ICM 1 - Exam 2 Flashcards
Borborygmi
Hyperactive bowel sounds. Near continuous, very high-pitched tinkles (diarrhea) or rushes (early bowel obstruction)
Normal bowel sounds
Clicks and gurgles every 2 - 12 seconds
Normal abdominal aorta width?
2-2.5 cm
Signs of peritonitis?
- Rebound tenderness: sudden release of deeply palpating hand results in signs of pain like grimace or grasping of abdomen
- Rigidity/involuntary guarding: uncontrollable markedly increased abdominal wall muscular tone
What positive test result will indicate ascites?
Shifting dullness. Percuss with the patient in supine and side positions to determine if there is shifting dullness in the abdomen
Positive signs suggesting appendicitis?
- McBurney’s Point
- Psoas sign
- Obturator sign
McBurney’s Point
involuntary guarding and rebound tenderness just below the middle of a line joining the umbilicus and the anterior superior iliac spine
positive result indicates appendicitis
Psoas sign
Patient flexes his or her hip and pushes their thigh against the examiner’s hand. Pain indicates a positive sign for appendicitis
Obturator sign
Flex the patient’s hip and rotate the thigh internally. Pain indicates a positive sign for appendicitis
Murphy’s sign
Test for acute cholecystitis
On exhale place hand below the costal margin and at the mid-clavicular line on the right side. Upon inspiration see if patient winces or stops breathing in, indicating a positive test result
Visceral pain
gnawing, cramping or aching and is often difficult to localize
Parietal pain
Inflammation from the parietal peritoneum. More severe than visceral and easily localized (i.e. appendicitis)
Referred pain
Originates at different sites but shares innervation from the same spinal level (i.e. gallbladder -> shoulder; pancreas -> back)
Three superior openings into the abdominal cavity
IVC, Esophagus, Aorta
Four types of abdominal Xrays
- Supine view
- Upright and supine view - allows evaluation of free air and air fluid levels in bowel
- Acute abdominal series (includes CXR/PA chest view)
- Decubitus view - allows evaluation of air and air fluid levels if patient is unable to stand
What is the initial imaging modality used for abdominal pain, nausea, vomiting, etc?
Xray
What is often the most important feature of abdominal xrays?
The bowel gas pattern. Is it normal, ileus (dilated/not moving right), or obstructed?
Plicae circularis
Vavulae conniventes or circular folds seen in the small bowel; they cross the entire diameter of small bowel loop
Haustra
Folds seen in large bowl; do not cross entire diameter of the bowel
Outside of xrays, what other imaging modalities are used on the GI tract?
Contrast studies (fluoroscopy), CT, MRI, ultrasound
Rehab swallow
Used typically in stroke patients to see how the patient is swallowing/what kind of diet they can tolerate
Contrasts used?
Barium sulfate or iodine-based. Can be given orally, rectally or through a tube
What are we not able to typically view with an endoscope?
Jejunum and ileum
Alternatives: capsule endoscope, small bowel follow through (timed looks), enterography (CT, MRI)
What can you view with an endoscope?
Esophagus, stomach, and duodenum
Single Contrast Barium Enema (SCBE)
Used predominately to look for leaks or at anatomy
Air Contrast Barium Enema (ACBE)
Contrast studies performed using fluoroscopy. Allow for the assessment of contour and position. Superior for detecting small lumen abnormalities
Common indications for abdominal CT?
Suspected appendicitis, diverticulitis, small bowel obstruction, inflammatory bowel disease, colitis
CT colonoscopy
Substitute for colonoscopy as screen for polyps and cancer. Rapid examination using air
When would you use ultrasound to view the abdomen?
Viewing the appendix. Otherwise gas will obscure structures
What modality is best for evaluation of rectal cancer?
MR defacography
What modality is best for evaluation of Crohn’s disease?
MR enterography
What kind of imaging is frequently used in pregnant women?
Ultrasound and MRI because CT has high levels of radiation that may affect the fetus
What imaging modality is commonly used to evaluate solid organs?
CT
MRI is also commonly used but due to time constraints is not used first
Uses of MRI in abdominal imaging?
Mass evaluation, esp. of liver, kidneys and adrenal glands, ductal evaluation of biliary tree and pancreas
Uses of CT in abdominal imaging?
Renal stone evaluation, pancreatitis evaluation, trauma evaluation, gastrointestinal bleed, etc
What imaging modality is commonly used to evaluate the hepatobiliary system, kidneys, and blood vessels?
Ultrasound
Not as good for adrenal glands or pancreas
First imaging modality often used to screen in patients with elevated liver function tests?
Ultrasound. CT and MRI used with multiple phases and contrast after to evaluate US findings
Blood inflow to liver? Blood outflow?
Inflow: hepatic artery & portal vein
Outflow: hepatic veins
Imaging modality of choice for gallbladder and bile ducts?
Ultrasound
Can also use CT, MRI, MRCP and ERCP
Endoscopic Retrograde Cholangio-Pancreaticogram (ERCP)
used to inject fluoroscopy into biliary system
MRI Cholangio-Pancreatogram (MRCP)
Utilizes fluid-sensitive sequences to create an image. Slow moving fluid becomes white
We get the same image from ERCP without having to stick a scope down someone’s throat. Usually done before an ERCP so DRs have an idea of what’s going on
Best imaging modality for the pancreas?
CT or MRI
Hard to see on US because of bowel gas
Retroperitoneal organs?
Duodenum, pancreas, kidneys
Best imaging modality for spleen?
All three depending on clinical concern
Splenomegaly - US
Injury from trauma - CT
Splenic mass - CT or MRI
Best imaging modality for adrenal glands?
CT or MRI. Not well seen with US
Best imaging modality for kidneys?
All three depending on clinical concern
Acute kidney injury or Hydronephrosis - US
Flank Pain, Stone or Hematuria - CT
Renal mass - MRI
Urography
IVP = Intravenous Pyleogram
Iodine contrast excreted by kidneys in 5-10 minutes. Allows evaluation of collecting systems, ureters, and bladder
Phases of evaluation in CT IVP?
Arterial Phase (cortex white) - 30 sec
Venous phase - 70 sec
Delayed/pyelogram phase - 7 mins (looking for filling defects here)
Mood
sustained emotional state; in the patient’s own words
Affect
observed from emotional responses
ex: full, constricted, blunted, flat, labile
Suicide risk: “SAD PERSONS”
Sex - male
Age > 60
Depression
Previous attempt Ethanol/drug use Rational thinking loss Suicide in family Organized plan/access No support Sickness
What is a non-modifiable risk factor?
You are always going to have these risk factors, cannot change
Ex: Being white and male
Examples of modifiable risk factors?
Psychiatric disorder, co-morbid medical disorder, low self esteem, hopelessness, low self esteem, lack of social acceptance, firearms, access to pills, lack of support
What is the best predictor of future suicide attempts?
Past suicide attempts
SBIRT?
Screening, Brief Introduction, and Referral to Treatment
Used for substance use. Target high-risk drinkers and probable alcohol dependence
What are substance-related disorders?
Intoxication, withdrawal, substance/medication-induced mental disorders
Substance use disorder
Problematic pattern of substance use leading to clinically-significant impairment or distress
Diagnosis based on DSM-5 criteria; must name the substance (e.g. alcohol, cannabis)
What two substance use criteria are not considered to be met for Rx drugs taken exclusively under appropriate medical supervision?
Tolerance and withdrawal
Early remission
No symptoms (except craving) present for 3-12 months
Sustained remission
No symptoms (except craving) present for more than 12 months
Gambling disorder
Persistent and recurrent problematic gambling behavior leading to clinically significant impairment or distress
The gambling behavior is not better explained by a manic episode
Addiction
moderate/severe substance use disorder (4+ criteria met)
NOT just a physiological dependence
Four C’s of Addiction
Compulsive use, inability to control, continued use despite consequences, craving
Are dopamine D2 receptors lower or higher in addicts?
Lower in virtually all drugs of abuse
Relationship between perceived risk of taking drug and drug usage?
Inverse
Naloxone (narcan)
Reverses opioid overdose if administered in a timely manner
Addiction is a treatable ________ _______
brain disease
disruptive behavior
no accepted standard definition; creates a hostile work environment and negatively impacts patient safety
abusive conduct, including sexual or other forms of harassment; behaviors that undermine a culture of safety
spectrum of disruptive behavior
aggressive, passive-aggressive, passive
What does most bone imaging begin with?
plain film xray
Reasons for CT imaging (MSK related)?
Evaluation of complex fractures, fractures at joint, pathologic fracture, unclear finding on xray
Reasons for MRI (MSK related)?
Evaluation of tendon, muscle or ligament injury, tumor evaluation
Lytic tumor
Destroys bone
Sclerotic tumor
lays down bone
Three joints that articulate at the shoulder?
- sternoclavicular joint
- Acromioclavicular joint
- Glenohumeral joint
What is included in a shoulder series (xray)?
AP - internal rotation, AP - external rotation, axillary or trans-scapular Y view
Which muscle(s) insert into the greater tubercle of the humerus?
Supraspinatus and infraspinatus
Which muscle(s) insert into the lesser tubercle of the humerus?
Subscapularis
Xray views needed for humerus evaluation?
Frontal and lateral
Xray views needed for elbow evaluation?
AP and lateral
What does it mean if there is a posterior fat pad in the elbow and an anterior “sail sign”?
There is a joint effusion (fluid in joint) at the elbow
Xray views needed for hand and wrist?
Usually 3: frontal, oblique, and lateral
What does the drop arm test examine?
Issues with the supraspinatus tendon
What does the lift off test examine?
Issues with the subscapularis muscle
What does the empty can test examine?
Supraspinatus impingement
What does internal rotation with resistance examine?
Subscapularis and teres major
What does external rotation with resistance examine?
Infraspinatus and teres minor
What are the six cardinal signs of MSK disease?
Redness, Swelling, Pain, Deformity, Loss of Function, Warmth
RS(W)P DL
Prevalence of mental health disorders in US adults?
57 million people (26%)
_______ is the 10th leading cause of death in the US
suicide
tangential thought process
gradual veering off topic
circumstantial thought process
over inclusion of details (what your grandparents might do)
flight of ideas
rapid disconnections of thoughts; ideas are hanging on by a thread
can overlap with disorganized thought process as well
How can you test a patient’s attention and concentration?
Spell “world” backward and give the days of the week backwards
Serial 7s from 100 or serial 3s from 20
Digit span - series of numbers increasing in length. Ask patient to remember until you get to 7
How can you test a patient’s cognition?
Abstraction (similarities, proverbs), math problems, orientation, memory, reading & writing
What is key when assessing patients with suicidal behaviors?
DOCUMENTATION
What things should you specifically inquire about during a suicide assessment?
suicidal thoughts, plans, and behaviors
Who attempts suicide more: males or females?
Females
Who dies from suicide more frequently: males or females?
Males
Who has a higher rate of suicide: Caucasians or African Americans?
Caucasians
List the non-modifiable risk factors for suicide
Race (white), sex (male), old age (over 65 esp), history of past attempts, family history of suicide, history or trauma or abuse, history of violent behaviors
What is the strongest indicator of future suicide attempts?
Past attempts
What should you ask about past suicide attempts?
How was it attempted? Did they leave a note? What were the circumstances?
Are patients at an increased or decreased risk for suicide after discharge from psychiatric inpatient care?
increased
What contributes to physician distress/disruption?
Substance use disorders, psychiatric symptoms/disorders, personality disorders, poor anger management/coping skills, physical illness, poor social skills, burnout or suppression of problems
What is a physician CME course?
It is designed to address specific needs of professionals whose workplace conduct has become problematic but not risen to the point of formal referral
Typically 3 days with additional 1 day follow-ups at 1, 3, and 6 months
Who is a good target for SBIRT?
Those that are high-risk or have a probable dependence
What are substance-related disorders?
Intoxication, withdrawal, substance/medication-induced mental disorders, and unspecified substance-related disorders
Define a substance use disorder
Problematic pattern of substance use leading to clinically significant impairment or distress, as manifested by at least 2 of 11 criteria in the last 12 months
What two criteria of substance use are not considered for Rx drugs taken exclusively under supervised medical care?
Tolerance and withdrawal
Addiction is a _____ disease
brain
All drugs of abuse increase what?
Dopamine
Some drugs of abuse can release how much dopamine compared to natural rewards?
2 to 10 times as much
In what age group does most illicit drug use begin?
Teenage years
“disease of pediatric origin”
What type of receptor is lower in addicts to virtually all drugs of abuse?
Dopamine D2 receptors
Drug use is _______ related to perceived risk of taking the drug
inversely
If a patient has an acute injury what exam should you perform first?
A neurovascular exam
Range of motion of the hip?
Six axes
Flexion, extension, abduction, adduction, internal & external rotation
Flexion _____ the joint angle
Decreases
Extension _____ the joint angle
Increases
Range of motion of the knee?
Four axes
Flexion, extension, internal rotation, external rotation
Valgus stress tests which ligament?
MCL by applying valgus stress to the lateral side of the knee
Varus stress tests which ligament?
LCL by applying varus stress to the medial side of the knee
How much should the knee be bent in the valgus and varus stress tests?
About 20 degrees
Name the three lateral ligaments of the ankle joint
Anterior and posterior talofibular ligaments + the calcaneofibular ligament
Range of motion of the ankle?
4 axes
Dorsiflexion, plantarflexion, inversion, eversion
What four questions do you ask your patient who has a lower extremity injury?
- What was the mechanism of injury?
- Where does the pain localize to?
- Was there any swelling?
- Could you bear weight?
Nerves of the anterior abdominal wall?
Thoraco-abdominal nerves (T7-T11)
Subcostal (T12)
Iliohypogastric (L1)
Ilioinguinal (L1)
Where does the inguinal ligament begin and end?
Anterior superior iliac spine and the pubic tubercule
Indirect inguinal hernia
Pass through the deep inguinal ring lateral to the inferior epigastric vessels
Usually congenital, more common in males
Direct inguinal hernia
Passes directly though the abdominal wall medial to the epigastric vessels
Femoral hernia
Pass through the femoral canal
More common in women
How many layers of peritoneum is a mesentery?
Two
Connects an organ to the posterior abdominal wall; contains blood and lymphatic vessels
How many layers of peritoneum is a ligament?
Two
Connects an organ to another organ
How many layers of peritoneum is the greater omentum?
four
What ligament of the greater omentum creates the “omental apron”?
The gastrocolic
What are the three ligaments of the greater omentum?
- Gatsrophrenic
- Gastrosplenic
- Gasrocolic
What are the three ligaments of the lesser omentum?
- Hepatoduodenal
- Hepatogastric
- Hepatoesophageal
Parasympathetic supply to the gut up until the left colic flexure?
Vagus nerve
Parasympathetic supply to everything after the left colic flexure?
Pelvic Splanchnic nerves (S2,3,4)
If you see varices (abnormally dilated veins) on a person, what should you suspect?
Portal hypertension
Peritoneal formations?
Mesenteries, ligaments, greater and lesser omentums
Duodenum: retroperitoneal or intraperitoneal?
Retro except the first part, which is intra
Where does the foregut become the midgut?
The major duodenal papilla
The common bile duct and the main pancreatic duct join to form what?
The hepatopancreatic ampulla (of Vater)
The hepatopancreatic ampulla drains where?
Into the major duodenal papilla
Pancreas: retroperitoneal or intraperitoneal?
Retro except for the tail
Innervation of the kidneys?
Renal plexus
Where does the superior suprarenal artery arise from?
Inferior phrenic artery
Where does the middle suprarenal artery arise from?
aorta
Where does the inferior suprarenal artery arise from?
renal artery
Order of the structures in the renal hilum from anterior to posterior?
Vein, artery, pelvis
Superior mesenteric artery syndrome
Compression of the 3rd part of the duodenum between the abdominal aorta and the superior mesenteric artery
Nutcracker syndrome
Compression of the left renal vein between the abdominal aorta and the superior mesenteric artery
What narrows to form the thoracic duct?
The cisterna chyli
What type of xray does an acute abdominal series include?
A chest xray - PA
What is often the most important feature of an abdominal film?
The bowel gas pattern
What does it mean if the abdominal gas pattern is described as “ileus”?
The bowel isn’t moving right; its dilated. Common in post-op patients or those on narcotics
What are the circular folds that cross the entire diameter of the small bowel?
plicae circularis or vavulae conniventes
Two types of abdominal GI contrast?
Barium sulfate and iodine-based like Gastroview and Gastrograffin
Barium can cause fibrosis in abdomen or chest and iodine can cause edema in the lungs. have to be careful!
Ligament of Trietz
Arises from the right crus of the diaphragm and attaches to the junction between the duodenum and jejunum
Can we view the jejunum and ileum with an endoscope?
Nope!
Alternatives are: capsule endoscope, small bowel follow through or enterography (Ct, MRI)
Small bowel enterography
Cross sectional study of small bowel with ingested oral contrast
Single Contrast Barium Enema (SCBE)
used predominately to look for leaks or at the anatomy of the colon
Air Contrast Barium Enema (ACBE)
superior for detecting small abnormalities of the lumen
Common indications for an abdominal CT?
Evaluate pain when suspected appendicitis, diverticulitis, small bowel obstruction, IBD, colitis
Which is more common: abdominal fluoroscopy or CT?
CT
When is ultrasound for the abdomen okay?
For appendix evaluation and in pregnant women & children
When is an abdominal MRI used?
Crohn’s patients (due to frequent imaging), evaluation of pain in pregnant patients, and in MR defacography/in rectal cancer evaluation
Imaging modality commonly used to evaluate solid organs?
CT
What is an MRI commonly used for in abdominal imaging?
Evaluating solid organs. Generally done after a CT or when people are allergic to the iodinated CT contrast/have renal problems.
Not typically done in an acute setting due to time constraints
What is an ultrasound commonly used for in abdominal imaging?
Hepatobiliary evaluation, kidney evaluation, and assessment of vessels
can also assess spleen size
ERCP
Endoscopic Retrograde Cholangio-Pancreaticogram
Goes through the major duodenal papilla to evaluate the biliary ducts
MRCP
Magnetic resonance cholangiopancreatography (MRCP) is a special type of magnetic resonance imaging (MRI) exam that produces detailed images of the hepatobiliary and pancreatic systems, including the liver, gallbladder, bile ducts, pancreas and pancreatic duct.
Imaging modality to evaluate splenomegaly?
Splenic injury or mass?
US
CT or MRI
Best imaging for suprarenal glands?
CT or MRI, not US
Best imaging for kidneys?
US
CT and MRI also work though!
Urography
Common evaluation for hematuria. IV contrast excreted by the kidneys in 5-10 minutes to evaluate urinary system
Types of IVC filters?
Nitinol, greenfield, bird nest
Shoulder xray series includes?
- AP - internal rotation
- AP - external rotation
- Axillary or transcapular Y view
How can we tell on an xray if there is a joint effusion in the elbow?
Posterior fat pad and anterior “sail sign”
Difference between T1 and T2 weight on MRI
T1 - fluids weighted dark
T2 - fluids weighted bright
Can you seen CSF and the spinal cord without contrast on MRI?
Yep!
