Gastrointestinal

Question 1

• Increased stool frequency (>3 BMs a day), liquidity of feces, and may vary from one individual from another
• Symptoms depend on causative agent but may include sudden onset of nausea, vomiting, and decreased appetite, crampy abdominal pain, loose stool, malaise, fatigue, diffuse abdominal tenderness, distention, increased bowel sounds
• May be +Tilts depending on fluid loss
• Usually afebrile

Answer 1

Diarrhea

Question 2

•Infrequent stool, excessive straining, sense of incomplete evacuation, or need for digital manipulation

Answer 2

Constipation

Question 3

• Non prolapsed internal hemorrhoids are not visible but may protrude through the anus with gentle straining
• Prolapsed hemorrhoids are visible as protuberant purple nodules covered by mucosa
• External hemorrhoids are readily visible on perianal inspection and appear as tense, bluish perianal nodules covered with skin that may be up to several centimeters in size and are extremely tender to palpation

Answer 3

Hemorrhoids

Question 4

• Severe, tearing pain during defecation followed by throbbing discomfort that may lead to constipation due to fear of recurrent pain
• Bright red blood may be seen on stool or toilet paper
• Acute fissures look like cracks in the epithelium
• Chronic fissures result in fibrosis and the development of a skin tag at the outermost edge

Answer 4

Anal Fissure

Question 5

• Dull, aching, or throbbing pain that becomes worse immediately before defecation, is lessened after defecation, but persists between bowel movements
• The pain is significantly increased by the increased pressure in the rectum, occurs just before defecation
• As the abscess spreads and comes nearer to the surface, the associated pain becomes more intense
• Pain will be aggravated by straining, coughing, or sneezing
• As the abscess progresses, pain interferes with walking or sitting
• Easily palpable and are usually NOT accompanied by fever, leukocytosis, and sepsis in the immunocompetent patient

Answer 5

Perianal Abscess

Question 6

• Non-healing anorectal abscess following drainage
• Chronic purulent drainage and a pustule like lesion in the perianal or buttock area
• Intermittent rectal pain, particularly during defecation but also with sitting
• Intermittent and malodorous perianal drainage and pruritus

Answer 6

Anorectal Fissure

Question 7

•Swelling, pain, or persistent discharge
•Examination reveals an area of inflammation in the midline of the gluteal crease, with one or more sinus openings
•Most common finding is a single opening from which hair is protruding
•Spontaneous and ongoing drainage is the most common indicator
•A history of recurrent infection at the base of the spine is diagnostic
**MEDAVICE**

Answer 7

Pilonidal Disease

Question 8

• PTs report low grade fever, malaise, weight loss, intermittent diarrhea, and loss of energy
• Cramping or steady right lower quadrant or periumbilical pain is common
• Large painful skin tags, anal fissures, perianal abscesses, and fistulas (Crohn’s Cronies)
• Oral aphthous lesions and increased prevalence of gallstones

Answer 8

Inflammatory Bowel Disease, Chron’s

Question 9

• Bloody diarrhea is the hallmark
• Stools may be formed or loose in consistency, fecal urgency and tenesmus
• Left lower quadrant cramps relieved by defecation are common; no significant abdominal tenderness
• Moderate - More severe diarrhea with frequent bleeding, abdominal pain and tenderness may be present but not severe, mild fever, anemia and hypoalbuminemia
• Severe - 6-10 bloody bowel movements per day resulting in severe anemia, hypovolemia, impaired nutrition and hypoalbuminemia; abdominal pain and tenderness are present

Answer 9

Inflammatory Bowel Disease, Ulcerative Colitis

Question 10

•Abnormal stool frequency, abnormal stool form, abnormal stool passage, passage of mucus, bloating or a feeling of abdominal distention

Diagnosis of IBS requires: abdominal discomfort or pain with at least 2 of the 3 features:
•Relieved with defecation
•Onset associated with change in frequency of stool
•Onset associated with a change in form (appearance) of stool

Answer 10

Irritable Bowel Syndrome

Question 11

• Heartburn occurs 30-60 minute after meals and upon bending over or reclining
• PTs often report relief after taking antacids or baking soda
• PTs may complain of regurgitation, dysphagia, or developing an esophageal stricture
• Atypical manifestations to include; asthma, chronic cough, chronic laryngitis, sore throat, non-cardiac chest pain

Answer 11

Gastroesophageal Reflux Disease (GERD)

Question 12

• Medication induced esophagitis usually presents with retrosternal pain or heartburn, odynophagia, and dysphagia
• Pill induced may have hematemesis, abdominal pain, and weight loss; history of taking pills without water commonly at bedtime
• Candida Esophagitis hallmarks are odynophagia, retrosternal pain, white mucosal plaque-like lesions on endoscopy; most common in HIV infected patients

Answer 12

Esophagitis

Question 13

• Localized substernal chest pain, heartburn, and dysphagia (cardinal feature)
• History of esophageal irritation from Chronic GERD

Answer 13

Esophageal Stricture

Question 14

•Gradual onset of dysphagia with solid foods and some liquids that can be present for months, substernal discomfort/fullness, lifting neck or throwing shoulders back to enhance gastric emptying, regurgitation and substernal chest pain

Answer 14

Esophageal Spasm

Question 15

•Hematemesis with or without melena
•History of retching, vomiting, or straining
•Boerhaave often presents with excruciating retrosternal chest pain due to an intrathoracic esophageal perforation
**MEDEVAC**

Answer 15

Mallory-Weiss/Boerhaave Syndrome

Question 16

• Erosive and hemorrhagic gastritis is most commonly seen in alcoholics, critically ill patients (mechanical ventilation, burns, trauma, shock, sepsis), or PTs taking NSAIDS
• May cause epigastric pain, nausea, and vomiting
• Coffee ground emesis is the hallmark

Answer 16

Gastritis

Question 17

• Epigastric pain (hallmark) that is described as gnawing, dull, aching, or ““hunger like””
• Relief of pain with food or antacids and a recurrence of pain 2 hours later
• Nocturnal pain in some patients
• Nausea and anorexia may occur with gastric ulcers

Answer 17

Peptic Ulcer Disease

Question 18

ACUTE UPPER GI BLEEDING
•Hematemesis (bright red blood or coffee grounds), Melena in most cases

ACUTE LOWER GI BLEEDING
•Hematochezia (bright red blood in stool) usually present
•Hx of Diverticulosis, IBD, or Anorectal Disease
•Painless, large volume bleeding usually suggests diverticular bleeding
**MEDEVAC**

Answer 18

Gastrointestinal Bleeding

Question 19

•Mild to moderate aching abdominal pain, usually in the left lower quadrant
•Constipation, loose stools, nausea and vomiting
•Low grade fever, LLQ tenderness, a possible, palpable mass
•Positive stool occult blood
**MEDEVAC**

Answer 19

Diverticulitis

Question 20

•Initial onset of vague/colicky periumbilical or epigastric pain that shifts to RLQ (McBurney’s Point) within 12 hours and becomes a steady ache that is made worse with walking or coughing
•Positive Psoas and/or Obturator Sign
•Positive Rebound Test with guarding
•Decreased to absent bowel sounds, localized pain when asked to cough
•Associated symptoms include; nausea, anorexia, constipation, low grade fever
**MEDEVAC**

Answer 20

Appendicitis

Question 21

•The attack is often precipitated by a large or fatty meal and is characterized by the sudden appearance of steady pain localized to the epigastrium or right hypochondrium which may gradually subside over a period of 12-18 hours
•Vomiting, fever, RUQ abdominal tenderness with muscle guarding
•Positive Murphy and Rebound Tenderness sign
**MEDEVAC**

Answer 21

Cholecystitis

Question 22

•Abrupt onset epigastric abdominal pain that is steady, boring, and severe
•Made worse by walking and laying supine and made better by sitting and leaning forward
•Pain may radiate to the back
•Nausea and vomiting
•May be alcohol induced or gallstone induced (heavy meal)
•Fever of 101.1 to 102.2, tachycardia, hypotension, pallor, and cool clammy skin are often present
•Mild jaundice and an upper abdominal mass can be palpated due to inflamed pancreas
•Positive Rovsing sign
**MEDEVAC**

Answer 22

Pancreatitis

Question 23

•Felt along the inguinal canal in males and the external ring of the labia majora in females and present as an abnormal soft tissue mass
•Swelling may extend into the scrotum
•If incarcerated, will be tender due to inflammation; erythema and ecchymosis may be present
•Tachycardia and mild fever may be present
**An acutely incarcerated hernia that cannot be reduced, regardless of type or the patients age, requires MEDEVAC for immediate surgical eval or repair**

Answer 23

Hernia

Question 24

•Most common cause of SBO are adhesions following abdominal surgery (ask on PSHx)
•Second most common cause of SBO is incarceration of a groin hernia
•Most common cause of LBO are neoplasms
•SBO presents as episodic hypogastric abdominal pain that may be distended, tympanic to percussion and mechanical obstructions will produce active, high pitched bowel sounds with occasional ““rushes””
**MEDEVAC**

Answer 24

Bowel Obstruction

Question 25

•Five most common causes are: Appendicitis, Cholecystitis, Diverticulitis, Pancreatitis, and Bowel Perforation
•Fever, tachycardia and possible hypotension
•PT in fetal position, any movement worsens pain; visible peristalsis suggests bowel obstruction
•Absent bowel sounds in all four quadrants; BOARD LIKE ABDOMEN during palpation
•Positive Iliopsoas and Obturator signs
**MEDEVAC**

Answer 25

Secondary Peritonitis

Question 26

•Can be from: blunt, direct blow, crush, deceleration injury, or penetrating
•May present as unexplained hypotension or shock, hypovolemic shock may be the only presenting sign
•Peritonitis Syndrome - fever, tachycardia, diffuse abdominal pain, tenderness and ileus
**MEDEVAC**

Answer 26

Abdominal Trauma