Midterm GI, GU, Reproductive

Question 1

When we divide the abdomen into 9 quadrants, what are they called?

Answer 1

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

Question 2

What organs are located in the RUQ?

Answer 2

Liver, gallbladder, duodenum, head of pancreas…

Question 3

Organs in the LUQ

Answer 3

Spleen, splenic flexure of colon, stomach, and body and tail of
pancreas

Question 4

Organs in LLQ

Answer 4

Sigmoid colon, descending colon, and left ovary

Question 5

Organs in RLQ

Answer 5

Cecum, appendix, ascending colon, terminal ileum, and right
ovary

Question 6

T/F the gallbladder is normally palpable

Answer 6

False - only if pathologic

Question 7

Which kidney may be palpable?

Answer 7

Lower pole of right kidney (especially in children and thin people)

Question 8

Is the spleen normally palpable

Answer 8

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).

Question 9

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?

Answer 9

Visceral
- caused by distension/stretched organs or ischemia of organs

Question 10

How does the pain in appendicitis progress?

Answer 10

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

Question 11

For abdo pain that seems disproportionate to physical findings, suspect what?

Answer 11

intestinal mesenteric ischemia

Question 12

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?

Answer 12

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”

Question 13

Your patient is suffering from renal stones. Are they typically more often seen lying still or squirmy-worming around?

Answer 13

Squirmy-worming - attempting to get comfortable
(this is in contrast to peritonitis)

Question 14

If your patient is experiencing referred pain, do you expect to see tenderness on palpation of the site of radiation?

Answer 14

No - Palpation at the site of
referred pain often does not result in tenderness.

Question 15

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

Answer 15

Ask if it’s precipitated by exertion and relieved by rest

Question 16

Define dyspepsia (what is felt and where in the abdomen?)

Answer 16

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.

Question 17

Your patient present with acute RLQ abdo pain. In addition to appendicitis, what else should be considered in a person with a uterus?

Answer 17

pelvic inflammatory disease (PID), ruptured ovarian follicle, and ectopic pregnancy.

Question 18

Pain in the LLQ accompanied by diarrhea in a patient with a
history of constipation is suggestive of __________ (diagnosis)

Answer 18

diverticulitis

Question 19

Nonspecific
diffuse abdominal pain with abdominal distention, nausea,
emesis, and lack of flatus and/or bowel movements is
symptomatic of ________ (diagnosis)

Answer 19

a bowel obstruction

Question 20

Causes of odynophagia (pain with swallowing)

Answer 20

Consider esophageal ulceration from ingestion of aspirin or
NSAIDs; caustic ingestion; radiation; or infection with Candida,
cytomegalovirus, herpes simplex, or HIV.

Question 21

Common causes of acute & chronic diarrhea

Answer 21

Acute - infectious
Chronic: IBD or food allergy

Question 22

Acute vs persistent vs chronic diarrhea - how long is each?

Answer 22

Acute = <14 days,

persistent diarrhea = 14 to 30 days

chronic diarrhea = > 30 days.

Question 23

Define tenesmus

Answer 23

Constant urge to defecate (even when bowels are empty)

Question 24

Drugs that commonly cause diarrhea

Answer 24

penicillin and macrolides
magnesium-based antacids, metformin, and herbal and
alternative medicines.

Question 25

Rome IV criteria for IBS

Answer 25

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

Question 26

Meds that commonly cause constipation

Answer 26

antidepressants, calcium-channel
blockers, calcium and iron supplements, and opioids

Question 27

What is obstipation?

Answer 27

No passage of either gas or stool (signifies obstruction)

Question 28

Causes of painful vs painless jaundice?

Answer 28

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

Question 29

What does grey stool indicate?

Answer 29

Bile obstruction

When excretion of bile into the
intestine is completely obstructed, the stools become gray or light colored, or
acholic, without bile

Question 30

Where is prostatic pain usually felt?

Answer 30

prostatic pain is felt in the perineum and occasionally in the rectum
- in prostatitis, see pain with urination

Question 31

Where is ureteral pain/colic felt (as in kidney stones)?

Answer 31

Lower back (just below CVA), radiating around the trunk into the lower abdomen and groin or possibly into
the upper thigh, testicle, or labium

Question 32

When performing a physical exam on a patient with abdo pain, do you examine the areas of pain first or last?

Answer 32

LAST

Question 33

Name some signs of peritonitis you will notice during the physical exam

Answer 33

involuntary guarding, rigidity, rebound
tenderness, positive cough test, percussion tenderness

Question 34

A protuberant abdomen that is tympanitic throughout suggests
________ or ________

Answer 34

intestinal obstruction or paralytic ileus

Question 35

How to distinguish involuntary and voluntary guarding? (describe technique)

Answer 35

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

Question 36

Signs of peritonitis:

Question 37

What causes peritonitis?

Answer 37

any inflammatory, infectious or ischemic
intraabdominal process, such as appendicitis, diverticulitis,
cholecystitis, bowel ischemia or perforation

Question 38

What is guarding?

Answer 38

is a voluntary contraction of the abdominal wall, often accompanied by a
grimace that may diminish when the patient is distracted.

Question 39

What is rigidity?

Answer 39

an involuntary reflex contraction of the abdominal wall from peritoneal
inflammation that persists over several examinations.

Question 40

What is Castell sign

Answer 40

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

Question 41

What does the belly look like in someone with ascites?

Answer 41

Protuberant abdo with bulging flanks

Question 42

What are the 4 tests for appendicities?

Answer 42

1) McBurney point tenderness
2) Rovsing sign (indirect
tenderness)
3) the psoas sign
4) and the obturator sign.

Question 43

Where is McBurney point?

Answer 43

Roughly half way between umbilicus and iliac spine

Question 44

What occurs in Rosving sign?

Answer 44

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)

Question 45

How to do psoas sign

Answer 45

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.

Question 46

How to do obturator sign

Answer 46

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.

Question 47

How to assess for Acute Cholescystitis (specific maneuver)

Answer 47

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.