Exam 3 Flashcards
GI, GU
Gastric ulcer s/s
Weight loss, not as painful as duodenal ulcer, pain not relieved by food or antacids, n/v, belching, bloating, common in people over age 50.
Duodenal ulcer s/s
Pain that wakes up at night, occurs intermittently over few weeks than disappears for months, then recurs, n/v, belching, bloating, heartburn, more common age 30-60 years
Pancreatic ca s/s
Painless jaundice, anorexia, weight loss, glucose intolerance, depression
Appendicitis s/s, positive sign names
- Visceral periumbilical pain due to distention of inflamed appendix which gradually changes to parietal pain the RLQ due to inflammation of adjacent parietal peritoneum.
- Rovsing sign, + Psoas sign, + Obturator sign, and/or tenderness at McBurney point
- [Note: visceral pain is gnawing, burning, cramping or aching. When severe it causes sweating, pallor, n/v, restlessness]
**Parietal pain
Steady, aching, more severe than visceral pain, usually aggravated by movement or coughing, patients prefer to lie still ex: peritonitis s/s pain with absent bowel sounds, rigidity, percussion tenderness and guarding
Referred pain
Pain felt distant to origin due to related innervation
Ex: duodenal or pancreatic origin pain referred to back. Pain from biliary tree referred to right scapular region or right posterior thorax
Pain from pleurisy or inferior wall myocardial infarction referred to epigastric region
Renal stone s/s
Colicky pain causing doubling over, frequent movement to find comfortable position, cramping pain radiating to the right or LLQ or groin
Pancreatitis s/s
Sudden knife-like epigastric pain often radiating to the back, acute onset, persistent pain which may be aggravated by lying supine, n/v, abdominal distention, fever, recurrent with alcohol abuse or gallstones, some relief with leaning forward with trunk flexed
GERD s/s
Heartburn and regurgitation more than once per week makes accuracy of diagnosis over 90% atypical symptoms:
- chest pain, cough, wheezing and aspiration PNA, hoarseness, chronic sore throat and laryngitis
- risk factors: reduced salivary flow, obesity, delayed gastric emptying; selected medications and hiatal hernia*
Alarm GI symptoms
Dysphagia, odynophagia, recurrent vomiting, evidence of GI bleeding, early satiety, weight loss, anemia, risk factors for gastric CA, palpable mass, painless jaundice warrant endoscopy to evaluate for esophagitis, peptic strictures, Barrett esophagus or esophageal CA
**Small or large bowel obstruction s/s
Diffuse abdominal pain, abdominal distention, hyperactive high-pitched bowel sounds, tenderness on palpation
Colon CA s/s
Change in bowel habits with mass lesion
Mesenteric ischemia s/s
Food fear, vomiting, bloody stool, signs of shock, abdominal pain, slightly distended/ soft/nontender abdomen, pain disproportionate to physical findings may have underlying cardiac disease, age > 50
**Ulcerative colitis What and s/s
Mucosal inflammation typically extending proximally from rectum to varying lengths of colon s/s: frequent watery stools, often containing blood, abrupt onset, night awakening, cramping pain, fever, fatigue, weakness, linked to Ashkenazi Jewish descendants and to altered CD4 T-cell Th2 response, increased risk of colon CA
**Crohn disease of small bowel What and s/s
Chronic transmural inflammation of bowel wall with skip pattern involving the terminal ileum and proximal wall, may cause strictures
s/s: pain happens insidiously, chronic and recurrent, crampy periumblical, RLQ or diffuse pain with anorexia, fever, and/or weight loss, perianal or perirectal abscesses and fistulas, may cause small or large bowel obstruction.
Often in teens or young adults, more common in Ashkenazi Jewish descendants, linked to altered CD4+ T-cell helper Th1 and 17 response
Acute vs. chronic diarrhea
Painless loose or watery stools during >=75% of defecations in prior 3 months, with symptom onset at least 6 months prior to diagnosis. acute: less than 2 weeks chronic: more than 4 weeks, usually due to Crohn’s or UC
Constipation criteria and s/s
Present in past 3 months with symptom onset at least 6 months prior to diagnosis and meet at least 2 of the following:
- fewer than 3 bms/week
- 25% or more defecations with either straining or sensation of incomplete evacuation;
- lumpy or hard stools;
- or manual facilitation.
Mechanisms of jaundice
- Increased production of bilirubin
- Decreased uptake of bilirubin by hepatocytes
- Decreased ability of liver to conjugate bilirubin
- Decreased excretion of bilirubin into bile, resulting in absorption of conjugated bilirubin back into the blood
Painless vs. painful jaundice
Painless: malignant obstruction of the bile ducts seen in duodenal or pancreatic carcinoma
Painful: infectious in origin, e.g. hepatitis A and cholangitis. Itching occurs in cholestatic or obstructive jaundice
Risk factors for liver disease
Travel, exchange of bodily fluids through sexual contact or use of shared needles, alcohol use, use of toxic agents, gallbladder disease or surgery, hereditary disorders
Classic findings of alcohol abuse
Hepatosplenomegaly, ascites, caput medusae (dilated abdominal veins), jaundice, spider angiomas, palmar erythema, Dupuytren contractures (finger muscle contractures), asterixis (flappy hand tremor) and gynecomastia
Screening for ETOH abuse
CAGE, Alcohol Use Disorders Identification Test (AUDIT) or the shorter AUDIT-C questionnaire
Moderate drinking
- Women <=1 drink/d
- Men <=2 drinks/d
Unsafe drinking
- Women > 3 drinks/d and > 7 drinks/wk
- Men > 4 drinks/d and > 14 drinks/wk
Binge drinking
- Women >=4 drinks on one occasion
- Men >=5 drinks on one occasion
1 drink = 12 oz of beer or wine cooler, 8 oz malt liquor, 5 oz wine, 1.5 oz 80-proof spirits
Hepatitis B vaccine prioritized for the following groups
- Sexual contacts
- People with percutaneous or mucosal exposure to blood
- Travelers to endemic areas
- People with chronic liver disease and HIV
- All adults in high risk settings, i.e. STD clinics, HIV test and tx programs, drug rehab programs, correctional facilities, hemodialysis facilities, facilities for people with developmental disabilities
High risk groups prioritized for Hepatitis A vaccine
- all children at age 1 year
- Individuals with chronic liver disease
- High risk groups: travelers to areas with high endemic rates, MSM, injection and illicit drug users, people who work with nonhuman primates and persons with clotting factor disorders
Hepatitis A: post-exposure ppx
Hepatitis A vaccine or a single dose of immune globulin within 2 weeks of exposure
Also apply to close personal contacts
Hepatitis B screening
More serious threat than Hep A infection
Screening for:
- People born in countries with high endemic prevalence
- Persons with HIV Injection drug users
- MSM
- Household contacts and sexual partners of HBV-infected persons
- All pregnant women in first trimester
Hepatitis C
Most prevalent chronic bloodborne pathogen in U.S.
Main risk factor: IVDA
Additional RF: blood transf or organ txp before 1992, transfusion with clotting factors before 1987, HD, HCW with needlestick injury or mucosal exposure to HCV-positive blood, HIV, birth from HCV-positive mother
Hepatitis C becomes a chronic illness in over 75% of those infected and is a major risk factor for subsequent cirrhosis, hepatocellular carcinoma, and need for liver txp for ESLD
Colorectal CA risk factors and prevention
- Increasing age, personal hx of colorectal CA, adenomatous polyps, or long standing IBD, family hx of colorectal neoplasia (1st degree relative, esp when relative age <60), or hereditary colorectal syndrome
- Weaker risk factors: AA, male sex, tobacco use, excessive alcohol use, red meat consumptions and obesity.
- Prevention: screen for and remove precancerous adenomatous polyps
**Colorectal CA screening tests
Adults ages 50-75 (grade A rec)
- High-sensitivity fecal occult blood testing annually, either a guaiac-based or fecal immunochemical test
- Sigmoidoscopy every 5 years wtih high-sensitivity FOBT every 3 years
- Screening colonoscopy every 10 years
Adults ages 76-85 years (grade C rec)
- Screening not advised because benefits small compared to risks
- Use individual decision-making if screening adult for first time
Adults > 85 years (grade D rec)
- Screening not advised d/t harm outweighs benefit
Any abnormal finding on a stool test, imaging study or flex sig warrants further evaluation with colonoscopy (gold standard)
Complications of colonscopy
Perforation and bleeding, patients are usually sedated during procedure but many are averse to the extensive bowel preparation required.
**Signs of intestinal obstruction
Protuberant abdomen, tympanic throughout, increased peristaltic waves
**Peritonitis s/s
Positive cough test
Guarding (voluntary contraction of abdominal wall, often accompanied by a grimace)
Rigidity (involuntary reflex due to peritoneal inflammation that persists over several examinations)
Rebound tenderness (pain expressed by patient with sudden removal of hand)
Percussion tenderness
Causes include: appendicitis, cholecystitis, and a perforation of the bowel wall
Normal liver span
6-12 cm in right MCL
4-8 cm in midsternal line
If enlarged, doubles the likelihood of cirrhosis
If decreased, may be indicative of resolution of hepatitis or HF, or less comonly, with progression of fulminant hepatitis
On inspiration, the liver is palpable about 3 cm below the right costal margin in the MCL
Clinical estimates of liver size should be based on both percussion and palpation.
Spleen percussion
- Traube space: percuss the left lower anterior chest wall from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin
Normal - tympanic throughout
Abnormal - dullness
- Splenic percussion sign: Percuss the lowest interspace in the left anterior axillary line (normal: tympanic). Ask patient to take deep breath and percuss again (normal: tympanic). If abnormal (not tympanic), pay attention to palpation of spleen.
Pyelonephritis on exam
Pain with pressure or fist percussion, especially when associated with fever and dysuria, although may be musculoskeletal.
**AAA
Risk factors
Likely rupture and relative mortality
Risk Factors
- Age >= 65 years
- Male gender
- Hx of smoking
- First-degree relative with a history of AAA repair
Periumbilical or upper abdominal mass with expansile pulsations that >= 3 cm in diameter suggests an AAA.
Widths of 3-3.9 cm, 29% AAA
4-4.9 cm, 50%
>=5 cm, 76%
Rupture is 15 times more likely in AAAs > 4 cm than in smaller aneurysms
Which carries 85-90% mortality rate
USPSTF recommends ultrasound screening for men over 65 years who have “ever smoked.”
Ascites Assessment
- Percuss outward to map dullness from ascites
- In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top.
- When percussing the border of tympany and dullness with a patient in supine position, in a person without ascites the border between the two remains constant. It shifts with ascites.
- Test for fluid wave - an easily palpable impulse suggests ascites
- Ballotte the organ or mass - make a brief jabbing movement directly toward the anticipated structure
A positive fluid wave, shifting dullness and peripheral edema makes the presence of ascites 3-6 times more likely
**Appendicitis diagnosis
- Twice as likely in the presence of RLQ tenderness, Rovsing sign and psoas sign
- Three times likely with McBurney point tenderness
- Pain begins in the umbilicus and then moves to RLQ
Note: McBurney point lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus.
Note: Rovsing sign is pain in the RLQ during left-sided pressure (deep and even)
Note: Psoas sign is pain when placing a hand on the patient’s right knee and s/he attemps to raise that thigh against the hand. Or, if turn to the left side, flexion of the leg at the hip, causes pain. Both are a positive Psoas sign.
Note: A less helpful sign, the obturator sign, is pain with flexion of the right thigh at the hip with knee bent and internal rotation of the leg at the hip.
**Murphy sign
Assessing for a positive sign in acute cholecystitis (p. 486)
- Hook left thumb or fingers of right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin.
- Ask pt to take a deep breath (INSPIRATION).
- Note breathing and degree of tenderness.
**Omphalitis
Infection of the umbilical stump
characterized by periumbilical edema and erythema
Palpation of liver in infants
normal: 1-3 cm below the right costal margin
An enlarged, tender liver may be due to HF or storage diseases.
Hepatomegaly in newborns is d/t hepatitis, storage disease, vascular congestion and biliary obstruction.
**Pyloric stenosis in infants
- Deep palpation: 2 cm firm pyloric mass in RUQ or midline
- While feeding, visible peristaltic waves across abdomen, follwed by projectile vomiting
- Infants present at about 4-6 weeks of age
Liver span in children
- Increases with age
- Reaches adult size during puberty
Rheumatoid arthritis
Persisting bilateral swelling and/or tenderness at the wrist
Symmetric deformity in the PIP, MCP and wrist joints
Later, there is MCP subluxation and ulnar devation
May show swan neck deformities
MCPs are often boggy and tender
Tenderness on compression of the forefoot is an early sign of RA
**Metatarsus adductus
Forefoot is adducted and not inverted.
AKA pigeon toes
**Gower’s sign
Tests for weakness of proximal muscles spec. LE muscles.
The sign describes a patient that has to use their hands and arms to “walk” up their own body from a squatting position due to lack of hip and thigh muscle strength.
