Exam 3: Muscle and Abdomen Flashcards
What are the screening recommendations for colorectal cancer?
Grade A Recommendation Adults age 50-75 years
Stool-based tests
Direct Visualization tests
CT colonography every 5 years
Grade C Recommendation Adults age 76-85 – Individualized decision making
Grade D Recommendation Adults older than 85 – DO NOT SCREEN
What are the screening recommendations for an abdominal aortic aneurysm?
USPSTF Grade B Recommendation for one time abdominal US screening for men 65-75 years old that have smoked more than 100 cigarettes in their lifetime.
Grade C Recommendation: Clinicians selectively screen men who have never smoked aged 65-75 years.
Grade D Recommendation: Do not screen women who have never smoked
When auscultating the abdomen What would a hepatic bruit suggest?
Vascular occlusive disease
Liver carcinoma or cirrhosis
When auscultating the abdomen what would Venous hum indicate?
portal hypertension r/t Hepatic Cirrhosis
increased collateral circulation between portal and systemic venous systems
When auscultating the abdomen what would a Friction rub indicate?
location
indication
LOCATION:
Liver & Spleen
INDICATION:
- Liver Cancer
- Chlamydial/gonoccocal perihepatitis
- Recent liver biopsy
- Splenic Infarct
What does a friction rub sound like?
Grating sound with respiratory variation
When auscultation the abdomen, when would an arterial bruit indicate?
Systolic and diastolic components = occlusion
= renal artery stenosis
= Renovascular hypertension
Acute Gouty Arthritis
Location
Characterisitcs
What is it commonly mistaken for?
Location:
- metatarsophalangeal joint of the great toe = site of initial attack
- Ankle, tarsal joints, & knee commonly involved
Characteristics:
- pain, tender, hot, dusky red swelling that extends beyond joint
- Commonly mistaken for cellulitis*
Ingrown toenail
What
Character
Assoc
Location
Sharp edge of toenail digs into lateral nail fold
Characteristics:
-Tender, red, overhanging nail fold.
Associated Manifestation:
-Sometimes with granulation tissue and purulent discharge
Location:
-Usually Great Toe
Hammer Toe
location
characteristics
associated with
Location:
-Usually 2nd toe
Characteristics:
-Hyperextension at the metatarsophalangeal joint w/flexion at proximal interphalangeal (PIP) joint
Associated with:
Corn develops at pressure point
Callus
Similar to corn
Involves skin that is usually thick under recurrent pressure
Painless (if there is pain suspect underlying wart)
Plantar Wart
Cause
Location
Characteristic
Cause:
-HPV
Location:
-Sole of foot
Characteristic:
- Small dark spots that give a stippled appearance
- Tender if pinched side to side
Neuropathic ulcer
how to detect loss of sensation
Cause:
-Dim/Absent pain sensation from diabetic neuropathy
Location:
-Pressure points on feet
Characteristics:
- Painless r/t sensory disruption
- Usually deep, infected and indolent
Associated with:
Osteomyelitis & ensuing amputation
**Use a nylon filament to detect loss of sensation*
When auscultating the abdomen, what would be normal findings?
Normal sounds consist of clicks and gurgles, occurring at an estimated frequency of 5-34 per minutes.
What is referred pain, give an example
duodenal/pancreas referred to?
biliary tree ….
MI…
Felt in more distant sites that are innervated at approximately the same spinal levels as disordered structures.
Develops as initial pain and becomes more intense
Site palpation is not tender
Example:
- duodenol/pancreas»_space;> back
- biliary tree»» R scapula or R post thorax
- MI»>epigastric
What is visceral pain, give example
RUQ
Periumbilical
RLQ
Pain disproportionate to findings
Abdominal organs unusually contracted OR distended
Palpation:
Near midline at varying levels depending which structure is involved
Ischemia stimulates visceral nerve pain fibers
Characteristic:
Gnaw/cramp/ache»_space; systemic s/s (sweat, N/V..)
Location: RUQ = Liver distension Periumbilical = acute appendicitis RLQ = progressive appendicitis Pain disproportionate to findings = mesenteric ischemia
What is parietal/somatic pain, give example
cause
characteristic #3
aggravators #2
alleviators
CAUSE:
inflammation parietal peritoneum (peritonitis)
CHARACTERISTIC:
Steady ache
More severe than visceral pain
More localized
AGGRAVATORS:
- Movement
- Coughing
ALLEVIATORS:
-lying still
How to percuss liver
start well below the umbilicus in the RLQ, percuss upward toward the liver identifying dullness (lower border).
Next, ID the upper border of liver for dullness starting at the nipple line and percuss downward.
How to palpate liver
- Place your left hand behind the patient, parallel to and supporting the right 11th and 12th rib and adjacent soft tissue below.
- Remind pt to relax on your hand.
- Press your left hand upward.
- INHALE
- Place your right hand on right abdomen lateral to the rectus muscle with your fingertips.
Hooking technique how to
for obse pt.
Stand to right and place both hands side by side and ask the pt to take a deep breath in.
If someone has hypertension, where would you auscultate and look for?
LOCATION:
- epigastrum
- CVA
- aorta
- iliac & femoral arteries
CVA = renal artery stenosis
What is borborgymi?
rumbling of bowel sounds
Techniques to assess liver for children
Scratch test:
- Diaphragm just above the costal margin, midclavicular line.
- With fingernail, lightly scratch moving below umbilicus toward the coastal margin.
- Scratching sound will change on the liver’s edge.
What history and exam findings are consistent with Diverticulitis?
Process location quality timing relieving factors #3 associates symptoms/setting #5
PROCESS:
acute inflame in sigmoid or descending colon
LOCATION:
LLQ or Pelvic
palpable mass
QUALITY:
cramping at first then steady
TIMING:
gradual onset
RELIEF:
analgesia
bowel rest
abx
ASSOC: fever diarrhea urinary s/s anorexia
What history and exam findings are consistent with Peritonitis?
cause #3
Signs #6
examples #5
Cause:
inflame
infection
ischemic intraabdominal process
Signs: \+cough test involuntary guarding rigidity absent bowel sounds rebound tenderness*** percussion tenderness
Example: appendicitis diverticulitis cholecystitis bowel ischemia perforation
What history and exam findings are consistent with acute appendicitis?
Process Location Quality: Timing Aggravating factors Relieving Factors Associated symptom/setting
PROCESS:
-inflame appendix w distention or obstruction
LOCATION:
- Poorly localized
- Periumbilical
- migrates to RLQ
QUALITY:
- Mild > increasing > severe
- steady
- cramping
TIMING:
-worsens until treatment
AGGRAVATE:
-movement/cough
RELIEF:
if subsides=perforation
ASSOC S/S:
- Anorexia
- Nausea/Vomit
- Low fever
What history and exam findings are consistent with cholecystitis?
Process Location/Radiates Quality: Timing Aggravating factors Relieving Factors Associated symptom/setting
PROCESS:
-inflamed gall bladder r/t persistent obstruction of cystic duct by gallstone
LOCATION:
- RUQ or epigastrum
- radiates R shoulder
QUALITY:
-steady, persistent cramp
TIMING:
-gradual onset
AGGRAVATE:
-prior history of biliary colic symptoms
RELIEF:
-NONE
ASSOC S/S: -anorexia -N/V -Fever NO JAUNDICE
What history and exam findings are consistent with acute/chronic pancreatitis?
Process Location/radiates Quality: Timing Aggravating factors Relieving Factors Associated symptom/setting
PROCESS:
-Pancreatic enzymes activated and autodigest and inflame pancreas
LOCATION:
- epigastric
- Radiate straight to back or other areas of abdomen
- 20% w/ severe sequelae of organ failure
QUALITY:
-steady, progressive & severe
TIMING:
-acute onset, persistent pain
AGGRAVATE:
-Movement
RELIEF:
- Hydration
- Bowel Rest
ASSOC S/S:
- N/V
- Abdominal distension
- 80% hx alcohol abuse or gallstones
What history and exam findings are consistent with Obstruction?
Process Location Quality: Timing Aggravating factors Relieving Factors Associated symptom/setting
PROCESS: -caused by adhesions/hernia small bowel OR -Cancer -Strictures
LOCATION:
- Generalized abdominal pain, nonspecific
- Distension
QUALITY:
- cramping
- colicky
TIMING:
- progressive
- intermittent
AGGRAVATE:
-ingestion food/liquids
RELIEF:
-bowel rest, hydration
ASSOC S/S:
- No flatus
- N/V
- Abdominal distension
What techniques can the FNP use to assess for ascites?
Shifting dullness
Fluid wave
What shifting dullness and how to assess?
+ ascites= Dullness shifts to a more dependent side and tympany shifts to top
Percuss tympanic border supine and again lateral
what is fluid wave and how to assess?
detect impulse transmitted through ascitic fluid from one flank to opposite side.
Only positive when ascites is obvious
Even people without ascites can be positive
Dysphagia
Presentation
Etiology
Difficulty swallowing
“not go down right”
Motility or Structural disorder
Etiology:
- Neurologic: stroke/parkinksons/ALS (old)
- Muscular: MD/myasthenia gravis (old)
- Structural: stricture (young)
Odynophagia
Presentation
Etiology
Painful swallowing
Etiology:
Ingestion: Esophageal ulceration r/t NSAIDS/ASA
Radiation
Infection: Candida, CMV, Herpes, HIV
What is the Murphy sign and what does it indicate?
Who would you do it for?
What is it?
What is a positive sign
what does it mean?
Who?:
RUQ pain, no tenderness on palpation but suspicious for acute cholecystitis
PERFORM:
deep palpation on deep inspiration
+Murphy sign = sharp halting in inspiratory effort d/t pain
Triples likelihood of acute cholecystitis
What is the Psoas sign and what does it indicate?
HOW TO:
supine, hand above R knee and patient raise thigh against hand
Pain w/increased intrabdominal pain = positive
+Psoas = appendicitis
What is the Obturator sign and what does it indicate?
+Obturator sign = R hypogastric pain = inflamed appendix
HOW TO:
Knee bent and internally rotate
What is the Rovsing sign and what does it indicate?
+Rovsing sign= Pain at RLQ during L sided pressure = appendicitis
HOW TO:
pt supine, press deep in LLQ, then quickly withdraw
“indirect tenderness & referred rebound tenderness”
What are the various presentations of bloody stool? What are the possible etiologies?
????
What are the various etiologies for constipation? How do they present?
Life Activities IBS mechanical obstruction painful anal lesions drugs depression neurologic disorders metabolic conditions
IBS
Process
Assoc Symptom, setting
Diagnosis
Fxal change w/o known pathology
Possibly change from intestinal bacteria
3 Patterns:
Diarrhea
Constipation
Mix
Diagnose S/S >6 months Pain >3 months 2-3 features (stool improvement, onset w change in stool frequency, form or appearance)
Rectum/Sigmoid Cancer
type of obstruction
s/s #4
MECHANICAL OBSTRUCTION
Narrowing of bowel from carcinoma
Change bowel habits
diarrhea, abdominal pain
Blood
Pencil shaped stools
Fecal Impaction
MECHANICAL OBSTRUCTION
rectal fullness
abdominal pain
diarrhea
usually older adults
Obstructing lesions:
diverticulitis, volvulus, intussusception, hernia
s/s
Colicky pain, distension
what do stools look like in intussception?
currant “jelly stools”
red & mucus
What drugs cause constipation?
anticholinergics
opiates,
antacids containing calcium or aluminum
What metabolic conditions cause constipation?
pregnancy
hypothyroidism
hypercalcemia
what does pain precipitated by exertion indicate?
CAD
