rule)

Hematochezia:
Blood unchanged by passage through the gut usually at the level of the colon or lower
Blood in the bowel is a cathartic
Blood mixed with stool suggests upper colon, blood outside the stool suggests sigmoid or rectum.
Hemocult testing for occult blood

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10
Q

currant jelly stool in infant is what?

A

intussusception

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11
Q

DDX for GI Bleeding Is it Upper or Lower GI?

A

Congenital:
Telangiectasias, hemophilia, Meckel diverticulum, A-V malformations

Inflammatory/Immune:
Ulcerative colitis, Crohn’s disease, PUD

Mechanical/Trauma:
Mallory-Weiss tear, intussusception, epistaxis, anal fissure, fecal impaction

Neoplastic:
Polyps, cancer, Zollinger-Ellison syndrome

Infectious:
Dysentery syndrome, gastroenteritis, Clostridium difficile, typhoid, parasites

Metabolic/Toxic:
NSAID, Vitamin K deficiency, anticoagulants

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12
Q

Jaundice

A

Staining of tissue and body fluids with bilirubin

Signs and Symptoms:
Yellow skin
Scleral yellowing
Pruritus
Urine color – darken urine from conjugated bilirubin
Acholic feces – malodorous, gray to light colored stools

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13
Q

Unconjugated hyperbilirubinemia

A

Unconjugated bilirubin being produced at a rate exceeding the maximal rate of liver conjugation and excretion or decreased conjugation.

Etiologies    
Hemolysis
Red cell defects – sickle cell
Ineffective erythropoiesis
Deficient hepatic uptake
Deficient hepatic conjugation – hepatitis
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14
Q

Conjugated Hyperbilirubinemia

A

Impaired excretion of conjugated bilirubin from hepatocytes in the bile canaliculi or obstruction of biliary flow.
* Serum alkaline phosphatase is elevated out of proportion to the transaminases.
Intrahepatic cholestasis – hepatocellular disease, drugs, sepsis, primary biliary cirrhosis
Extrahepatic obstruction – gallstones, biliary carcinoma, sclerosing cholangitis, parasites, pancreatic cancer, pancreatitis

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15
Q

Ascites

A

An increase accumulation of peritoneal fluid by any one or more of several mechanisms:
Transudation of fluid from portal hypertension
Lymphatic obstruction
Decreased plasma oncotic pressure
Peritoneal inflammation – peritonitis

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16
Q

Four signs of free fluid (ascites)

A

Bulging flanks
Tympany at the top of the abdomen
Fluid wave
Shifting dullness

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17
Q

Ascites Differential Diagnosis

A 
Cirrhosis (80-85%)
Malignancy (10%)
Congestive heart failure (3%)
Tuberculous peritonitis
Dialysis 
Nephrotic syndrome
Bile or pancreatic ascites
Lymphatic tear
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18
Q

Fluid wave

A 
Place patient’s or
assistant’s hand in midline.  Tap on
one flank and palpate with the other
hand.  An easily palpable impulse 
suggests ascites.
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19
Q

Shifting dullness

A

percuss the patient on their
back and then their side. Note where the sound
changes from tympany to dull and the shift of the
sound when the patient is turned to the side.

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20
Q

The physical examination of the abdomen and rectum includes:

A 
Inspection
Auscultation
Percussion
Palpation 
Rectal examination
Special techniques
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21
Q

Examination of the Abdomen

A
  1. Inspection
  2. Auscultation
    Before palpation/percussion
    All 4 quadrants
  3. Palpation
    Light in 4 quadrants
    Deep in 4 quadrants
    Liver
    Spleen
    Kidneys
    Aorta
  4. Percussion all 4 quadrants
  5. TART exam looking for viscersomatic lesion in spine
Investigating Exam Skills
1. Bowel sounds
Aorta
Renal arteries
2. Palpation
Rebound over area of tenderness
Rovsing’s
Murphy
Shifting dullness
Fluid wave
3. Percussion
Lloyds
Liver span
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22
Q

inspection of the abdomen

A

Must adequately expose the abdomen

Skin - scars, striae, superficial veins
Umbilicus – hernia, “Caput medusa”
Contour – flat, scaphoid, protuberant
Pulsations or peristalsis

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23
Q

Auscultation

A

Listen for bowel sounds before palpation and percussion.
All 4 quadrants
RLQ – best place to listen
Normal bowel sounds – high pitched “tinkle” about every 3-5 seconds.
No bowel sounds after 2 minutes – report as “absent”.

24
Q

Borborygmi

A

Increased, hyperactive bowel sounds,
Low pitched rumbling
Hyperperistalsis

25
Q

Abdominal bruits

A

A soft sound made by disrupted arterial flow through a narrowed artery.

  • Aortic – between the umbilicus and xiphoid
  • Renal artery – just lateral to the aorta
  • Femoral artery – along the inguinal ligament
26
Q

Proper technique for
auscultation of the
abdomen.

A 
Listen in all 4 quadrants.
Listen for bruits in the 
midline between the 
xiphoid and umbilicus.
Femoral arteries B/L.
27
Q

Percussion – helps evaluate the presence of:

A

Gaseous distention
Fluid
Solid masses
Size and location of the liver and spleen

28
Q

Percussion of the Abdomen

A

Percuss all 4 quadrants
Best done with the patient in the supine position

Tympany:
Most common percussion note.
Presence of gas in the stomach and small bowel.

Percussion of the liver:
Percuss along the right mid-clavicular line from top to bottom.
Resonant (lungs) to dull (liver) to tympanic (intestine)

29
Q

Abdominal palpation is usually divided into the following segments:

A 
Light palpation
Deep palpation
Liver palpation
Spleen palpation
Kidney palpation
Rebound palpation
30
Q

Technique for light palpation

A

Detect tenderness and areas of muscular spasm or rigidity.

Palpate all 4 quadrants.

Use finger tips with a gentle motion.

31
Q

Technique for deep palpation

A

Used to evaluate organ size, abnormal masses, aorta, deep pain etc.

One hand placed on top of the other.

32
Q

Rebound Tenderness

A

Evaluate for peritoneal tenderness and inflammation.

Technique :
In the suspected area of the abdomen, *slowly, gently and deeply palpate.
Then, quickly remove the palpating hand.
If the patient experiences pain = “+ rebound tenderness”.
* Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.

33
Q

DDX for Peritonitis

A 
Spontaneous bacterial peritonitis
Secondary bacterial peritonitis
- Appendicitis
- Diverticulitis
- Perforated PUD/ Perforated bowel 
- Cholecystitis 
Pancreatic ascites
PID
Ectopic pregnancy
Fitz-Hugh-Curtis syndrome
34
Q

Technique for palpation of the liver

A

Place left hand under the right 11th and 12th rib.

Right hand in the RUQ

Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.

Can repeat the maneuver.

35
Q

Technique for palpation of the liver

“Hooking Technique”

A

Stand near the patient’s head .

With both hands “hook” your fingers around the lower right costal margin.

Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver.

36
Q

DDX for Hepatomegaly

A 
Hepatitis
- Viral
- Bacterial 
- Protozoal
- Alcoholic
- Toxic
Fatty liver
Cirrhosis
Congestive heart failure 
Hepatocellular carcinoma or metastatic cancer
Leukemia or lymphoma
Autoimmune disease
Infiltrative disease 
Sickle cell disease 
Glycogen storage disease
37
Q

Liver EnzymesA General Approach

A

Extrahepatic: AST, ALT elevated, Alk Phos VERY elevated

Hepatic: AST/ ALT VERY elevated, alk phos moderately up

38
Q

Palpation of the Spleen

A

Place left hand under the 11th and 12th ribs.

Place right hand in the LUQ under the costal margin.

Instruct the patient to breath deeply as the examiner gently presses inward and upward.

Repeat the maneuver for deeper palpation.

The spleen is normally not palpated in normal conditions.

39
Q

DDX for Splenomegaly

A 
Infections
- Mononucleosis – EBV
- Cytomegalovirus – CMV 
- HIV
- Malaria
- Histoplasmosis
Leukemia/Lymphoma
Extramedullary hematopoiesis
CHF
Polycythemia vera/thrombocytosis
SLE
RA – Felty’s syndrome
Metastatic disease
Amyloidosis
40
Q

Palpation of the Aorta

A

Press firmly and deep in the upper abdomen with two hands.
Normal aorta is 2.5 to 3.0 cm wide.
Aortic aneurysm – pathologic dilatation of the aorta. Can be associated with a bruit.
Assessed with an ultra sound or CT scan.

41
Q

Palpation of the Kidneys

A

“Sandwich method”

Place a hand above and below the costal margins just lateral to the midline.

Deep and gentle palpation attempt to palpate the lower pole of each kidney.

The kidneys are normally not palpated under normal conditions.

42
Q

Percussion of the kidneys,

A

a.k.a. CVA tenderness

With a fist, gently hit the area over the costovertebral angle on each side of the spine.

Pain over a kidney may indicate an inflammatory or infectious process of the kidney.

The examiner may also place a flat hand over the CVA and strike the hand.

43
Q

DDX for CVA Tenderness

A 
Nephrolithiasis
Pyelonephritis
Renal cell carcinoma
DJD
Pneumonia – lower lobe
SLE
Perinephric abscess
AAA
Glomerulonephritis
44
Q

The Rectal Examination

A

Position the Patient
Patient on their back – Modified Lithotomy
Lying on left side – a.k.a. – Sims’ Position
Standing, bent over the exam table

Inspection
Spread the buttocks
Sacrococcygeal and perianal areas
Anus and rectum
Note: Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors
45
Q

Palpation or Digital Rectal Examination (DRE)

A

Inform the patient of what is going to happen.
Lubricate your gloved index finger.
Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.
Slowly insert the finger as the sphincter relaxes as far as possible.

46
Q

Fecal Occult Blood Testing

A 
Patients with a positive FOBT require
a through evaluation for CRC.
Colonoscopy is the study of choice.
Sigmoidoscopy and air contrast barium
enema are acceptable alternatives.
47
Q

Documentation Example

A

Flat, + RLQ 4 inch surgical scar
BS x 4, neg. aortic or femoral bruits
Tympanic percussion, neg. distension, liver 9 cm
Neg. tenderness or masses to superficial and deep palpation, aorta not enlarged
Neg. hepatosplenomegaly or tenderness
Neg. CVA tenderness
Rectal: neg. external lesions, good sphincter tone, no masses or tenderness, stool for occult blood negative

48
Q

Appendicitis: etiology and history

A

Etiology:
Obstruction of the appendiceal lumen. Fecal or foreign matter, tumors or lymphomas.

History:
Pain starts peri-umbilical then shifts to the right lower quadrant.
Nausea and vomiting
Anorexia
Fever
49
Q

Appendicitis physical exam

A

RLQ pain and RLQ rebound tenderness
Decreased or absent bowel sounds
Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
Psoas sign – turn patient on left side and extend the right leg to check for psoas muscle inflammation.
Obturator sign – place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
Always do a rectal examination and a pelvic exam on a female.

50
Q

Appendicitis Diagnostic Work Up

A

CBC – moderate leukocytosis with left shift.
Urine – may contain a few WBC or RBC. Helps R/O any GU condition.
Plain x-ray – rarely helpful.
Ultrasound – enlarged and thick walled appendix.
CT scan – most sensitive. 90 – 98% sensitive.
Female patient – Must do a pregnancy test to R/O ectopic pregnancy.
BMP – evaluate electrolytes and renal functions, especially if patient has been vomiting.

51
Q

Acute Cholecystitis etiology and history

A

Etiology:
Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.

History:
RUQ postprandial pain.  Biliary colic pain.
Pain radiating to the right shoulder.
Nausea and vomiting.
Anorexia
Obesity
Fever
The 5 “f’s” – female, fat, fertile, fair, flatulent.
52
Q

Acute Cholecystitis Physical Examination

A

RUQ pain and RUQ rebound tenderness.
Decreased or absent bowel sounds.
Abdominal distention.
* Murphy’s sign – RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
* Diagnostic Triad – RUQ pain, fever and leukocytosis.

53
Q

Acute Cholecystitis Diagnostic Work Up

A

CBC – leukocytosis with left shift
Serum bilirubin – can be mildly elevated.
AST/ALT – can be elevated.
Ultrasound – will detect stones, thicken GB wall, dilated bile duct and fluid.
HIDA scan – radionuclide biliary scan.
CT scan

54
Q

Acute Pancreatitis Etiology and history

A 
Etiology:
Alcohol use
Obstruction – gallstones, cancer
Hyperlipidemia
Drugs and medications
Infection
History:
Acute onset
Nausea/vomiting
Pain radiating to the back
Constant pain
55
Q

Acute Pancreatitis Physical exam

A

Low grade fever
Hypotension
Decreased or absent bowel sounds
Epigastric tenderness
* Turner’s sign – discoloration around the flanks
* Cullen’s sign – discoloration around the umbilicus
D/T Hemorrhagic pancreatitis

56
Q

Acute Pancreatitis Diagnostic workup

A 
CBC
Liver function tests
* Amylase and lipase (most specific) 
Glucose & Calcium
Abd film
Ultrasound/CT Scan/MRI
ERCP

PCM III Exam 2 (9 decks)

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