Brainscape's Knowledge GenomeTM

Browse over 1 million classes created by top students, professors, publishers, and experts.


See full index

Physical Diagnosis > Lecture Three (abdominal)- Exam 2 > Flashcards

Lecture Three (abdominal)- Exam 2 Flashcards

1
Q

What are the quadrants that we care about for abdominal area?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

History Taking of Problems of the Abdomen: GI Tract

What do you need to ask?

A

How is the patient’s appetite? (can they eat, does it come back up?)

Any symptoms of the following?
* Heartburn: a burning sensation in the epigastric area radiating into the throat; often associated with regurgitation
* Excessive gas or flatus; needing to belch or pass gas by the rectum; patients often state they feel bloated
* Abdominal fullness or early satiety (cancer)
* Anorexia: lack of an appetite

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

History Taking of Problems of the Abdomen: GI Tract

  • What is regurgitation?
  • What is retching? What do you need to ask about vomiting?
A

Regurgitation: the reflux of food and stomach acid back into the mouth; brine- like taste

retching (spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed)
* Ask about the amount of vomit
* Ask about the type of vomit: food, green- or yellow-colored bile, mucus, blood, coffee ground emesis (often old blood)
o Blood or coffee ground emesis is known as hematemesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is hematemesis?

A

Blood or coffee ground emesis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What are the three qualifying pains about the abdomen?

A
  • Visceral pain: when hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)
  • Parietal pain: when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain is more severe and is usually easily localized (appendicitis) -> More painful, usually sharp
  • Referred pain: originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

History Taking of Problems of the Abdomen: GI Tract

What do you need to ask? (hint: OLD CARTS-9)

A
  • Ask patients to describe the pain in their own words
  • Ask patients to point with one finger to the area of pain
  • Ask about the severity of pain (scale of 1 to 10)
  • Ask what brings on the pain (timing)
  • Ask patients how often they have the pain (frequency)
  • Ask patients how long the pain lasts (duration)
  • Ask if the pain goes anywhere else (radiation)
  • Ask if anything aggravates the pain or relieves the pain
  • Ask about any symptoms associated with the pain

OLD CARTS

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What do you need to know about patient’s bowel movements? (6)

A
  • Frequency of the bowel movements
  • Consistency of the bowel movements (diarrhea vs. constipation)
  • Any pain with bowel movements
  • Any blood (hematochezia) or black, tarry stool (melena) with the bowel movement
  • Ask about the color of the stools (white or gray stools can indicate liver or gallbladder disease)
  • Look for any associated signs such as jaundice or icteric sclerae
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

What are some prior medical probelms about the abdomen that you need to ask about?

A

Hepatitis, cirrhosis, gallbladder problems, or pancreatitis, for example

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

What else do you need to ask about the GI? (4)

A
  • Ask about prior surgeries of the abdomen (women-scar easily and cause pain later on)
  • Ask about any foreign travel and occupational hazards
  • Ask about use of tobacco, alcohol (need to know how much and what type), illegal drugs, as well as medication history
  • Ask about hereditary disorders affecting the abdomen
    in the history of the patient’s family
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What do you need to ask when looking at the urinary tract? (6)

A
  • Ask about frequency (how often one urinates) and urgency (feeling like one needs to urinate but very little urine is passed)
  • Ask about any pain with urination (burning at the urethra or aching in the suprapubic area of the bladder)
  • Ask about the color and smell of the urine; red urine usually means hematuria (blood in the urine)
  • Ask about difficulty starting to urinate (especially in men) or the leakage of urine (incontinence, especially in women)
  • Ask about back pain at the costovertebral angle (kidney) and in the lower back in men (referred pain from the prostate)
  • In men, ask about symptoms in the penis and scrotum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

Label the areas of cutaneous hypersensitivity

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q
  • Why is it hard to determine ovary and tube pain?
  • What is bilateral and unilateral kidney pain mean?
A
  • Hard because close to bladder and uterus
  • Bilateral: pelvic inflammatory disease or pyelonephritis
  • Unilateral: kidney stones
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

What are the causes of RUQ pain? (5)

A
  • Acute Cholecystitis
  • Duodenal Ulcer
  • Hepatitis
  • Hepatomegaly
  • Pneumonia

Gallbladder, liver and lung

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What are the causes of pain in LUQ? (6)

A
  • Pancreatitis
  • Gastric Ulcer
  • Ruptured Spleen
  • Aortic aneurysm
  • Perforated colon
  • Pneumonia

Spleen, stomach, colon, pancreas

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What are the causes of RLQ pain? (7)

A
  • Appendicitis
  • Salpingitis
  • Ovarian Cyst
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Perforated cecum
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What are the causes of LLQ pain? (8)

A
  • Diverticulitis
  • Salpingitis
  • Ovarian cyst
  • Ruptured ectopic pregnancy
  • Renal/ureteral stone
  • Strangulated hernia
  • Perforated colon
  • Ulcerative colitis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What are some causes of periumbilical pain?

A
  • Intestinal obstruction
  • Early appendicitis (then moves to RLQ)
  • Mesenteric ischemia (dying bowels)
  • Aortic aneurysm
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What is the classic presentation of acute appendicitis?

A
  • Diffuse periumbilical pain and anorexia early
  • Pain localizes to RLQ as peritonitis develops
  • Low grade fever, nausea and vomiting may not be present
  • X-rays and other tests are often negative so you need to be careful (CT will show us)
  • WBC might go up
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What do you we need to remember about the appendix?

A
  • Caveat - Remember that the position of the appendix is highly variable.
  • In addition to its “normal” position it can be found against the abdominal wall (anterior), below the pelvic brim (pelvic), behind the cecum (retrocecal), or behind the terminal ileum (retroileal).
  • pain will be in other places
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

What is the classic presentation of acute cholecystitis?

A
  • Localized or diffuse RUQ pain
  • Radiation to right scapula
  • Vomiting and constipation
  • Low grade fever
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is the classic presentation of acute renal colic?

A
  • Severe flank pain (possible no pain because stone is smaller)
    * Pain comes into waves
  • Radiation to groin
  • Vomiting and urinary symptoms
  • Blood in the urine (esp young people)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

How do you treat acute renal colic?

A
  • Blast them or go to surgery
  • Can see what the stone is made up of and change diet (usually Ca+)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

Where does ulcer, biliary, renal, uterus and renal pain radiate to?

A
  • Perforated Ulcer (shoulder)
  • Biliary Colic (under right scapula)
  • Renal Colic (all over)
  • Renal Colic (Groin)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What are associated symptoms of bowel and bladder?

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
Q

What are associated symptoms of reproductive system?

A

Sexual Activity, Contraception, Last Menstrual Period

Always Consider Pregnancy in Reproductive Age Women
* Have a Low Threshold for Pregnancy Testing
* “Everyone is pregnant until proven otherwise.”

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
26
Q

For abdominal pain, what do you need to ask about for past medical history

A
  • Gastrointestinal disorder
  • Hepatitis or cirrhosis of the liver
  • Abdominal injury or surgeries
  • UTI
  • Blood transfusions
  • Hepatitis vaccines
  • Colorectal or other cancers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
27
Q

For abdominal pain, what do you need to ask about for family history?

A
  • Gallbladder disease
  • Kidney disease
  • Malabsorption (CF or celiac)
  • Colorectal or other cancers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
28
Q

For abdominal pain, what do you need to ask about for social history?

A
  • Nutrition
  • LMP
  • Alcohol use
  • Exposure to infectious disease
  • Travel history (for eating at other places)
  • Drug use
  • Tobacco use
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
29
Q

What is the ROS for abdominal pain?

A
  • Abdominal pain
  • Nausea
  • Vomiting
  • Dysphagia
  • Odynophagia
  • Heartburn
  • Belching
  • Changes in appetite
  • Change in stool color, size or caliber
  • Pain with defecation
  • Melena
  • Hematachezia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
30
Q

What is the first step in any physical examination?

A

Inspection

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
31
Q
  • What do you need to look at for abdominal? What do you need to record?
A
  • Look at the abdominal contour and note any asymmetry.
  • Look for peristalsis or pulsations.
  • Record the location of scars, rashes, or other lesions.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
32
Q

What is umbilical hernia?

A
  • The navel may protrude, either during relaxation or when intra- abdominal pressure is increased by standing or Valsalva maneuver

more common in kids andmore out when if up and running

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
33
Q

What is an inguinal hernia? (and the types)

A
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
34
Q

What are some reasons for distended abdomen?

A
  • Fat
  • Fluid
  • Feces
  • Fetus
  • Flatus
  • Fibroid
  • Full bladder
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
35
Q

Physical Examination of the Abdomen: Auscultation
* How do you do this? What are listening for?

A
  • Always auscultate before palpating or percussing the abdomen ⭐️
  • Place the diaphragm over the abdomen to hear bowel sounds (borborygmi) which are long gurgles. The normal frequency of sound is 5-34 sounds per minute.
  • Place the diaphragm over the aorta, iliac, and femoral arteries to assess for bruits (vascular sounds resembling the whooshing of heart murmurs)
  • Place the diaphragm over the liver or spleen to listen for friction rub
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
36
Q

What are the sites to auscultate for bruits?

A
  • In addition to bowel sounds, abdominal bruits are sometimes heard.
  • Listen over the aorta, renal, and iliac arteries.
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
37
Q

Physical Examination of the Abdomen: Percussion
* Where do you do this? What are listening for?

A

Percuss over all four quadrants, listening for tympany (hollow sounds) versus dullness (which could be a large stool or a mass)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
38
Q

Where do you percuss the liver? What indicates a smaller and largers liver?

A

Percuss over the liver in both the midclavicular line and at the midsternal line
* Midclavicular percussion should be 6–12 cm; longer than this indicates an enlarged liver
* Midsternal line percussion should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver

39
Q

When do you perform auscultation? What is recorded?

A
  • Unlike other regions of the body, auscultation comes before percussion and palpation (the sounds may change after manipulation).
  • Record bowel sounds as being present, increased, decreased, or absent
40
Q

For percussion, where is tympany and dullness?

A
  • Tympany is normally present over most of the abdomen in the supine position.
  • Unusual dullness may be a clue to an underlying abdominal mass (liver)
41
Q

How do you perform a liver percussion? How big should the liver be?

A
42
Q

Light Palpation:
* How is pt positioned?
* How do you do this?
* Identify what?
* Assess for what?

A
  • Position patient with both knees bent, arms at the side with head supported.
  • Start palpating the abdomen using gentle probing with
    the hands; this reassures and relaxes the patient
  • Identify any superficial organs or masses
  • Assess for voluntary guarding (patient consciously flinches when you touch him) versus involuntary guarding (muscles spasm when you touch the patient, but he cannot control the reaction)
43
Q

Light palpation:
* What do you use to assess voluntary guarding? How do you do this?

A

Use relaxation techniques to assess voluntary guarding
* Tell the patient to breathe out deeply
* Tell the patient to breathe through the mouth with the jaw dropped open

44
Q

Palpation:
* What do you start with? What are looking for?
* The most sensitive indicator of tenderness is what?

A
  • Begin with light palpation. At this point you are mostly looking for areas of tenderness.
  • The most sensitive indicator of tenderness is the patient’s facial expression.
45
Q

What is the systematic route for abdominal palpation?

A
46
Q

Deep palpation:
* When do you proceed to this?
* Try to identify what?
* Depress skin how much?

A
  • Proceed to deep palpation after light palpation.
  • Try to identify abdominal masses or areas of deep tenderness.
  • Depress skin 2-3 inches
47
Q

How do you palpate the liver? A normal liver is not what?

A
  • To palpate the liver edge, place your fingers just below the costal margin and press firmly.
  • Ask the patient to take a deep breath.
  • You may feel the edge of the liver press against or slide under your hand.
  • A normal liver is not tender.
48
Q

Physical Examination of the Liver-Key Points

  • Lower border of a normal liver is often palpable where?
  • What is as important as its size?
  • Normally the liver edge is what?
  • The cirrhotic liver edge is what?
  • Individual cirrhotic nodules are what?
  • Discernable lumps suggest what?
A

Lower border of a normal liver is often palpable at or slightly below the right costal margin

Quality of the liver on palpation is as important as its size
* Normally the liver edge is rubbery-soft, sharp and smooth
* The cirrhotic liver edge is usually firm, blunt, and irregular
* Individual cirrhotic nodules are rarely palpable
* Discernable lumps suggest malignancy

Cancer loves the liver

49
Q

Physical Examination of the Liver-Key Points

  • What are rare but valuable clues to a tumor?
  • True tenderness is best elicited by what?
  • Tenderness most often felt in what?
A
  • Audible friction rubs or bruits over the liver although rare, are other valuable clues to a tumor
  • True tenderness (a deep-seated ache) is best elicited by fist percussion or compression of the rib cage
  • Tenderness most often felt in acute hepatitis and malignancy
50
Q

Physical Examination of the Abdomen:Deep Palpation

  • What is helpful when a patient is obese to feel the liver? How do we do this?
  • What else do we palpate and how do we do this?
A
  • The “hooking technique” can be helpful when a patient is obese.
    - Place both hands, side by side, on the right abdomen below the border of liver dullness.
    - Press in with the fingers and go up toward the costal margin. Ask the patient to take a deep breath. The liver edge should be palpable under the finger pads of both hands.
  • Palpate the spleen on the left side in much of the same way as the liver, with the left hand supporting the back and the right hand palpating the abdomen. Generally, the spleen cannot be palpated this way even with deep inspiration. Palpating a splenic tip may indicate splenomegaly.
51
Q

Palpation of the Spleen:
* How do we do this? What may help?
* Is it usually palpable?

A
  • Reach over and press down just below the left costal margin with your right hand while asking the patient to take a deep breath.
  • It may help to use your left hand to lift the lower rib cage and flank.
  • The spleen is not normally palpable on most individuals
52
Q

Physical Examination of the Abdomen: Deep Palpation
* How do you palpate the kidney?

A
53
Q
  • Are kidneys usually palpate?
  • When can you feel kidney?
A
54
Q
  • How do you figure out the aortic width?
  • What does prominent lateral pulsation suggest?
  • Although the aortic pulse may be felt, particularly in thin individuals, the pulse should be where?
A
  • With the patient in the supine position, palpate deep enough with fingertips trapping each side of the aorta, just left of midline and feel for the aortic pulsation.
  • If the pulsation is prominent, try to determine the direction of pulsation.
  • A prominent lateral pulsation suggest an aortic aneurysm.
  • Although the aortic pulse may be felt, particularly in thin individuals, the pulse should be in an anterior direction
55
Q

For palpation of aorta: Assess what? What is an abdominal aortic aneurysm?

A
56
Q
  • Is the aorta easily palpable? What should you feel?
  • An enlarged aorta may be a sign of what?
A
  • The aorta is easily palpable on most individuals.
  • You should feel it pulsating with deep palpation of the central abdomen.
  • An enlarged aorta may be a sign of an aortic aneurysm.
57
Q

What are the special techniques we need to know about?

A
  • CVA tenderness
  • Rovsing’s Sign
  • Psoas Sign
  • Obturator Sign
  • Rebound tenderness
  • McBurney’s Point
  • Murphy’s Sign
58
Q

Costovertebral Angle Tenderness:
* CVA tenderness is often associated with what?
* How do you check?

A
  • CVA tenderness is often associated with renal disease.
  • Use the heel of your closed fist to strike the patient firmly over the costovertebral angles.
59
Q

What are the appendicitis tests and signs?

A
  1. Iliopsoas (Psoas) Sign: Appendicitis
  2. Obturator Sign: Appendicitis
  3. Rovsing’s sign: Appendicitis
  4. McBurney’s Sign: Appendicitis
60
Q
  • What is the iliopsoas muscle test?
  • What is unexpected?
A
61
Q
  • What is the obturator muscle test?
  • What is unexpected?
A
62
Q

What is the Rovsing’s sign?

A
  • Right lower quadrant pain intensified by left lower quadrant abdominal palpation
  • Associated condition - Appendicitis
63
Q

What is mcburney’s point?

A
  • Rebound tenderness and sharp pain when McBurney’s point is palpated
  • Associated condition - Appendicitis
64
Q

What is rebound tenderness?

A

More tenderness is elicited when examiner removes hand from deep palpation vs deep palpation action.

65
Q

How do you assess the abdomon for rebound tenderness?

A
66
Q

What is ascites? When is it present?

A
  • Free fluid in the peritoneal cavity
  • In liver disease, ascites indicates a chronic or subacute disorder and does not occur in acute conditions(uncomplicated viral hepatitis, drug reactions, biliary obstruction)
67
Q

Ascites:
* What is happening to the abdomen?
* Characterized by what?
* What happens when you percuss?
* What also suggests ascites?

A
  • A protuberant abdomen +/- bulging flanks
  • Characterized by shifting dullness
  • As you percuss, map areas of tympany and dullness with patient supine and with the patient on his or her side
  • A fluid wave also suggests ascites
68
Q

What does it mean to shift dullness in ascites?

A

Dull over lateral regions dt fluid. Tympanic over non-fluid areas

69
Q

What are the special techniques for ascites?

A
  • A protuberant abdomen with bulging flanks is suspicious for ascites (fluid in the abdomen from diseases such as cancer).
  • Percuss the abdomen for areas of tympany and dullness. Due to gravity, dullness should be located along the lateral sides of the abdomen, while the anterior portion should be tympanitic.
  • Test for shifting dullness: after mapping out the areas of tympany and dullness, have the patient roll to one side. Remap the areas of tympany and dullness. In ascites, there should be a shift due to free fluid moving with gravity.
  • Test for a fluid wave: have the patient or an assistant press hands firmly down the midline. This pressure stops the transmission of the wave through fat tissue. Now tap on one flank sharply and feel with your own hand if the wave transmits to the other side of the flank.
70
Q

What are other exam findings in liver disease (12)

A
71
Q

What is usually the first sign of liver disease?

A

Hepatomegaly

72
Q

What is caput medusae? What is this caused by?

A
  • Dilated veins seen on the abdomen of a patient with cirrhosis of the liver.
  • Portal hypertension results from the abnormal blood flow pattern in liver created by cirrhosis.
73
Q

What is this?

A
  • Spider angiomas
74
Q

What abdominal structures frequently felt as masses?

A
75
Q

For each test, what are they for:
* Murphy’s sign
* Cullen’s sign
* Grey Turner’s sign
* Kehr’s sign

A
  1. Murphy’s Sign: Acute Cholecystitis (Only one on Checklist)
    - Felt after fatty meal
    - Pain in RUQ, right scapula
    - Nausa and vomit
  2. Cullen’s Sign: Necrotizing Pancreatitis
  3. Grey Turner’s Sign: Necrotizing Pancreatitis
  4. Kehr’s Sign: Splenic Rupture &Ectopic Pregnancy Rupture
76
Q

How do you preform a murphy’s sign? What is a positive sign?

A

.

77
Q

What is the cullen and grey turner signs?

A
78
Q

What is this?

A

cullen’s sign

79
Q

What is this?

A

Gray turner sign

80
Q

Denotes inflammation of peritoneum (Peritonitis) and is characterized by pain that is worse with what? (4)

A
  • coughing
  • when you remove your hand from deep palpation (rebound tenderness)
  • when you bump into the patient’s bed
  • when you hit the patient’s heel (heel jar test)
81
Q

What are the Peritoneal Signs?

A

Rebound Tenderness/Blumberg Sign
* Palpate deeply and then quickly release pressure.
* If it hurts more when you release, the patient has rebound tenderness.

Markle (heel jar)
* Patient stands with straightened knees, then raises up on toes, relaxes, and allows heels to hit floor, thus jarring body. Action will cause abdominal pain if positive
* Associated with peritoneal irritation; appendicitis

82
Q

What are things we need to remember? (4)

A
83
Q

An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1–2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation?

  1. Decreased fecal bulk
  2. Impairment of autonomic innervations
  3. Functional change in bowel movement
  4. Spasm of the external sphincter
  5. A large, firm fecal mass in the rectum
A

Functional change in bowel movement

Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation-predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis.

A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals.

Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation.

Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment.

84
Q

A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam?

  1. Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease
  2. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation
  3. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line
  4. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant
  5. A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration
A
  1. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant

Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left.
A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal.
Liver dullness will occur in the left upper quadrant with organ reversal.
Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis.

85
Q

A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic?

  1. Positive McBurney point tenderness
  2. Poorly localized periumbilical pain
  3. Associated right shoulder pain
  4. Exacerbating factor includes alcohol intake
  5. Vomiting of bile
A
  1. Associated right shoulder pain

Rationale: Pain with biliary colic can produced referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm.

Alcohol is not an exacerbating factor for biliary colic.

Positive McBurney point tenderness is associated with acute appendicitis.

The Murphy sign is associated with acute cholecystitis.

Poorly localized periumbilical pain is associated with early stages of acute appendicitis.

Vomiting bile is associated with small bowel obstruction.

86
Q

An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis?

  1. Ruptured ovarian cyst
  2. Perforated bowel wall
  3. Ruptured tubal (or ectopic) pregnancy
  4. Acute cholecystitis
  5. Ruptured appendix
A
  1. Ruptured tubal (or ectopic) pregnancy
87
Q

An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis?

  1. Voluntary contraction of the abdominal wall that persists over several examinations
  2. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus
  3. Pain with internal rotation of the right hip
  4. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain
  5. Abdominal pain that increases with hip flexion
A
  1. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain

Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis.

Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity.

Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason.

Localized pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but not peritonitis.

88
Q

A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6–8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis?

  1. Inflammation of colonic diverticulum
  2. Fibrosis of the pancreas
  3. Helicobacter pylori infection
  4. Reduced blood supply to the bowel
  5. Inflammation of the gallbladder
A
  1. Fibrosis of the pancreas

Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and diabetes mellitus.

H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea.

Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower-quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease.

Reduced blood supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk factors such as coronary artery disease.

89
Q

A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA?

  1. Family history of ruptured aneurysm
  2. Female gender
  3. Hypertension
  4. Underweight
  5. History of smoking
A
  1. History of smoking

Rationale: History of smoking is her most significant risk factor for an AAA.

Male gender, not female gender, is considered as risk factor.

Underweight is not a risk factor for AAA. Family history of ruptured aneurysm is vague and could be a cerebral aneurysm.

Further, her family history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and children).

Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one elevated blood pressure reading.

90
Q

A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly?

  1. Liver span of 11 cm at the midclavicular line
  2. Dullness to percussion over a span of 8 cm at the midsternal line
  3. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration
  4. Dullness to percussion over a span of 11 cm at the midclavicular line
  5. Liver span of 8 cm at the midsternal line
A
  1. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration

Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration.

Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at the midclavicular line.

For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity.

The liver span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular line and 4-8 cm at the midsternal line are considered normal.

91
Q

A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient?

  1. Do not screen routinely
  2. Sigmoidoscopy every 5 years with FOBT every 3 years
  3. Continue annual FOBT screening until age 80 years
  4. Continue annual FOBT screening until age 85 years
  5. Repeat colonoscopy this year
A
  1. Do not screen routinely
    The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient.

Annual FOBT screening may continue until age 80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years is necessary for screening to be potentially beneficial.

There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago.

Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age >75 years.

92
Q
A
93
Q
A

Physical Diagnosis (17 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2024 Bold Learning Solutions. Terms and Conditions