General diagnosis - abdominal exam Flashcards
Abdominal aorta aneurysm
vascular surgeon
- often asymptomatic
- symptomatic: LBP, pulsating mid-line mass, in abdomen above umbilicus, bruit in region
- saccular or fusiform dilation o aorta below renal aa. caused by atherosclerosis
- abdominal xray: curvilinear lines of calcification adj to Lx vertebra
- US confirms Dx and size
Acute pancratitis
urgent referral
- sever epigastric pain that radiates through the back
- acute inflammation of pancreas caused by: alcohol abuse, stone in ampulla of vater, viral infection (mumps virus)
- labs: marked elevation of serum amylase and lipase
- CT shows swollen pancreas
- Cullen and Grey Turner’s signs may be present in small % of pts
Appendicitis
urgent referral (CT confirm Dx)
- periumbilical pain followed by n/v, fever, then pain radiates to right iliac fossa,
- Rovsing’s, psoas or obturator signs may be present
- acute inflammation of appendix (often in kids)
- caused by: fecalith obstructing the orifice of the appendix, viral infection
Celiac disease
Co-manage with gastroenterologist (recomment gluten-free diet)
- weight loss, fatigue, diarrhea, steatorrhea in adults, failure to thrive in kids
- may have: chronic papular vesicular skin rash-dermatitis herpetiformis
- Gluten hypersensitivity causing chronic disease of the SI.
- MC: iron deficiency anemia, less common: folic acid, B12 deficiency
- labs: elevated antigliadin (IgA) and IgG antibodies: mucosal biopsy confirms Dx
Cholecystitis
urgent referral
- RUQ pain that can radiate to the rigth infrascapular region, fever, n/v and Murphy’s sign
- common: fair, fat, fertile females in 40’s, 95% associated w/ gallstones
- acute inflammation of the GB (MC E. coli)
- US shows stones in GB better than xray of the abdomen
Cirrhosis
Co-manage with gastroenterologist
- fatigue, jaundice, palmer erythema, enlarged non-tender liver, gynnecomastia, caput mdusa, esophageal varices and internal hemorrhoids, signs of portal HTN like ascites
- liver condition d/t chronic damage (alcohol abuse, hepatitis C infection)
- Liver function test: elevated liver enzymes (AST, ALT, alkaline phosphatase), bilirubin; liver biopsy confirm Dx
crohn’s disase
Co-manage with gastroenterologist
- recurrent RLQ pain, diarrhea, fatigue
- characterized by: cobblestone appearance of the mucosa of terminal ileum, skip lesions, non-caseous granulomas
- chronic inflammatory bowel disease (idiopathic)
- Lab: CBC (macrocytic normochromic anemia, Vitamin B12 deficiency)
- endoscopy and biopsy confirm Dx
Diabetic ketoacidosis
urgent referral
- shortness of breath, acetone smell, polyuria, polydypsia, polyphagia, Kussmaul’s brathin (deep rapid=air hunger) present, 50% pts have abdominal pain
- characterized by: excess ketone production from beta oxidation of fats
- poorly controlled diabetes mellitus (especially Type 1)
- raised Fasting Blood Glucose level, hyperkalemia and ketonuria
Diverticulitis
urgent referral if bright red rectal bleeding
- lower left sided abdominal pain with blood in stool, low grade fever
- acute inflammation of diverticula in LI (associated w/: lack of iber, after 70yo)
- barium enema or colonoscopy will confirm Dx
Ectopic pregnancy
urgent referral, 911 if pts BP <90/60
- 6-8wks of amenorrhea followed by lower abdominal pain, vaginal spotting, Kehr’s (left shoulder pain) may be present
- pregnacy developing in uterus (MC in fallopian tube)
- associated w/: previous gonorrhea or chlamydia infection
- abdominal US confirm Dx
Epididymo-orhitis
hospital referral
- pain in scrotum and periumbilical region, history of dysuria, urinary frequency
- Prehn’s test (reduction of pain w/ elevation of scrotum) may be +
- infection of epididymis and testis (Neisseria infection)
Femoral hernia
general surgeon referral
- irreducible swelling I. and lateral to pubic tubercle
- defect in femoral canal (MC females)
Generalized peritonitis
urgent referral
- sever generalized abdominal pain, guarding, fever, ABSENT bowl sounds
- Blumberg’s sign (rebound tenderness)
- acute inflammation of peritoneum d/t rupture of the bowel or ruptured ectopic pregnancy
- xray: distended loops of bowel with multipule air-fluid levels
Hepatitis
gastroenterologist referral
- fever, n/v, jaundice, tender swollen liver
- acute/chronic inflammation of liver d/t viral infections (hep A, B, C or E0
- Hep A, E are spread vi orofecal route; Hep B, C by sex or contaminated blood
- Labs: elevated liver enzymes (AST, ALT and alkaline phsphatase) and bilirubin
- serology confirms type of virus
Inguinal hernia
general surgeon referral
- reducible mass in inguinoscrotal region
- congenital defect or traumatic (MC hernia type, M > F)
Intestinal obstruciton
urgent referral
- cramping abdominal pain, abdominal distention with hyperactive vowel sounds
- blockage of small/large bowel d/t mass or adhesions form previous surgery obstructing bowel from the outside
- abdominal xray: distended loops of bowel with multiple air-fluid levels
Irritable bowel syndrome
Co-manage with gastroenterologist
- bouts of abdominal pain relieved by defecation, diarrhea, constipation
- closed eye sign may be present; NO confirmatory test
- chronic functional gut disorder (idiopathic)
Mesenteric Vascular Occlusion
urgent referral (angiography to confirm)
- sever abdominal out of proportion to findings (mild tenderness early), blood in stool, shock (late stage)
- sudden blockage of mesenteric artery/vein
- associated w/: atherosclerosis
Nephrotic Syndrome
hospital referral
- fatigue, BL ankle swelling, ascites, Muehrcke’s lines (curved transverse lines on the nails), frothy/foamy urine
- chronic disease of kidney affecting basement membrane, associated w/ diabetes mellitus and SLE
- UA: massive proteniuria > 3.5g/d, hypoproteinemia, hypercholesterolemia
- renal biopsy confirms Dx
Pelvic Inflammatory disease (PID)
hospital referral
- fever, lower abdominal pain, cervical motion tenderness and mucopurulent discharge
- inflammatory disease of the uterus, Fallopian tubes and surrounding pelvic connective tissue (Neisseria gonorrhea or Chlamydia trachomatis)
Peptic Ulcer Disease
Co-manage with gastroenterologist (stress reduction + dietary modification)
- epigastric pain: worse with food (gastric ulcer) or beter with food (duodenal ulcer), might have melena (black tarry stools) if ulcer bleeds
- ulceration of stomach/duodenum associated w/; helicobacter pylori infection (NSAIDS, smoking or alcohol)
- gastroscopy and biopsy confirm Dx
Portal HTN
gastroenterologist referral
- fatigue, caput medusae, esophageal varices and internal hemorrhoids, ascites
- cirrhosis complication: blood flow from portal vein to liver is obstructed d/t increase fibrosis
Prostatisis
urologist referral
- suprapubic/perineal discomfort, dysuria, frequency of urination, tender soft boggy prostate on digital rectal examination
- acute/chronic inflammation of the prostate
- associated w/: E. coli, chlamydia infection
Pyelonephritis
hospital referral
- chills, fever, n/v, flank pain with costovertebral angle tenderness, + Murphy’s punch
- acute/chronic inflammation of pelvis of kidney and ureter d/t ascending infection from bladder (E. coli MC)
- UA: numerous WBC, WBC casts and bacteria
Tertiary Syphilis
neurologist referral
- lightning pains in the abdomen (idiopathic) and/or chronic non-healing ulcers with undetermined edges (gumma)
- Romberg’s sign might be present, Argyll Robertson pupils in neurosyphilis
- 3rd stage syphilis caused by Treponema pallidum (can take 3-15y to develop after exposure)
Testicular cancer
urologist referral
- dull ache in scrotum with enlarged irregular testis and possible gynecomastia (some leydig cells testicualr aners produce estrogen)
- uncommon malignancy in testis (MC type is seminoma)
- spreads to para-aortic lymph nodes
- US confirms the ECHOdensity of the mass and biopsy will confirm Dx
Torsion of the testis
urgent referral (confirm and surgery)
- sudden onset of testicular or scrotal pain (in periumbilical region), n/v
- (-) Prehn’s sign, affected testis is higher than the other
- uncommon twisting of testis d/t a long mesorchium (testicular mesentery)
Ulcerative colitis
Co-manage with gastroenterologist
- left sided abdominal pain, fatigue, anemia, recurrent bloody diarrhea
- chronic inflammatory bowel disorder (idiopathic)
- characterized by: superficial ulcerations of the descending and sigmoid colon
- Lab: microcytic and hypochromic anemia (iron deficiency) d/t blood loss
- colonoscopy and biopsy confirm Dx
Volvulus
urgent referral
- sever abdominal pain, distension with hyperactive bowel sounds
- acute twisting of the bowel on itself (MC in sigmoid colon)
- abdominal xray: classic coffee-bean (inverted U) sign
abdominal bruit in midline of epigastrum
AAA
abdominal bruit left of midline epigastrium
unilateral renal artery stenosis
absent bowel sounds (paralytic ileus)
generalized peritonitis
acetone breath
diabetic ketoacidosis
argyll robertson pupil
tertiary syphilis
ascites (fluid in the abdomen-shifting dullness)
cirrhosis, nephrotic syndrome, cancer
beef red smooth tongue
vitamin B12 deficiency
BL kidney enlargemnt
poly-cystic disease of the kidneys
bluish discoloration in flanks (grey turner sign)
pancreatitis or ectopic pregnancy
bluish discoloration in unbilicus (cullen sign)
pancreatitis or ectopic pregnacy
blumberg’s sign (rebound tenderness)
generlized peritonitis
caput medusa (dilated veins radiating from navel)
portal hypertension as in cirrhosis
cessation of inspiration on RUQ pressure (murphy sign)
Cholecystitis
CVA tender on percussion (murphy’s punch)
pyelonephritis
dull percussion note in traube’s space
splenomegaly
epigastric tenderness
PUD, gastritis, pancreatitis
friction rub
trauma, infection or cancer
hepatojugular reflex (increased JVP with RUQ pressure)
congestive heart failure
hyperactive bowel ounds with borborygmi
intestinal obstruction
hyper-resonant percussion note
intestinal obstruction
irregular hard prostate
prostate cancer
kehr’s sign (left shoulder pain in actue abdomen)
ruptured ectopic pregnancy or spleen
left iliac fossa tenderness
diverticulitis, ulcerative colitis
liver edge below right costal margin
hepatomegaly
magenta tongue
riboflaven deficiency
mcburney’s sign (tenderness ++ over mcburney’s point)
appendicitis
murphy’s punch (CVA tenderness on percussion)
pyelonephritis
murphy’s sign (RUQ pain on deep inspiration)
choecystitis
non-tender hepatomegaly
cirrhosis, hepatic metastases
obturator internus test (RIF pain on hip internal ROT)
APPENDICITIS
PAINFUL BOGGY PROSTATE
prostatitis
painless testicular mass
testicular cancer
prehn’s sign
epididymo-orchitis
puddle sign
ascites
reducible gurgling mass in the inguinal gegion
inguinal hernia
RIF pain with pressure in legt quadrant
Rovsing’s sign
RIF pain with internal rotation of right hip
obturators sign
right hypochondriac tenderness with jaundice
hepatitis
right hypochondria tenderness, +murphy’s sign
cholecystitis
right iliac fossa tenderness maximum at mcburney point
appendicitis
right iliac fossa tenderness wit hrecurrent diarrhea
crohn’s disease
right iliac fossa tenderness, purulent vaginal discharge
pelvic inflammatory disease
rogoff’s sign (costoverteral angle tenderness)
adrenal inflammation
rovsing’s sign (RUQ pain on pressure in the LLQ)
APPENDICITIS
Scaphoid abdomen
sever malnurition
sharp pain on sudden removal of pressure
blumberg’s sign
shifting dullness
ascites
small liver on percussion
cirrhosis or ephysema
tender hepatomegaly
hepatitis, congestive heart failure
