GI Flashcards

1
Q

why is it important to ask about a history of mouth ulcers?

A

symptoms of Crohns or ulcerative colitis

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2
Q

if a patient has severe abdo pain pain ad a history of relapsing epigastric pain what could it be?

A

perforated peptic ulcer

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3
Q

why is important to as about abdo surgery?

A

result in adhesions-> intestinal obstruction

damage to bile duct in cholecystectomy->biliary stricture->jaundice

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4
Q

what hereditary condition predisposes to bowel cancer?

A

familial adenomatous polyposis

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5
Q

what GI disorders is cigarette smoking associated with?

A

increased risk gastric and oesophageal cancer

worsens GOR

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6
Q

what medications are associated with GI disorders?

A

NSAIDs: GI bleeding
codeine and some antidepressants: constipation
phenytoin, tetracyclines and amiodarone: damage liver
paracetamol overdose: acute liver cell necrosis
chlorpromazine, sulponamides, sulphonylureas, rifampicin, nitrofurantoin, combine OCP: hypersensitivity=cholestasis
anticholinergic, CCB, theophylline and nitrates: increase GOR
opiates, dopamine agonists and cytotoxics: vomiting

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7
Q

why is the radiation of the pain important in abdo pain?

A

to back=pancreatic disease, perforated peptic ulcer or ruptured AAA
up to neck=oesophageal reflux
loin to groin=renal colic
shoulder tip=diaphragm irritation

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8
Q

why is the character of the pain important in abdo pain?

A

colicky=obstruction of hollow viscus e.g. bowel, ureter

dull or burning=potential peptic ulceration

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9
Q

why is the intermittency of tha pain important in abdo pain?

A

episodic=peptic ulcer disease

steady=pancreatic

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10
Q

what may relieve different causes of abdo pain?

A

rolling around=trying to relieve colicky pain
aggravated by moving or coughing=peritonitis
antacids or vomiting=relieve peptic ulcer pain or GOR
defecation=relieved IBD
sitting or leaning forward=relieves pancreatic pain

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11
Q

how may eating effect GI pain?

A

precipitate pain from gastric ulcer
relieve that of a duodenal ulcer
fatty foods precipitate GB pain

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12
Q

why is it important to ask about bowel changes in abdo pain?

A

disturbance plus pain and bloating=ibd
constipation or diarrhoea and colicky pain=malignancy or stricture
increased freq and incomplete emptying=renal malignancy

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13
Q

why is it important to ask about pregnancy in abdo pain?

A

cause could be threatened abortion and ruptured ectopic pregnancy before realise pregnant

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14
Q

what is the difference between progressive and intermittent dysphagia?

A

progressive=carcinoma or stricture, progressive from solids to liquids
intermittent=motility disorder e.g. achalasia

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15
Q

when is dysphagia painful?

A

if infection or ulceration of oesophagus

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16
Q

if the dysphagia eases after the first few swallows what is it likely to be?

A

oesophageal spasm

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17
Q

if there is regurgitation what does this suggest?

A

cause is in pharynx e.g. neurological disease

or severe GOR

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18
Q

why is it important to ask about heartburn in dysphagia?

A

predisposes to stricture formation and development of oesophageal carcinoma

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19
Q

how can a lump in the throat be associated with dysphagia?

A

can be caused by retrosternal goitre

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20
Q

why is it important to ask about cough in dysphagia?

A

bronchial carcinoma

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21
Q

what medication is associated with dysphagia?

A

tetracyclines

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22
Q

which foods aggravate reflux sx?

A

alcohol, chocolate, caffeine, fatty meals

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23
Q

which positions aggravate reflux?

A

bending, stooping, lying down

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24
Q

what causes acute vs longstanding vomiting?

A

acute: infection, small bowel obstruction
pregnancy, drugs, peptic ulcer disease, gastric outlet obstruction, hepatobiliary disease, alcoholism, increased icp, psychogenic disorder

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25
Q

how does the time of day effect cause of vomiting?

A

early morning: pregnancy, alcoholism, increased icp

1hr or more after meal: gastric outlet obstruction or gastroparesis

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26
Q

what can cause abdo pain and vomiting?

A

pancreatitis, small bowel obstruction, biliary disease

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27
Q

what does a large vol of vomit suggesr?

A

intestinal obstruction

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28
Q

what causes projectule vomiting?

A

gastric outlet obstruction

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29
Q

how does the colourof vomit suggest the cause?

A

green=small bowel obstruction
red/brown=blood=ulceration
faeculant=late sign of large bowel obstruction

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30
Q

how to bowel habits effect cause of vomiting?

A

diarrhoea=infection

constipation=intestinal obstruction

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31
Q

what are the causes of acute, chronic and fluctuating jaundice?

A

progressive=malignacy, chronic liver disease
short=hepatitis, gallstones
fluctuating=bile duct stones

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32
Q

what does abdominal pain and jaundice indicate?

A

gallstones

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33
Q

what does vomiting and jaundice indicate?

A

acute hepatobiliary disease

advanced carcinoma of head of the pancreas->duodenal obstruction

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34
Q

how is bruising linked to jaundice?

A

obstructive jaundice->shortage of bile salts-> decreased vit K absorption-> decreased clotting factors->easy bruising and bleeding

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35
Q

why is travel important in the history of jaundice?

A

viral hepatitis: B and C higher in Africa and parts of Asia

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36
Q

why are blood transfusions important in the history of jaundice?

A

HBV and HCV transmitted via blood

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37
Q

why is drug use and homosexuality important in the history of jaundice?

A

HBV and HCV

HBV

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38
Q

why is the time course important in diarrhoea?

A

acute=infective

chronic=irritable bowel, endocrine disturbance

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39
Q

what causes mucus in the stool?

A

rectal ulcer, fistula or villous adenoma or IBS

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40
Q

what are foul smelling stools a feature of?

A

malabsorption syndromes

41
Q

when can defecation relievde abdo pain?

A

diverticulitis or IBS

42
Q

what can cause faecal incontinence?

A

faecal impaction with overflow diarrhoea, anorectal disease, post-childbirth pelvic floor trauma, neurological disorders, senile demential, DM

43
Q

what medications can cause diarrhoea?

A

many including abx

44
Q

do bowel cancer and IBD have hereditary links?

A

yes

45
Q

what causes constipation?

A

chronic: habitual neglect of impulse to defaecate, drugs, metabolic or endocrine disease, abnormal colic motility
recent onset: malignancy

46
Q

what does straining on defaecation indicate?

A

disorders of pelvic floor muscles, nerves or anorectal disease

47
Q

how does the colour of blood affect where it comes from?

A

bright red=anus or rectum

darker=higher up GI tract

48
Q

what casues rectal bleeding and abdo pain?

A

colorectal carcinoma, IBD, intussusception, massive upper GI haemorrhage, diverticular disease

49
Q

what causes a “dragging down sensation” +/- bleeding?

A

rectal prolapse

50
Q

how is warfarin associated with rectal bleeding?

A

INR may be too high->bleed more readily from potential site

51
Q

what does tachycardia suggest in a GI examination?

A

infection or hypovolaemia (due to bleeding)

52
Q

what effect can AF have on the GI system?

A

emboli to mesenteric arteries-> bowel ischaemia and severe abdo pain

53
Q

what hand and nail changes are associated with GI disease?

A

clubbing: GI lymphoma, IBD, coeliac
leuconychia: hypoalbuminaemia
palmar erythema: liver disease
dupytrens contracture (thickening of palmar fascia->permanent flexion, often rinf finger)=alcoholism, manual workers, familial

54
Q

when does liver flap occur?

A

liver failure

55
Q

give some changes in the eyes related to GI disorders?

A

pale conjunctivva=anaemia
jaundice in sclera
Kayser-Fleischer rings=Wilsons

56
Q

give some changes in the mouth in GI disease.

A
angular stomatitis (cracking)=vit B6, B12, folate and iron deficiency. infection in children
circumoral pigmentation=small bowel polyposis
glossitis (smooth tongue)=B12 defiency and folate deficiency (painful), iro defiency (painless)
aphthous ulcers=IBD, coeliac, 
ulcers on tongue=maligant
fetor hepaticus (sweet breath)=hepatocellular disease
leukoplakia (white mucosa of tongue)=premalignant
candidiasis=creamy white patches in mouth
57
Q

when are virchows nodes enlarged?

A

dysphagia, upper GI malignancy

58
Q

what can cause striae?

A

ascites, pregnancy, recent weight loss, cushings (wide and purple)

59
Q

what is the link between spider naevi and GI disease?

A

> 5=cirrhosis

60
Q

what can visible peristalsis indicate?

A

pyloric obstruction, obstruction of distal small bowel

61
Q

what can cause hepatomegaly?

A

fatty infiltration, myerloproliferative disease, congestive cardiac failure, acute viral hepatitis, metastases, primary tumours

62
Q

what is Courvoisers law?

A

patient jaundiced and GB palpable malignancy more likely than gallstones

63
Q

when is splenomegaly detected and what causes it/

A

2-3x normal size

portal htn, leukaemia, lymphoma, haemolytic anaemia, connective tissue disorders, infection (malaria)

64
Q

what can cause unilateral palpable kidney?

A

renal cell carcinoma, hydronephrosis, polycystic kidney disease, renal abscesses

65
Q

what can cause bilateral palpable kidney disease?

A

polycystic kidneys, bilateral hydronephrosis

66
Q

what can cause rectal mass?

A

rectal carcinoma, rectal polyp, uterine or ovarian malignancy, prostatic or cervical malignancy, endometriosis, signoid colon carcinoma

67
Q

what causes ileus (lack of movement in intestines->blockage)?

A

mesenteric ischaemia, drugs (aluminium hydroxide, Ca carbonate, opiates, TCA, verapamil), surgical, peritonitis, pancreatitis, mechanical obstruction, gram negative sepsis, electrolyte imbalance, retroperitoneal bleed, spinal or pelvic fracture

68
Q

what are the key associated sx in abdo pain?

A
Weight loss
Anorexia
Dysphagia
Dyspepsia
Nausea & vomiting
Change in bowel habit
PR bleeding
Urinary symptoms
69
Q

what are the common differentials for abdo pain>

A

cardioresp: atypical ACS/MI, basal pneumonia
GI: gastritis, peptic ulcer disease, pancreatitis, gallstones, cholecysitis, cholangitis, malignancy
gynaie: ectopic pregnancy, ovarian cyst, testicular torsion, PID, malignancy,
urinary: ureteric colic, testicular torsion, malignancy
other: mesenteric adenitis, AAA

70
Q

give the pain patterns of visceral, perforation and inflammatory pain in abdo pain/

A

colicky
sudden onset severe sustained
gradual onset sustained

71
Q

what are the radiation patterns in abdo pain?

A

through to back: pancreas, aorta
around back: GB
loin to groin:ureter
shoulder tip: diaphragmatic irritation

72
Q

what do the associated sx in abdo pain indicate?

A

haematamesis or malena: upper GI bleed
faecal vomiting: bowel obstruction, fistula
rigors: sepsis, abscess, cholangitis, cholecystitis, pyelonephritis,
complete constipation: bowel obstruction
diarrhoea: gastroenteritis, divertisulitis
rectal bleeding: IBD, malignancy, upper GI bleed, diverticulitis
urinary sx: lower UTI, pyelonephritis

73
Q

in what areas of the abdomen are the different organs/common problems?

A

R hypochondriac: biliary tree (biliary colic, cholecytitis, cholangitis), liver (hepatitis, malignancy, abscess), subphrenic space( abscess)
epigastric: oesophagus( oesophagitis, malignancy, perforation), stomach (peptic ulcer, gatritis), pancreas (pancreatitis)
L hypochondriac: speen (traumatic rupture, infection), pancreas (pancreatitis, malignancy), subphrenic space (abscess)
R loin: kidneys(malignancy, infection, PKD), ureters (colic due to stone),
L loin: pancreas (pancreatitis, malignancy), bowel (obstruction, perforations, adhesions, IBD), lymph (mesenteric adenitis), AAA ruptire
R iliac: terminal ileum (meckels diverticulum, infection), appendix (appendicitis), caecum (paracolic abscess, diverticulitis, UC, malignancy), ovary (ectopic, ovarian cyst, PID, ovarian torsion, malignancy)
L iliac: sigmoid (paracolic abscess, diverticulitis, UC, malignancy), ovary (ectopic, ovarian cyst, PID, ovarian torsion, malignancy)
suprapubic: bladder (UTI, acute retention), uterus (PID, endometriosis)

74
Q

what are the common ix done in abdo pain?

A

Bloods: FBC, U&E, LFT, Amylase, CRP, Clotting, G&S
AXR
Erect CXR
USS
CT (contrast / non-contrast)
Endoscopic procedures (OGD, sigmoidoscopy, colonoscopy etc. )
Contrast studies (barium swallow, barium enema)

75
Q

what are the 6 causes of distension?

A

fat, foetus, flatus, faeces, fibroids, fluids

76
Q

what is cullens sign>

A

superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus

77
Q

what is turners sign?

A

bruising of the flanks, the part of the body between the last rib and the top of the hip. The bruising appears as a blue discoloration, and is a sign of retroperitoneal hemorrhage

78
Q

what should be done after an abdo examination?

A
S – stool sample
H – hernial orrifices
R – rectal examination
U - urinalysis
G – genitals
79
Q

what should be asked about in a GI history?

A

Pain
• Abdominal distension
• Nausea and vomiting
• Dysphagia (difficulty swallowing)
• Dyspepsia (indigestion / heartburn), hiatus hernia and peptic ulceration
• History of gallstones or previous pancreatitis
• Jaundice
• Altered bowel habit, diarrhoea, constipation or alternating diarrhoea and constipation
• Blood loss (haematemesis or rectal bleeding)
• Mucus or slime per rectum
• Appetite
• Weight change
• Continence

80
Q

where is pain from unpaired structures usually felt?

A

centrally

81
Q

what is the typical pattern of pain for a peptic ulcer (socrates)

A

Site: Epigastric
Onset: Acute or gradual. Remissions for weeks or months.
Character: Gnawing
Radiation: Into the back
Associated symptoms: Can lead to GI haemorrhage, peritonitis if perforates
Timing: Lasts 0.5 – 3 hours.
Exacerbating factors: Irregular meals (hunger), smoking, alcohol, aspirin and
NSAIDs
Alleviating factors: Food, antacids, vomiting
Severity: Mild to moderate

82
Q

what is the typical pattern of pain for acute cholecystitis (socrates)

A

Site: Epigastric or right hypochondriacal
Onset: Constant. Unpredictable frequency or periodicity.
Character: Stabbing, piercing
Radiation: Right scapula or tip of right shoulder
Associated symptoms: Vomiting, fever, rigors
Timing: 3 – 24 hours
Exacerbating factors: Sometimes food.
Alleviating factors: Pain relief by medication?
Severity: Severe

83
Q

what is the typical pattern of pain for acute pancreatitis (socrates)

A
Site: Epigastric
Onset: Sudden or gradual
Character: Piercing, stabbing, burning
Radiation: Into the back. May develop generalised peritonitis with 
widespread pain.
Associated symptoms: Nausea, vomiting, abdominal distension, shock
Timing: Lasts more than 24 hours.
Exacerbating factors: Eating
Alleviating factors: Sitting upright
Severity: Very severe
84
Q

what can cause vomiting?

A

Nervous system: motion sickness, labyrinthine disorders, migraine, meningitis,
intracranial tumour
• Severe pain e.g. renal colic, myocardial infarction
• Systemic conditions e.g. pregnancy, renal failure, diabetic ketoacidosis,
hyperparathyroidism
• Drugs by central action or local gastric irritation
However, it is also a common symptom of gastrointestinal disorders e.g. gastric outlet
obstruction, acute gastritis, acute cholecystitis, acute pancreatitis, hepatitis

85
Q

what can cause dysphagia?

A

Painful lesion in mouth or throat
• Neurological disorder e.g. pseudobulbar palsy
• Neuromuscular disorder e.g. myasthenia gravis
• Obstruction in the post-cricoid area e.g. pharyngeal pouch, tumour, stricture
• Obstruction at the lower end of the oesophagus e.g. tumour, achalasia of the cardia,
stricture

86
Q

what is important in the hx for dysphagia?

A

Is it continuous or intermittent?
• How long does it last for?
• Where does the food stick?
• Is it solids, liquids or both?
• Does it occur between meals (may suggest globus hystericus, a psychogenic
condition)?
• Do you suffer from acid reflux or dyspepsia?
• Nocturnal coughing or dyspnoea (2° to regurgitation and aspiration)?
• Enquire about the risk factors for oesophageal carcinoma: smoking, alcohol, obesity
and diet lacking in fruit and vegetables

87
Q

what is important in the hx for jaundice

A

Colour of urine and stools (differentiate haemolytic from obstructive jaundice)
• History of gallstones?
• Pain (pain of Ca pancreas is traditionally felt in the back and made worse on
recumbency)?
• Fever and rigors?
• Itching?
• Social history
o Alcohol
o Drugs
o Foreign travel, including transfusions and tattooing abroad
o Unprotected sex

88
Q

what is important in the hx for altered bowel habit?

A

How has the habit altered? Diarrhoea, constipation or both?
• Frequency of stools?
• Any associated abdominal discomfort or urgency?
• Incontinence?
• Appearance of stool? Consistency (formed or unformed)? Does it float in the pan?
Associated blood, pus or mucus (slime)?
• Associated vomiting?
• Foreign travel?
• Medications, including over-the-counter remedies?

89
Q

give some causes of rectal bleeding.

A

Haemorrhoids (fresh red, clearly separate from the stool and may be seen only on the
paper. Bleeding from haemorrhoids may splash into the pan after a motion and is
generally painless)
• carcinoma of the colon or rectum (may be associated with mucus)
• inflammatory bowel disease (may be mixed with pus or mucus; stool may be unformed)
• diverticular disease
• anal fissures (fresh red, associated with severe anal pain during and after defaecation)
• melena (severe bleeding from the upper GI tract tends to be dark in colour (“altered”)
and may contain clots – the patient may be in shock; smaller degrees of bleeding may
result in dark stools

90
Q

what GI problems have a familial element?

A

carcinomas, Crohn’s disease and ulcerative colitis,
malabsorption syndromes and Gilbert’s syndrome (inherited unconjugated
hyperbilirubinaemia)

91
Q

what are some GI causes of clubbing?

A

hepatic cirrhosis, ulcerative colitis, Crohn’s

disease and Coeliac disease)

92
Q

what changes in the hands and nails may be seen in GI problems?

A

Pallor of the palmar creases suggests anaemia
§ Palmar erythema (2° to increased circulating oestrogens in liver
disease)
Leukonychia. Leukonychia partialis: small isolated white patches or striae are
often seen in the nail plates of normal persons in response to minor trauma to
the germinal matrix. However, striae affecting all of the nail beds can occur
following a course of chemotherapy, for example.
Terry’s nails or leukonychia totalis: Whitening of the entire nail occurs with
hypoalbuminaemia (e.g. nephrotic syndrome, liver failure, protein
malabsorption and protein-losing enteropathies).
o Koilonychia (spoon-shaped nails, suggesting chronic iron-deficiency)
o Spider naevi (single central arteriole with radiating dilated capillaries). Occur in
15-20% of healthy individuals but multiple spider naevi suggest underlying liver
disease with increased circulating oestrogens. 99% occur on the upper trunk,
head, neck and arms. Only 1% occur below the umbilicus.
o Dupuytren’s contracture (fibrosis and shortening of the palmar aponeurosis).
Usually idiopathic or familial but there is a possible unproven association with
trauma, diabetes, epilepsy, alcoholism and liver disease.

93
Q

what does asterixis suggest?

A

liver failure with failure of ammonia metabolism to
urea. However, asterixis can also be seen in renal failure and in respiratory
failure with CO2 retention.

94
Q

what changes in the eyes may be seen in GI problems?

A

Jaundice
o Anaemia (subconjunctival pallor)
o Xanthelasma
o Corneal Arcus
[45]
o Kayser-Fleischer rings (Wilson’s disease). These are brown rings that encircle
the iris, resulting from copper deposition. In the early stages they are best seen
with a slit lamp, but later they can be seen with the naked eye.

95
Q

what changes in the mouth may be seen in GI problems?

A

o Telangiectasia (HHT – see above)
o Pigmentation (Peutz-Jegher syndrome, associated with small bowel
hamartomas)
o Angular stomatitis (sore corners of mouth), which may be caused by deficiency
of Vitamin B6, B12, folate or iron.
o Glossitis, an abnormal smooth red appearance of the tongue. Painful glossitis
is seen in Vitamin B12 or folate deficiency whereas glossitis due to irondeficiency tends to be painless.
o Dehydration
o Halitosis (bad breath)
o Dental caries
o Ulcers (can be associated with Vitamin B12 deficiency, iron-deficiency, Crohn’s
disease, Coeliac disease)

96
Q

what is Troisier’s sign

A

enlarged left supraclavicular lymph node (Virchow’s node) due to a metastasis
from an intra-abdominal malignancy)

97
Q

5 F’s of abdominal distension:

A
Fluid (ascites)
§ Faeces (constipation)
§ Flatus (subacute intestinal obstruction)
§ Foetus (pregnancy)
§ Fat (obesity)
98
Q

what is Murphy’s sign

A

asking the patient to breathe out and then gently placing
the hand below the right costal margin in the mid-clavicular line (the approximate
location of the gallbladder). If inspiration is prevented by the inflamed gallbladder
coming into contact with the examiners fingers, the test is considered positive. A
positive test also requires no pain on performing the manoeuvre on the patient’s left
hand side. This test is done when suspecting acute cholecystitis in a patient.