Midterm GI, GU, Reproductive Flashcards
When we divide the abdomen into 9 quadrants, what are they called?
From top (on sides):
R/L Hypochondriac (at costal margin)
R/L Lumbar (either side of umbilical region)
R/L iliac/inguinal
Again from top but in the middle:
Epigastric
Umbilical
Hypogastric or suprapubic
What organs are located in the RUQ?
Liver, gallbladder, duodenum, head of pancreas…
Organs in the LUQ
Spleen, splenic flexure of colon, stomach, and body and tail of
pancreas
Organs in LLQ
Sigmoid colon, descending colon, and left ovary
Organs in RLQ
Cecum, appendix, ascending colon, terminal ileum, and right
ovary
T/F the gallbladder is normally palpable
False - only if pathologic
Which kidney may be palpable?
Lower pole of right kidney (especially in children and thin people)
Is the spleen normally palpable
The tip of the spleen may be palpable below the
left costal margin in a small percentage of adults (in contrast to readily
palpable splenic enlargement, or splenomegaly).
Your patient presents with generalized, nonspecific abdo pain and is having difficulty localizing it. They describe the quality as cramping and gnawing. What general category of pain might this be?
Visceral
- caused by distension/stretched organs or ischemia of organs
How does the pain in appendicitis progress?
Visceral periumbilical pain can be suggestive of early acute
appendicitis from distention of an inflamed appendix. It
gradually changes to parietal pain in the RLQ from
inflammation of the adjacent parietal peritoneum
For abdo pain that seems disproportionate to physical findings, suspect what?
intestinal mesenteric ischemia
Your patient has abdo pain that they describe as 10/10, constant, aching, diffuse, and they refuse to move. They have guarding/rigidity on exam What kind of pain is this likely?
Somatic or parietal pain
“originates from inflammation of the parietal
peritoneum, called peritonitis, which can be localized or diffuse. It is a
steady, aching pain that is usually more severe than visceral pain and more
precisely localized over the involved structure. It is typically aggravated
by movement or coughing. Patients with parietal pain usually prefer to lie
still”
Your patient is suffering from renal stones. Are they typically more often seen lying still or squirmy-worming around?
Squirmy-worming - attempting to get comfortable
(this is in contrast to peritonitis)
If your patient is experiencing referred pain, do you expect to see tenderness on palpation of the site of radiation?
No - Palpation at the site of
referred pain often does not result in tenderness.
If a patient presents with “indigestion” and you suspect a cardiac cause (such as inferior wall CAD), how can you help distinguish a cardiac cause during the interview
Ask if it’s precipitated by exertion and relieved by rest
Define dyspepsia (what is felt and where in the abdomen?)
chronic or recurrent discomfort or pain centered in the UPPER abdomen,
characterized by EPIGASTRIC PAIN or BURNING (or both) and postprandial
fullness or early satiety (or both
*Note that bloating, nausea, or belching
can occur alone but also can accompany other disorders. If these conditions
occur alone, they do not meet the criteria for dyspepsia.
Your patient present with acute RLQ abdo pain. In addition to appendicitis, what else should be considered in a person with a uterus?
pelvic inflammatory disease (PID), ruptured ovarian follicle, and ectopic pregnancy.
Pain in the LLQ accompanied by diarrhea in a patient with a
history of constipation is suggestive of __________ (diagnosis)
diverticulitis
Nonspecific
diffuse abdominal pain with abdominal distention, nausea,
emesis, and lack of flatus and/or bowel movements is
symptomatic of ________ (diagnosis)
a bowel obstruction
Causes of odynophagia (pain with swallowing)
Consider esophageal ulceration from ingestion of aspirin or
NSAIDs; caustic ingestion; radiation; or infection with Candida,
cytomegalovirus, herpes simplex, or HIV.
Common causes of acute & chronic diarrhea
Acute - infectious
Chronic: IBD or food allergy
Acute vs persistent vs chronic diarrhea - how long is each?
Acute = <14 days,
persistent diarrhea = 14 to 30 days
chronic diarrhea = > 30 days.
Define tenesmus
Constant urge to defecate (even when bowels are empty)
Drugs that commonly cause diarrhea
penicillin and macrolides
magnesium-based antacids, metformin, and herbal and
alternative medicines.
Rome IV criteria for IBS
Recurrent abdominal pain on average at least 1 day/week in the last 3 months, associated with two or more of the following criteria:
Related to defecation
Associated with a change in frequency of stool
Associated with a change in form (appearance) of stool
Meds that commonly cause constipation
antidepressants, calcium-channel
blockers, calcium and iron supplements, and opioids
What is obstipation?
No passage of either gas or stool (signifies obstruction)
Causes of painful vs painless jaundice?
Painless jaundice points to malignant obstruction of the bile
ducts, seen in duodenal or pancreatic carcinoma
painful jaundice
is commonly infectious in origin, as in hepatitis A and
cholangitis
What does grey stool indicate?
Bile obstruction
When excretion of bile into the
intestine is completely obstructed, the stools become gray or light colored, or
acholic, without bile
Where is prostatic pain usually felt?
prostatic pain is felt in the perineum and occasionally in the rectum
- in prostatitis, see pain with urination
Where is ureteral pain/colic felt (as in kidney stones)?
Lower back (just below CVA), radiating around the trunk into the lower abdomen and groin or possibly into
the upper thigh, testicle, or labium
When performing a physical exam on a patient with abdo pain, do you examine the areas of pain first or last?
LAST
Name some signs of peritonitis you will notice during the physical exam
involuntary guarding, rigidity, rebound
tenderness, positive cough test, percussion tenderness
A protuberant abdomen that is tympanitic throughout suggests
________ or ________
intestinal obstruction or paralytic ileus
How to distinguish involuntary and voluntary guarding? (describe technique)
Ask the patient to bend the lower extremities at the hip to make the
abdominal muscles less tense.
Ask the patient to mouth-breathe with the jaws wide open.
Palpate after asking the patient to exhale, which usually relaxes the
abdominal muscles.
**Will see involuntary guarding despite this technique in peritonitis
Signs of peritonitis:
What causes peritonitis?
any inflammatory, infectious or ischemic
intraabdominal process, such as appendicitis, diverticulitis,
cholecystitis, bowel ischemia or perforation
What is guarding?
is a voluntary contraction of the abdominal wall, often accompanied by a
grimace that may diminish when the patient is distracted.
What is rigidity?
an involuntary reflex contraction of the abdominal wall from peritoneal
inflammation that persists over several examinations.
What is Castell sign
For detecting splenomegaly
Percuss the lowest
interspace in the left anterior axillary line. This area is usually tympanic. Then ask the patient to take a deep breath to let the airfilled lungs and diaphragm push the spleen and percuss again. When
spleen size is normal, the percussion note usually remains tympanitic
despite this downward displacement by the diaphragm.
- change to dullness = possible splenomegaly
What does the belly look like in someone with ascites?
Protuberant abdo with bulging flanks
What are the 4 tests for appendicities?
1) McBurney point tenderness
2) Rovsing sign (indirect
tenderness)
3) the psoas sign
4) and the obturator sign.
Where is McBurney point?
Roughly half way between umbilicus and iliac spine
What occurs in Rosving sign?
Pain in the RLQ during left-sided pressure is a positive
Rovsing sign.
(may also elicit referred rebound tenderness, which is pain when you withdraw your hand in the LLQ)
How to do psoas sign
With the patient supine, place your hand just above
the patient’s right knee and ask the patient to raise that thigh against your
hand. Alternatively, ask the patient to turn onto the left side. Then extend
the patient’s right thigh at the hip. Flexion of the thigh at the hip makes the
psoas muscle contract; extension stretches it.
Increased abdominal pain on either technique is a positive
psoas sign, suggesting irritation of the right psoas muscle by
an inflamed retrocecal appendix.
How to do obturator sign
Flex the patient’s right
thigh at the hip, with the knee bent, and rotate the leg internally at the hip.
This maneuver stretches the internal obturator muscle.
Right hypogastric pain is a positive obturator sign, from
irritation of the right obturator internus muscle by an inflamed
appendix located in the pelvis. **This sign has very low
sensitivity.
How to assess for Acute Cholescystitis (specific maneuver)
Murphy Sign
**only need this if pt not already having pain with palpation of RUQ.
Deeply palpate the RUQ. Ask the patient
to take a deep breath, which forces the liver and gallbladder down toward
the examining fingers.
A sharp halting in inspiratory effort due to pain from palpation of
the gallbladder on examination is a positive Murphy sign.
