Module 6

Question 1

has small, rounded elevations formed by sebaceous glands (called Montgomery glands), sweat glands, and accessory areolar glands

Answer 1

The surface of the areola

Question 2

There are two fascial layers of the breast:

Answer 2

The superficial fascia (lies deep to the dermis), and the deep fascia (lies anterior to the pectoralis major muscle)

Question 3

suspensory Cooper ligaments

Answer 3

The breast is attached to the skin by suspensory Cooper ligaments, fibrous bands that travel through the breast and insert perpendicular to the dermis

Question 4

Occasionally, one or more extra nipples are located along the “milk line” (usually, only a small nipple and areola are present, often mistaken for a common mole. They may be familial, and, in the absence of associated glandular tissue, there is little evidence of association with other congenital anomalies. Those containing glandular tissue occasionally show increased pigmentation, swelling, tenderness, or even lactation during puberty, menstruation, or pregnancy and can be associated with other congenital anomalies, mainly renal and thoracic.2 Treatment is recommended if there is diagnostic ambiguity, cosmetic concerns, or possible pathology

Answer 4

supernumerary nipples

Question 5

To describe clinical findings, the breast is often divided into four quadrants based on horizontal and vertical lines crossing at the nipple (A fifth area, the axillary tail of breast, sometimes termed the…extends laterally across the anterior axillary fold.

Answer 5

The tail of Spence

Question 6

is of great importance in the spread of carcinoma, and about three-quarters of it is to the axillary nodes.

Answer 6

The lymphatic drainage of the breast

Question 7

l nodes that are most likely to be palpable during physical examination.

Answer 7

central nodes

Question 8

a proliferation of palpable glandular tissue generally defined as more than 2 cm in boys or men

Answer 8

gynecomastia,

Question 9

Causes of gynecomastia include

Answer 9

increased estrogen, decreased testosterone, and medication side effects.

Question 10

an accumulation of subareolar fat

condition in which the male breast area has excess adipose (fat) tissue behind, around and under the nipples

Answer 10

pseudogynecomastia,

Question 11

These are the most common breast-related complaints.

Answer 11

lumps, pain, or nipple discharge of her breasts.

Question 12

15–25 yrs, usually puberty and young adulthood, but up to age 55 yrs
-usually single, maybe multiple
-round, disc-like shape
-maybe soft, usually firm
-well delineated
-very mobile
-usually nontender
-absent retraction signs

A noncancerous breast tumor that most often occurs in young women.

Answer 12

Fibroadenoma
(A benign neoplasm derived from glandular epithelium, in which there is a conspicuous stroma of proliferating fibroblasts and connective tissue elements; commonly occurs in breast tissue.)

Question 13

-30–50 yrs, regress after menopause except with estrogen therapy
-single or multiple
-round
-soft to firm, usually elastic
-well delineated
-mobile
-often tender
-retraction signs is absent

Answer 13

Cysts

A fluid-filled sac in the breast, which usually isn’t cancerous.
Breast cysts are common in women ages 35 to 50. They usually disappear after menopause, unless a woman is taking hormone therapy.

Question 14

-30–90 yrs, most common over age 50 yrs
-usually single, although may coexist with other nodules
-Irregular or stellate
-firm or hard
-not clearly delineated from surrounding tissue
-May be fixed to skin or underlying tissues
-usually nontender
retraction signs maybe present

Answer 14

Cancer

Question 15

visible signs of breast cancer

Answer 15

Retraction signs
-abnormal contours
-skin dimpling
-nipple retraction and deviation
-Paget Disease of the Nipple
-edema of skin

Question 16

As breast cancer advances, it causes fibrosis (scar tissue). Shortening of this tissue produces dimpling, changes in contour, and retraction or deviation of the nipple. Other causes of retraction include fat necrosis and mammary duct ectasia.

Answer 16

Retraction signs

Question 17

Look for any variation in the normal convexity of each breast and compare one side with the other. Special positioning may again be useful. Shown here is marked flattening of the lower outer quadrant of the left breast.

Answer 17

Abnormal contours

Question 18

Look for this sign with the patient’s arm at rest, during special positioning, and on moving or compressing the breast, as illustrated here.

Answer 18

Skin dimpling

Question 19

A retracted nipple is flattened or pulled inward, as illustrated here. It may also be broadened and feels thickened. When involvement is radially asymmetric, the nipple may deviate or point in a different direction from its normal counterpart, typically toward the underlying cancer.

Answer 19

Nipple Retraction and Deviation

Question 20

This uncommon form of breast cancer usually starts as a scaly, eczema-like lesion on the nipple that may weep, crust, or erode. A breast mass may be present. Suspect Paget disease in any persisting dermatitis of the nipple and areola. Often (>60%) presents with an underlying in situ or invasive ductal or lobular carcinoma.

Answer 20

Paget Disease of the Nipple

Question 21

Edema of the skin is produced by lymphatic blockade. It appears as thickened skin with enlarged pores—the so-called peau d’orange (orange peel) sign. It is often seen first in the lower portion of the breast or areol

Answer 21

Edema of the skin

Question 22

risks of breast cancer in males

Answer 22

Risk factors include increasing age, radiation exposure, BRCA gene mutations, Klinefelter syndrome, testicular disorders, alcohol use, liver disease, diabetes, and obesity.

Question 23

The strongest risk factors for breast cancer in women are

Answer 23

increasing age, first-degree family members diagnosed with breast cancer (especially two or more diagnosed at an early age), inherited genetic mutations, personal history of breast cancer or ductal or lobular carcinoma in situ, biopsy-confirmed precancerous lesions, relatively denser breasts on mammography, high-dose radiation to the chest at a young age, and high levels of endogenous hormones.24

Question 24

One of the most commonly used tools is … which incorporates age, race/ethnicity, personal history of breast cancer or ductal or lobular carcinoma in situ, chest radiation, genetic mutations, first-degree relatives with breast cancer, previous breast biopsy results, age at menarche, and age at first delivery.25

Answer 24

the National Cancer Institute’s Breast Cancer Risk Assessment Tool (also known as the Gail model),

Question 25

Heartburn

Answer 25

a burning sensation in the epigastric
area radiating into the throat; often associated
with regurgitation

Question 26

needing to belch or pass
gas by the rectum; patients often state they feel bloated

Answer 26

excessive gas or flatus

Question 27

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

Answer 27

Regurgitation

Question 28

Blood or coffee ground emesis is known as

Answer 28

hematemesis

Question 29

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)
Visceral pain is typically nonspecific and difficult to localize.
As the pain progress, systemic symptoms such as sweating, pallor, nausea, vomiting, and restless May follow.

Answer 29

Visceral pain

Question 30

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)
- 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. Patient with parietal pain prefers to lie still.

Answer 30

Parietal pain or somatic pain

Question 31

originates at different sites but shares innervation from the same spinal level (gallbladder pain in the
shoulder
Palpating at the site of referred pain often does not result in tenderness

Answer 31

Referred pain

Question 32

normal abdominal sounds on percussion
-what sound could be a large stool or a mass?

Answer 32

tympany (hollow sounds)
-Dullness

Question 33

Midclavicular percussion of the liver should be 6–12 cm; longer than this indicates an

Answer 33

enlarged liver

Question 34

Midsternal line percussion should be 4–8 cm; shorter than this can indicate

Answer 34

a small, hard cirrhotic liver

Question 35

Liver, gallbladder, pylorus, duodenum, hepatic flexure of colon, and head of pancreas

Answer 35

RUQ

Question 36

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

Answer 36

LUQ

Question 37

Sigmoid colon, descending colon, and left ovary

Answer 37

LLQ

Question 38

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

Answer 38

RLQ

Question 39

…which rests against the inferior surface of the liver, and the more deeply lying duodenum are generally not palpable unless pathologic

Answer 39

The gallbladder,

Question 40

rib cage with its xiphoid process, which protects …

Answer 40

the stomach.

Question 41

… can have visible pulsations and may be palpable in the upper abdomen, or epigastrium in thin patients

Answer 41

The abdominal aorta

Question 42

In the left upper quadrant (LUQ), the …is lateral to and behind the stomach, just above the left kidney in the left midaxillary line. Its upper margin rests against the dome of the diaphragm. The 9th, 10th, and 11th ribs protect most of the…. its tip may be palpable below the left costal margin in a small percentage of adults (in contrast to readily palpable splenic enlargement, or splenomegaly).

Answer 42

the spleen

Question 43

the appendix is located in the right lower quadrant (RLQ) at the base of the cecum, the first part of the large intestine where the terminal ileum enters the large intestine at the ileocecal valve. and the pancreas in the LUQ.

Answer 43

In healthy people, these are not palpabl

Question 44

In the lower midline are the… which can often be palpated when distended and in women, the uterus and ovaries.

Answer 44

urinary bladder

Question 45

lie posteriorly in the abdominal cavity behind the peritoneum (retroperitoneal). The ribs protect their upper poles (

Answer 45

the kidneys

Question 46

formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae, defines where to elicit for kidney tenderness, called

Answer 46

-The costovertebral angle (CVA)
-The costovertebral angle tenderness

Question 47

Continuous with the abdominal cavity, but angulated posteriorly, lies the funnel-shaped…, which contains the terminal ureters; bladder; pelvic genital organs; and, at times, loops of small and large intestine. These organs are partially protected by the surrounding pelvis.

Answer 47

pelvic cavity

Question 48

is a hollow reservoir with strong smooth muscle walls composed chiefly of detrusor muscle. It accommodates roughly 400 to 500 mL of urine filtered by the kidneys into the renal pelvis and the ureters.

Answer 48

The urinary bladder

Question 49

may be palpable above the symphysis pubis.

Answer 49

A distended bladder

Question 50

painful swallowing

Answer 50

odynophagia

Question 51

increasing age; personal history of colorectal cancer, adenomatous polyps, or longstanding inflammatory bowel disease (IBD); and family history of colorectal neoplasia—particularly with diagnoses in multiple first-degree relatives, a single first-degree relative diagnosed before age 60, or a hereditary colorectal cancer syndrome.52 While the lifetime risk of colorectal cancer is extremely high in patients with hereditary syndromes, about 75% of colorectal cancers arise in people without any obvious hereditary risk or family history

Answer 51

The strongest risk factors for colorectal cancer

Question 52

colorectal screening guidelines

Answer 52

-Adults age 50 to 75 yrs—options (grade A recommendation)
Stool-based tests
Fecal immunochemical test (FIT) annually
High-sensitivity guaiac-based fecal occult blood testing annually
FIT-DNA testing every 1 or 3 yrs
Direct visualization tests
Colonoscopy every 10 yrs.
Sigmoidoscopy every 5 yrs
Flexible sigmoidoscopy every 10 yrs with FIT every 3 yrs
CT colonography every 5 yrs
Adults age 76 to 85 yrs—individualized decision making (grade C recommendation), decisions should take into consideration life expectancy and previous screening. Previously unscreened adults might benefit from screening.
Adults older than age 85—do not screen (grade D recommendation), because “competing causes of mortality preclude a mortality benefit that would outweigh the harms”

Question 53

-Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or excess relaxations of the lower esophageal sphincter; Helicobacter pylori may be present
-Chest or epigastric
-After meals, especially spicy foods
-ying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter
-Antacids, proton pump inhibitors; avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers

Answer 53

Gastroesophageal Reflux Disease (GERD

Question 54

-Mucosal ulcer in stomach or duodenum >5 mm, covered with fibrin, extending through the muscularis mucosa; H. pylori infection present in 90% of peptic ulcer
-Epigastric, may radiate straight to the back
-Quality: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike No symptoms in up to 20%
-timing:Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs
-aggravating factor: variable
-Food and antacids may bring relief (less likely in gastric ulcers)

Answer 54

Peptic Ulcer and Dyspepsia

Question 55

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.

Answer 55

acute appendicitis

Question 56

Place the diaphragm over the abdomen to hear bowel sounds called….which are long gurgles. These sounds are transmitted across the abdomen so it is not necessary to listen at multiple places. The normal frequency of sound is 5-34 sounds per minute.

Answer 56

(borborygmi)

Question 57

(rebound tenderness in the left lower quadrant)

Rovsing’s sign (a.k.a. indirect tenderness) is a right lower quadrant pain elicited by pressure applied on the left lower quadrant. The phenomenon is generally named after the Danish surgeon Niels Thorkild Rovsing

Answer 57

Rovsing’s sign

Question 58

the patient flexes his thigh against the examiner’s hand; pain indicates a positive sign)

Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscl

Answer 58

psoas sign

Question 59

flex the patient’s thigh
and rotate the leg internally at the hip; pain indicates
a positive sign)

pain that is elicited in a supine patient by internally and externally rotating the flexed right hip.

Answer 59

obturator’s sign

Question 60

If patients report heartburn and effortless regurgitation together more than once a week, the accuracy of diagnosing … is over 90%.

Answer 60

GERD

Question 61

the diagnostic criteria for GERD

Answer 61

hese symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include reduced salivary flow, which increases mucosal acid exposure by dampening the actions of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; hiatal hernia and increased intraabdominal pressure.

Question 62

GERD atypical sx

Answer 62

Some patients with GERD have atypical respiratory symptoms such as chest pain, cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness chronic sore throat, and laryngitis

Question 63

endoscopic evaluation

Answer 63

Patients who have uncomplicated GERD who fail empiric therapy, age >55 years, and “alarm symptoms” warrant endoscopy to evaluate possible esophagitis, peptic strictures, Barrett esophagus, or esophageal cancer.

Question 64

alarm symptoms with GERD

Answer 64

Difficulty swallowing (dysphagia)
Pain with swallowing (odynophagia)
Recurrent vomiting
Evidence of GI bleeding
Early satiety
Weight loss
Anemia
Risk factors for gastric cancer
Palpable mass
Painless jaundice

Question 65

a metaplastic change in the esophageal lining from normal squamous to columnar epithelium. In those affected, dysplasia on endoscopy increases the risk of esophageal cancer from 0.1% to 0.5% (no dysplasia) to 6% to 19% per patient year (high-grade dysplasia).1

Answer 65

Barrett esophagus,
Approximately 10% of patients with chronic longstanding heartburn have Barrett esophagu

Question 66

RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for

Answer 66

appendicitis.
In women, consider pelvic inflammatory disease (PID), ruptured ovarian follicle, and ectopic pregnancy.

Question 67

pain in the LLQ accompanied by diarrhea in a patient with a history of constipation is suggestive of

Answer 67

diverticulitis

Question 68

Nonspecific diffuse abdominal pain with abdominal distention, nausea, emesis, and lack of flatus and/or bowel movements is symptomatic of a

Answer 68

bowel obstruction

Question 69

marked by severe diffuse abdominal pain with guarding and rigidity on examination. Patients may or may not have accompanying abdominal distention.

Answer 69

peritonitis

Question 70

Change in bowel habits with a palpable mass warns of late-stage

Answer 70

colon cancer.

Question 71

a diagnosis of exclusion and requires intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity.15

Answer 71

Diagnostic criteria for IBS

Question 72

Anorexia, nausea, and vomiting accompany many disorders

Answer 72

from benign to more insidious, including pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, and adverse drug reactions.

Question 73

Induced vomiting without nausea

Answer 73

is more indicative of bulimia.

Question 74

involuntary spasm of the stomach, diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth.

Answer 74

Retching

Question 75

common symptom of GERD; however, it can also be a presenting symptom of esophageal stricture, Zenker diverticulum, or esophageal or gastric malignancy.

Answer 75

regurgitation

Question 76

Vomiting and nausea with constipation or obstipation (severe constipation with inability to pass both stool and gas) is indicative of

Answer 76

bowel obstruction and warrants further imaging workup.

Question 77

Hematemesis may accompany .

Answer 77

esophageal or gastric varices, Mallory–Weiss tears, or PUD

Question 78

If fullness or early satiety, consider

Answer 78

diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, and gastric cancer

Question 79

globus sensation,

Answer 79

The sensation of a lump or foreign body in the throat at rest that improves or disappears with swallowing, called a globus sensation, is not true dysphagia.

Question 80

Xerostomia

Answer 80

(insufficient saliva) commonly present in older adult men and women ≥70 years can give rise to the sensation of difficulty swallowing food. For types of dysphagia,

Question 81

Indicators of oropharyngeal dysphagia

Answer 81

delay in initiating swallowing, postnasal regurgitation or coughing from aspiration, and repetitive swallowing to achieve clearance. Causes may be neurologic like stroke, Parkinson disease, or amyotrophic lateral sclerosis; muscular like muscular dystrophy or myasthenia gravis; or structural as seen in esophageal stricture and hypopharyngeal diverticuli (Zenker diverticulum). Causes are generally structural in younger adults and neurologic/muscular in older adults.16

Question 82

Ask the patient to point to where the dysphagia occurs.Pointing to below the sternoclavicular notch suggests

Answer 82

esophageal dysphagia

Question 83

solid vs solid and liquid food

Answer 83

If solid foods, consider structural causes like esophageal stricture, webbing or narrowing (Schatzki ring), and neoplasm; if solids and liquids, a motility disorder like achalasia is more likely.

Question 84

Consider esophageal ulceration from

Answer 84

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

Question 85

excessive gas causes

Answer 85

Causes include excessive and repetitive air swallowing (aerophagia), ingestion of legumes or other gas-producing foods, intestinal lactase deficiency, and IBS.

Question 86

(aerophagia),

Answer 86

excessive and repetitive air swallowing (aerophagia),

Question 87

acute diarrhea
-persistent diarrhea
-chronic diarrhea

Answer 87

last less than 14 days
Acute diarrhea, especially foodborne, is usually caused by infection
-persistent diarrhea as lasting 14 to 30 days
-lasting more than 30 days.Chronic diarrhea is typically noninfectious in origin, as in IBS (Crohn disease and ulcerative colitis) or food allergy.

Question 88

High-volume frequent watery stools are usually from the small intestine; small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions.

Answer 88

High-volume frequent watery stools are usually from the small intestine; small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions.

Question 89

primary or functional constipation

Answer 89

the cause cannot be identified from the history and physical examination. Types include normal transit, slow transit, impaired expulsion (from pelvic floor dysfunction), and combined causes

Question 90

Secondary or organic constipation

Answer 90

has an identified underlying cause, which may include medications, amyloidosis, diabetes, and central nervous system disorders

Question 91

Thin, pencil-like stool occurs in

Answer 91

an obstructing “apple-core” lesion of the distal colon.

Question 92

causes of constipation

Answer 92

Anticholinergic agents, antidepressants, calcium-channel blockers, calcium and iron supplements, and opioids can cause medication-induced constipation. Constipation also occurs with diabetes, hypothyroidism, hypercalcemia, hypomagnesemia, multiple sclerosis, Parkinson disease, and systemic sclerosis.

Question 93

Ostipation

Answer 93

intestinal obstruction.
here is no passage of either stool or gas

Question 94

is usually apparent when plasma bilirubin is >3 mg/dL.

Answer 94

jaundice

Question 95

Carotenemia

Answer 95

the presence of the orange pigment carotene in the blood due to ingestion of carrots, presents as a yellow discoloration of the skin, especially palms and soles, but not the sclera or mucous membranes.

Question 96

Rome IV criteria

Answer 96

constipation should be present for the last 3 months with symptom onset at least 6 months prior to diagnosis and should have at least two of the following conditions: less than three bowel movements per week, ≥25% or more defecations with either straining or sensation of incomplete evacuation, lumpy or hard stools, or manual facilitation.17,18

Question 97

Painless jaundice points to

Question 98

painless jaundice

Answer 98

malignant obstruction of the bile ducts, seen in duodenal or pancreatic carcinoma;

Question 99

painful jaundice

Answer 99

ainful jaundice is commonly infectious in origin, as in hepatitis A and cholangitis.23

Question 100

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

Answer 100

acholic

Question 101

Dark urine indicates.

Answer 101

impaired excretion of bilirubin into the GI tract

Question 102

occurs in cholestatic or obstructive jaundice when bilirubin levels are markedly elevated

Answer 102

itching or pruritus
Does the skin itch without other obvious explanation? I

Question 103

Risk Factors for Liver Disease

Answer 103

Infectious hepatitis: Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A); parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis B); illicit injection drug use or blood transfusion (hepatitis C). Hepatitis B is also endemic in certain regions of the world and can present in patients with no risk factors.Nonalcoholic steatohepatitis in patients with metabolic syndromeAlcoholic hepatitis or alcoholic cirrhosis: screen patients carefully about alcohol useToxic liver damage from medications, industrial solvents, environmental toxins, or some anesthetic agentsGallbladder disease or prior surgery that may result in extrahepatic biliary obstructionHereditary disorders such as family history of hemolytic anemia or liver disease, such as hemochromatosis, α-1-antitrypsin deficiency, Wilson disease

Question 104

Involuntary voiding or lack of awareness suggests

Answer 104

cognitive or neurosensory deficits.

Question 105

Paget disease of the breast

Answer 105

Asymmetry due to change in nipple direction suggests an underlying cancer. Eczematous changes with rash, scaling, or ulceration on the nipple extending to the areola occurs in Paget disease of the breast, associated with underlying ductal or lobular carcinoma
-This uncommon form of breast cancer usually starts as a scaly, eczema-like lesion on the nipple that may weep, crust, or erode. A breast mass may be present. Suspect Paget disease in any persisting dermatitis of the nipple and areola. Often (>60%) presents with an underlying in situ or invasive ductal or lobular carcinoma.

Question 106

here are five broad categories of incontinence.

Answer 106

-In stress incontinence, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck.
-In urge incontinence, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance.
- In overflow incontinence, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended.
-Functional incontinence arises from impaired cognition, musculoskeletal problems, or immobility.
-Combined stress and urge incontinence is called mixed incontinence.

Question 107

Pink–purple striae on the abdomen are a hallmark of

Answer 107

Cushing syndrome.

Question 108

…..suggest portal hypertension from cirrhosis (caput medusae) or inferior vena cava obstruction.

Answer 108

dilated vein of the abdomen

Question 109

Ecchymosis of the abdominal wall is seen in

Answer 109

intraperitoneal or retroperitoneal hemorrhage.

Question 110

tympani sounds of abdomen on percussion

Answer 110

tympany usually predominates because of gas in the GI tract
-dullness from fluid and feces are also common

Question 111

Dull areas on abdominal percussion

Answer 111

Dull areas characterize an intrauterine pregnancy, an ovarian tumor, a distended bladder, large volume ascites, or a large liver or spleen.

Question 112

Signs of peritonitis

Answer 112

Guarding is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted.
-Rigidity is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations.
-Rebound tenderness refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand. To assess rebound tenderness, ask the patient, “Which hurts more, when I press or let go?” Press down with your fingers firmly and slowly, then withdraw your hand quickly. The maneuver is positive if withdrawal produces pain. Percuss gently to check for percussion tenderness.

Question 113

splenic percussion sign (Castell sign).

Answer 113

A change in percussion note from tympany to dullness on inspiration is a positive splenic percussion sign, but this sign is only moderately useful for detecting splenomegaly

Question 114

With the patient supine, press deeply and evenly in the LLQ. Then quickly withdraw your fingers.
Pain in the RLQ during left-sided pressure is a positive Rovsing sign.

Answer 114

Rovsing sign (indirect tenderness)-referred rebound tenderness

Question 115

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.

Answer 115

the psoas sign

Question 116

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. Internal rotation of the hip is described on p. 643.
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

Answer 116

obturator sign

Question 117

tenderness at site two thirds of the distance between the umbilicus and the anterior superior iliac spine; seen in appendicitis.

Answer 117

McBurney sign

Question 118

Murphy sign can be performed.
Deeply palpate the RUQ at the location of the patient’s pain. 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. When positive, Murphy sign triples the likelihood of acute cholecystitis.39 Of note, this finding is only useful in a patient who does not have tenderness in the RUQ with regular palpation.

Answer 118

Possible Acute Cholecystitis

Question 119

a benign 2- to 3-cm gap in the rectus muscles often seen in obese and postpartum patients.

Answer 119

diastasis recti, which is