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Internal Medicine > OHCEPS - The Abdomen > Flashcards

OHCEPS - The Abdomen Flashcards

1
Q

Principal symptom of esophageal disease?

A

Dysphagia

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2
Q

Dysphagia - what to know?

A
  1. Level of obstruction
  2. Onset
  3. Course
  4. Solids/Liquids
  5. Associated symptoms
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3
Q

Course of dysphagia?

A
  1. Intermittent?
  2. Present for only the first few shallows (lower esophageal ring, spasm)?
  3. Progressive (cancer, stricture, achalasia)?
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4
Q

Dysphagia - associates symptoms?

A
  1. Heartburn –> leads to esophageal strictures.
  2. Weight loss, wasting, fatigue –> perhaps cancer.
  3. Coughing ang choking suggest “pharyngeal dysphagia” due to motor dysfunction –> Motor neuron disease causing bulbar or pseudobulbar palsy.
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5
Q

Odynophagia?

A

PAIN on shallowing.
Substernal sensation DURING shallowing –> Esophageal inflammation –> Candida, Herpes, CMV, peptic ulceration, caustic damage, esophageal perforation.
Remember ask about drugs.

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6
Q

GERD - typical features?

A

Site –> mid-line, retrosternal.
Radiation –> Throat, occasionally infra-scapular regions
Nature –> burning
Aggravating factors –> Worse after meals, when performing postures which raise the intra-abdominal pressure (bending, stooping, lying supine) + pregnancy.
Associated symptoms –> Acid/bitter taste (acid regurgitation), or sudden filling of the mouth with saliva (“waterbrash”).

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7
Q

Foods that worsen GERD?

A

Chocolate, alcohol, caffeine, fatty meals.

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8
Q

Drugs that worsen GERD?

A

CCBs
Anticholinergics
which act to lower the GOJ sphincter pressure.

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9
Q

Dyspepsia?

A
  1. Upper abdominal discomfort
  2. Bloating
  3. Belching
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10
Q

Dyspepsia - be alert for features suggestive of a serious pathology?

A
  1. Anemia
  2. Weight loss
  3. Dysphagia
  4. PR blood loss
  5. Melena
  6. Abdominal masses
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11
Q

Dysphagia - oral causes?

A
  1. Painful mouth ulceration

2. Oral/throat infections

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12
Q

Dysphagia - Neurological causes?

A
  1. Cerebrovascular event
  2. Bulbar and pseudobulbar palsies
  3. Myasthenia gravis
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13
Q

Dysphagia - Dysmotility?

A
  1. Achalasia
  2. Systemic sclerosis
  3. Presbyesophagus
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14
Q

Dysphagia - Mechanical causes?

A
  1. Pharyngeal pouch
  2. Esophageal cancer
  3. Peptic stricture
  4. Other benign strictures
  5. Extrinsic compression of the esophagus (large lung or thyroid tumor)
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15
Q

Vomiting - timing?

A
  1. Vomiting delayed >1h after meal –> Gastro-esophageal obstruction or gastroparesis.
  2. Early morning vomiting is typical of pregnancy or raised intracranial pressure.
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16
Q

Hematemesis - ask specifically?

A
  1. Amount of blood + exact nature.
  2. Previous bleeding episodes + treatment + outcome (previous surgery?).
  3. Smoking
  4. Drugs –> aspirin, NSAIDs, warfarin.
    Remember –> Weight loss, dysphagia, abdominal pain and melena (consider cancer possibility)
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17
Q

Nature of vomitus - Bile?

A

Assess the presence/absence of bile.
Bile comes largely in 2 colors:
1. Green (biliverdin) often seen to color the vomitus in the absence of UNdigested food.
2. Yellow pigment (bilirubin) appears as orange, often occurring in small lumps.

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18
Q

Vomiting - acute etiology?

A
  1. GI infections
  2. Systemic bacterial infections
  3. Mechanical bowel obstruction
  4. Alcohol intoxication
  5. Acute upper GI bleed
  6. Urinary tract infection
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19
Q

Vomiting - chronic causes?

A
  1. Pregnancy
  2. Uremia
  3. Drugs
  4. Gastroparesis
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20
Q

Drugs that cause chronic vomiting?

A
  1. Narcotics
  2. Digitalis
  3. Aminophylline
  4. Cancer chemo
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21
Q

Vomiting - other causes?

A
  1. PUD
  2. Motor disorders (post-surgery or autonomic dysfunction).
  3. Hepatobiliary disease
  4. Alcoholism
  5. Cancer
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22
Q

Upper GI bleeding - etiology?

A
  1. Peptic ulceration
  2. Erosive or ulcerative esophagitis
  3. Gastritis
  4. Varices (esophageal/gastric)
  5. Gastric/esophageal tumors)
  6. Mallory-Weiss tear
  7. Dieulafoy’s lesion
  8. Vascular anomalies - angiodysplasia, AV malformation
  9. Hereditary hemorrhagic telangiectasia
  10. Connective tissue disorders
  11. Vasculitis
  12. Bleeding disorders
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23
Q

Nature of hematemesis?

A
  1. Large volume of fresh, red blood.
  2. Small streaks –> Minor trauma at the GEJ (Mallory-Weiss tear)
  3. Coffee-ground –> Blood that has been altered by exposure to stomach acid - appears brown and in small lumps.
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24
Q

Sites of abdominal pain and embryologic origin?

A
  1. Epigastric (foregut) –> Stomach, duodenum, liver, pancreas, gallbladder.
  2. Periumbilical (midgut) –> Small and large intestines including appendix.
  3. Suprapubic (hindgut) –> Rectum and urogenital organs.
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25
Q

Very localized abdominal pain?

A

May originate from the parietal peritoneum

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26
Q

Abdominal pain - radiation examples?

A
  1. Right scapula –> Gallbladder
  2. Shoulder-tip –> Diaphragmatic irritation
  3. Mid-back –> Pancreas
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27
Q

Abdominal pain - character?

A
  1. Colicky –> This is pain that comes and goes in waves and indicates obstruction of a hollow, muscled-walled organ (intestine, gallbladder, bile duct, ureter).
  2. Burning –> Usually indicates an acid cause and is related to the stomach, duodenum or lower end of esophagus.
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28
Q

Renal colic?

A

Colicky pain at the renal angles +/- loins, which are tender to touch, radiating to the groins/testicles/labia.
Typically –> Patient writhes around, unable to find a position that relieves the pain.

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29
Q

Bladder pain?

A

Diffuse severe pain in the suprapubic region.

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30
Q

Prostatic pain?

A

Dull ache which may be felt in the lower abdomen, rectum, perineum or anterior thighs.

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31
Q

Urethral pain?

A

Variable in presentation ranging from a “tickling” discomfort to a severe sharp pain felt at the end of the urethra (tip of the penis) and exacerbated by micturition.
Can be so severe that patients attempt to “hold on” to urine causing yet more problems!

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32
Q

Small bowel obstruction pain?

A

Colicky central pain associated with vomiting, abdominal distention +/- constipation.

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33
Q

Colonic pain?

A

As above under “small bowel” but sometimes temporarily relieved by defecation or passing flatus.

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34
Q

Bowel ischemia pain?

A

Dull, severe, constant, RUQ/Epigastric pain that can last hours and is often worse after eating fatty foods.

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35
Q

Pancreatic pain?

A

Epigastric, radiating to the back and partly relieved by sitting up + leaning forward.

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36
Q

Peptic ulcer pain?

A

Dull, burning pain in the epigastrium.
Typically episodic at night, waking the patient from sleep.
Exacerbated by eating and sometimes relieved by consuming milk or antacids.

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37
Q

Normal bowel habit?

A

Ranges from 3 times/day to once every 3 days.

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38
Q

Constipation is?

A

Passage of stool <3 times/week or stools that are hard or difficult to pass.

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39
Q

Thorough history of constipation should include?

A
  1. Duration
  2. Stool size and consistency
  3. Straining, particularly at the end
  4. Ass. symptoms - nausea/vomiting, weight loss
  5. Pain on defecation
  6. Rectal bleeding
  7. Intercurrent diarrhea
  8. Fluid and fibre intake
  9. Depression, lack of exercise
  10. Drugs
  11. Met. or endocrine diseases
  12. Neurological problems
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40
Q

Drugs associated with constipation?

A
  1. Codeine
  2. Antidepressants
  3. Aluminium
  4. Calcium antacids
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41
Q

Constipation - met. or endocrine causes?

A
  1. Thyroid disorders
  2. Hypercalcemia
  3. Diabetes
  4. Pheochromocytoma
  5. Hirschsprung disease
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42
Q

Constipation - neurological problems?

A
  1. Autonomic neuropathy
  2. Spinal cord injury
  3. MS
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43
Q

Diarrhea - definition?

A

Incr. in stool volume (>200mL daily) and frequency (3/day). Also a change in consistency to semi-formed or liquid stool.

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44
Q

Acute diarrhea is suggestive of?

A

Infection

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45
Q

Diarrhea - ask specifically?

A
  1. Color, consistency, offensive smell, ease of flushing.
  2. Duration
  3. Does the diarrhea disturb patient’s sleep?
  4. Is there any blood, mucus or pus?
  5. Associated pain or colic?
  6. Is there urgency?
  7. Nausea/vomiting, weight loss?
  8. Any difference if patient fasts? (osmotic vs secretory)
  9. Foreign travel
  10. Recent antibiotics
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46
Q

Constipation - etiology?

A
  1. Low-fibre diet
  2. Physical immobility
  3. Functional bowel disease
  4. Drugs (e.g. opiates, antidepressants, aluminium, antacids)
  5. Met. and endocrine diseases
  6. Neurological disorders
  7. Colonic stricture
  8. Anorectal disease
  9. Habitual neglect
  10. Depression
  11. Dementia
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47
Q

Diarrhea - etiology - malabsorption?

A

May cause steatorrhea - fatty, pale stool, EXTREMELY ODOROUS and difficult to flush.

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48
Q

Diarrhea - etiology - Incr. intestinal motility?

A
  1. Hyperthyroidism

2. Irritable bowel syndrome

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49
Q

Diarrhea - etiology - exudative?

A

Inflammation of the bowel causes small volume, frequent stools, often with blood or mucus (e.g. colonic carcinoma, Crohn, UC).

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50
Q

Diarrhea - etiology - osmotic?

A

Large volume of stool which disappears with fasting.

Causes: Lactose intolerance, gastric surgery.

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51
Q

Diarrhea - etiology - secretory?

A

High volume of stool which disappears with fasting. No pus, blood or excessive fat.
Causes: GI infections, carcinoid syndrome, villous adenoma of the colon, Z-E syndrome, VIPoma

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52
Q

Rectal bleeding - determine?

A
  1. Amount –> small amounts can appear dramatic, coloring toilet water red.
  2. Nature of the blood (red, brown, black)
  3. Is it mixed with stool or “on” the stool?
  4. Is it spattered over the pan, with the stool on only seen on the paper?
  5. Any associated features (mucus may indicate inflammatory bowel disease or colonic cancer).
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53
Q

Melena - bleed where?

A

Upper GI or right side of the colon.

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54
Q

Melena - what to ask about?

A

Do you take iron supplements/bismuth containing compounds?

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55
Q

Mucus - what is it?

A

Clear viscoid secretion of the mucus membranes.

Contains mucus, epithelial cells, leukocytes and various salts suspended in water.

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56
Q

Mucus - may indicate?

A
  1. IBD
  2. Solitary rectal ulcer
  3. Small or large bowel fistula
  4. Colonic villous adenoma
  5. Irritable bowel syndrome
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57
Q

Excessive flatus - feature of?

A
  1. Hiatus hernia
  2. Peptic ulceration
  3. Chronic gallbladder disease
  4. Air-shallowing (aerophagy)
  5. High-fibre diet
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58
Q

Causes of lower GI bleeding?

A
  1. Hemorrhoids
  2. Anal fissure
  3. Diverticular disease
  4. Colonic carcinoma
  5. Polyp
  6. Angiodysplasia
  7. IBD
  8. Ischemic colitis
  9. Meckel’s diverticulum
  10. Small bowel disease (tumor, diverticulae, intussusception, Crohn’s)
  11. Solitary rectal ulcer
  12. Hemobilia
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59
Q

Hemobilia?

A

Bleeding into the biliary tree.

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60
Q

Fat malabsorption?

A
  1. Pancreatic insufficiency - Chronic pancreatitis, CF.
  2. Celiac disease
  3. IBD
  4. Blind bowel loops
  5. Short bowel syndrome
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61
Q

Fat malabsorption - what does the patient tell?

A
  1. Pale stool
  2. Offensive smelling
  3. Poorly formed
  4. Difficult to flush (floats)
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62
Q

Jaundice - ask about?

A
  1. Color of the urine (dark in cholestatic jaundice).
  2. Color and consistency of the stools (pale in cholestatic jaundice)
  3. Abdominal pain (caused by gallstones).
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63
Q

Jaundice - ask especially about?

A
  1. Previous blood transfusions
  2. Past history of jaundice
  3. Drugs (e.g. antibiotics, NSAIDs, OCPs, phenothiazines)
  4. IV drug abuse
  5. Tattoos and body piercing
  6. Foreign travel
  7. Sexual history
  8. FHx of liver disease
  9. Alcohol consumption
  10. Personal contacts who also have jaundice
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64
Q

Jaundice - PREhepatic etiology?

A
  1. Hemolysis
  2. Gilbert
  3. Dubin-Johnson
  4. Rotor
  5. Hemodialysis
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65
Q

Jaundice - HEPATOCELLULAR etiology?

A
  1. Cirrhosis
  2. Acute hep - viral, alcoholic, autoimmune, drug-induced.
  3. Liver tumors
  4. Cholestasis from drugs - chlorpromazine.
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66
Q

Jaundice - Posthepatic etiology?

A

Obstruction of biliary outflow:

  1. Luminal –> Gallstones
  2. Wall pathology –> congenital bile abnormalities, PBC, trauma, tumor.
  3. External compression –> Pancreatitis, lymphadenopathy (!), pancr. tumor, Ampulla of Vater tumor.
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67
Q

5 causes of abdominal swelling - 5 F’s + 1:

A 
Fat
Fluid
Flatus
Feces
Fetus 
\+ Tumor.
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68
Q

5 types of urinary incontinence?

A
  1. “True”
  2. Giggle
  3. Stress
  4. Urge
  5. Dribbling or overflow
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69
Q

True urinary incontinence?

A

Total lack of control of urinary excretion –> Suggestive of a fistula between the urinary tract and the exterior or a neurological condition.

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70
Q

Giggle urinary incontinence?

A

Incontinence during bouts of laughter - Common in young girls.

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71
Q

Stress urinary incontinence?

A

Leakage associated with a sudden Incr. in intra-abdominal pressure of any cause –> coughing, laughing, sneezing.

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72
Q

Urge urinary incontinence?

A

Intense urge to urinate such that the patient is unable to get to the toilet in time.

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73
Q

Causes of urge urinary incontinence?

A
  1. Over-activity of the detruser muscle
  2. Urinary infection
  3. Bladder stones
  4. Bladder cancer
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74
Q

Dribbling or overflow?

A

Continual loss of urine from a chronically distended bladder.
Typically in elderly males with prostate disease.

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75
Q

Terminal dribbling?

A

Male complaint - usually indicative of prostate disease.

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76
Q

Dysuria?

A

Pain on micturition –> described as “burning” or “stinging” and felt at the urethral meatus.
Ask whether it is throughout the passage of urine or only at the end (“terminal dysuria”).

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77
Q

Incomplete emptying suggests?

A

Detruser dysfunction or prostatic disease.

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78
Q

Intermittency?

A

Stop-start manner of urine flow.

Suggests –> BPH, bladder stones, ureteroceles

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79
Q

Oliguria - definition?

A

Scanty or low-volume urination and is defined as the excretion of <300mL urine in 24h.

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80
Q

Causes of oliguria?

A

Physiological –> Dehydration

Pathological –> Intrinsic renal disease, shock, or obstruction.

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81
Q

Polyuria should be differentiated from???

A

Urinary frequency - In polyuria we got LARGE volumes.

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82
Q

Causes of polyuria?

A
  1. Hysterical polydipsia
  2. DM
  3. Diabetes insipidus - failure of ADH
  4. Chronic renal failure –> defective urine concentration.
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83
Q

Polyuria - remember to ask?

A

Use of diuretics!

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84
Q

Weight loss in a patient with ascites?

A

BEWARE –> Ascites weighs 1kg/L and some patients with liver failure may have 10-20L of ascites - MASKING any “dry weight” loss.

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85
Q

Weight loss - try to determine?

A
  1. When the symptom first noticed.
  2. Quantify the problem - How and over what time period.
  3. Cause of anorexia - does eating make patient feel sick?
  4. Does eating cause pain? (ulcer, mesenteric angina, pancreatitis)
  5. Accompanying symptoms - Abdominal pain, nausea/vomiting, fever.
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86
Q

Weight loss - ALSO ask about?

A
  1. Color and consistency of stools (steatorrhea)
  2. Urinary symptoms
  3. Recent change in temperature tolerance
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87
Q

Combination of weight loss with incr. appetite may suggest?

A

May suggest malabsorption or thyrotoxicosis (or other hypermetabolic state).

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88
Q

The abdomen - PMH - Ask specifically?

A
  1. Previous surgeries –> including peri- and postoperative and anesthetic complications.
  2. Chronic bowel disease –> IBD
  3. Possible associated conditions –> diabetes with hemochromatosis.
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89
Q

The abdomen - DHx - Drugs that precipitate hepatitis?

A
  1. Halothane
  2. Phenytoin
  3. Chlorothiazides
  4. Pyrazinamide
  5. Isoniazid
  6. Methyl dopa
  7. Statins
  8. Sodium valproate
  9. Amiodarone
  10. Antibiotics
  11. NSAIDs
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90
Q

The abdomen - DHx - Drugs that precipitate cholestasis?

A
  1. Chlorpromazine
  2. Sulfonamides
  3. Sulfonylureas
  4. Rifampin
  5. Nitrofurantoin
  6. Anabolic steroids
  7. OCPs
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91
Q

The abdomen - DHx - Drugs that precipitate fatty liver?

A
  1. Tetracycline
  2. Sodium valproate
  3. Amiodarone
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92
Q

Drug that precipitate acute liver necrosis?

A

Paracetamol

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93
Q

The rest of history - Smoking?

A
  1. Incr. risk for peptic ulceration, esophageal cancer, colorectal cancer.
  2. Detrimental effect in Crohn
  3. Protect against UC
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94
Q

Rest of history - Family history?

A

Ask especially:

  1. IBD
  2. Celiac disease
  3. PUD
  4. Hereditary liver diseases (Wilson’s, hemochromatosis)
  5. Bowel cancer
  6. Jaundice
  7. Anemia
  8. Splenectomy
  9. Cholecystectomy
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95
Q

Rest of the history - SHx?

A
  1. Risk of exposure to hepatotoxins and hepatitis through occupation.
  2. Tattoos
  3. Illicit drug use (especially sharing needles)
  4. Social contacts with a similar phase (particularly relevant to jaundice)
  5. Recent foreign travel
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96
Q

Rest of history - Dietary history?

A
  1. Amount of fruit, vegetables and fibre in the diet.
  2. Evidence of lactose intolerance.
  3. Change in symptoms related to eating certain food groups
  4. Sensitivities to wheat, fat, caffeine, gluten.
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97
Q

The CAGE questionnaire?

A

C - Have you ever felt that you should Cut down your drinking?
A - Have you ever got Angry when someone suggested that you should cut down drinking?
G - Do you ever feel Guilty about your drinking?
E - Do you ever need an “Eye-opener” in the morning to steady your nerves or get rid of a hangover?

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98
Q

Framework for the abdominal examination?

A
  1. General inspection
  2. Hands
  3. Arms
  4. Axillae
  5. Face
  6. Chest
  7. Inspection of abdomen
  8. Palpation of abdomen - light/deep/specific organs/examination of hernial orifices/external genitalia.
  9. Percussion (+/- examination of ascites)
  10. Auscultation
  11. Digital exam of the anus/rectum/prostate
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99
Q

General inspection - Look especially for?

A
  1. High or low body mass
  2. State of hydration
  3. Fever
  4. Distress
  5. Pain
  6. Muscle wasting
  7. Peripheral edema
  8. Jaundice
  9. Anemia
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100
Q

Nails - examine for?

A
  1. Leukonychia
  2. Koilonychia
  3. Muerhrcke’s lines
  4. Clubbing
  5. Blue lunulae
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101
Q

Leukonychia?

A

Whitening of the nail bed due to hypoalbuminemia (eg malnutrition, malabsorption, hepatic disease, nephritic syndrome).

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102
Q

Koilonychia?

A

“Spooning” of the nails making a concave shape instead of the normal convexity.

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103
Q

Koilonychia - Causes?

A

Congenital/Chronic iron deficiency.

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104
Q

Muehrcke’s lines?

A

Transverse white lines –> Seen in hypoalbuminemic states including severe liver cirrhosis.

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105
Q

Clubbing - abdominal causes?

A
  1. Cirrhosis
  2. IBD
  3. Celiac disease
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106
Q

Blue lanulae?

A

Bluish discoloration of the normal lanulae seen in Wilson.

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107
Q

Palmar erythema?

A

“Liver palms”:
Blotchy reddening of the palms of the hands –> thenar/hypothenar.
Can also affect soles of feet.

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108
Q

Palmar erythema - associated with?

A
  1. Chronic liver disease
  2. Pregnancy
  3. Thyrotoxicosis
  4. RA
  5. Polycythemia
  6. Chronic leukemia (rarely)
    It can also be a normal finding.
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109
Q

Dupuytren contracture?

A
  1. Thickening and fibrous contraction of the palmar fascia.
  2. Early –> Palpable irregular thickening of the fascia is seen - especially overlying the 4th and 5th metacarpals.
  3. Often BILATERAL - May also affect the feet.
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110
Q

Dupuytren contracture - causes?

A

Seen especially in alcoholic liver disease but may also be seen in manual workers (or may be familial).

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111
Q

Hepatic flap - associated with?

A

Hepatic encephalopathy - precipitated by:

  1. Infection
  2. Diuretic medication
  3. Electrolyte imbalance
  4. Diarrhea
  5. Constipation
  6. Vomiting
  7. Centrally acting drugs
  8. Upper GI bleeding
  9. Abdominal paracentesis
  10. Surgery
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112
Q

Examine the upper limb for any signs of?

A
  1. Bruising
  2. Petechiae
  3. Muscle wasting
  4. Scratch marks (excoriations)
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113
Q

Bruising may be a sing of?

A
  1. Hepatocellular damage –> coagulation disorder.
  2. Thrombocytopenia –> hypersplenism.
  3. Marrow suppression with alcohol.
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114
Q

Petechia may be a sign of?

A

Pin-prick bleeds which do not blanche with pressure –> Sign of THROMBOCYTOPENIA.

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115
Q

Upper limb - be careful not to miss?

A
  1. AV fistulae

2. Hemodialysis catheters

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116
Q

Axillae - examine for?

A
  1. Lymphadenopathy

2. Acanthosis nigricans

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117
Q

Acanthosis nigricans?

A

Thickened, blackening of the skin. Velvety in appearance –> May be associated with INTRA-ABDOMINAL malignancy.

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118
Q

Eyes - look especially for?

A
  1. Jaundice
  2. Anemia
  3. Kayser-Fleischer rings
  4. Xanthelasma
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119
Q

Kayser-Fleischer rings?

A

Greenish-yellow pigmented ring just inside the cornea-scleral margin - due to Cu deposition.

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120
Q

Mouth - look for?

A
  1. Angular stomatitis
  2. Circumoral pigmentation
  3. Dentition
  4. Telangiectasia
  5. Gums
  6. Breath
  7. Tongue
  8. Candidiasis
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121
Q

Angular stomatitis - sign of?

A 
Reddening and inflammation at the corners of the mouth --> A sign of:
1. Thiamine
2. B12
3. Iron 
deficiencies :).
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122
Q

Circumoral pigmentation - seen in?

A

Hyperpigmented areas around the mouth - Peutz-Jegher’s syndrome.

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123
Q

Dentition?

A

Note false teeth or if there is evidence of tooth decay.

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124
Q

Telangiectasia - seen in?

A

Osler-Weber-Rendu syndrome.

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125
Q

Gums - look for?

A
  1. Ulcers –> Celiac disease/IBD/Behcet/Reiter.

2. Hypertrophy –> Pregnancy/Phenytoin/Leukemia/Scurvy/Gingivitis

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126
Q

Breath - especially for?

A
  1. Fetor hepaticus - sweet-smelling breath.
  2. Ketosis - sickly sweet pear-drop smelling breath.
  3. Uremia - a fishy smell.
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127
Q

Tongue - look especially for?

A
  1. Glossitis
  2. Macroglossia
  3. Leukoplakia
  4. Geographical tongue
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128
Q

Glossitis?

A

Smooth, erythematous swelling of the tongue.

129
Q

Glossitis - causes?

A

Iron/B12/Folate def

130
Q

Macroglossia - etiology?

A
  1. Amyloidosis
  2. Hypothyroidism
  3. Acromegaly
  4. Down
  5. Neoplasia
131
Q

Leukoplakia?

A

White-colored thickening of the tongue and oral mucus membranes - PREMALIGNANT condition.

132
Q

Leukoplakia - etiology?

A
  1. Smoking
  2. Poor dental hygiene
  3. Alcohol
  4. Sepsis
  5. Syphilis
133
Q

Geographical tongue?

A

Painless red rings and lines on the surface of the tongue looking rather like a map.

134
Q

Geographical tongue - etiology?

A

B2 deficiency or may be a normal variant.

135
Q

Candidiasis - etiology?

A
  1. Immunosuppression
  2. Antibiotic use
  3. Poor oral hygiene
  4. Fe def.
  5. Diabetes
136
Q

Neck - examine?

A

Cervical + supraclavicular lymph nodes.

137
Q

Chest - examine for?

A
  1. Spider naevi

2. Gynecomastia

138
Q

Spider nevi - where to find?

A

In the distribution of SVC.

139
Q

Spider nevi - allowed how many nevi?

A

Up to 5.

140
Q

Spider nevi etiology?

A
  1. Chronic liver disease

2. Estrogen excess

141
Q

Gynecomastia - etiology?

A
  1. Alcoholic liver disease
  2. Congenital adrenal hyperplasia
  3. Several commonly used drugs - spironolactone/digoxin/cimetidine.
142
Q

Inspection of the abdomen - Look especially for?

A
  1. Scars
  2. Abdominal distention
  3. Focal swellings
  4. Divarication of the recti
  5. Prominent vasculature
  6. Obvious pulsations
  7. Peristaltic waves
  8. Striae
  9. Skin discoloration
  10. Stomas
143
Q

Inspection of the abdomen - scars?

A
  1. Trauma or surgery.
  2. Recent scars –> Pink and vascular.
  3. Old scars –> White and may be indurated.
144
Q

Inspection of the abdomen - Divarication of the recti?

A

Particularly in the elderly + patients who had abdominal surgery –> twin rectus abdominis muscles may separate laterally on contraction –> causing underlying organs to bulge through the resultant mid-line gap.

145
Q

Inspection of the abdomen - Prominent vasculature?

A

Note the exact location:

  1. Inferior flow of blood suggests SVC obstruction.
  2. Superior flow of blood suggests IVC obstruction.
  3. Flow radiating out from the umbilicus - caput medusae –> Indicates portal HTN.
146
Q

Inspection of the abdomen - peristaltic waves?

A

Usually seen in thin, fit, young individuals –> A very obvious bowel peristalsis is seen as rippling movements beneath the skin and may indicate intestinal obstruction.

147
Q

Inspection of the abdomen - striae?

A
  1. May be normal in rapidly growing pubescent teens.
  2. Obesity
  3. Pregnancy (“Striae gravidarum”)
  4. Ascites
  5. Following rapid weight loss or abdominal paracentesis.
  6. Pink/purple in Cushing’s
148
Q

Inspection of the abdomen - Skin discoloration?

A

2 Classical patterns seen:
Bruising/discoloration –> Presence of retroperitoneal blood (esp. in pancreatitis).
Cullen sign –> Discoloration at the umbilicus and surrounding skin.
Grey-Turner sign –> Discoloration at the flanks.

149
Q

Stomas - colostomy?

A

Usually seen in the left iliac fossa and will be flush to the skin - bag may contain semi-solid to formed stool.

150
Q

Stomas - Ileostomy?

A

Usually in the right iliac fossa and formed as a “spout” of bowel mucosa extending from the abdominal wall to prevent the luminal contents harming the abdominal wall –> Bag will contain semi-formed and liquid stool.

151
Q

Stomas - Urostomy?

A

Often formed as an ileal conduit with ureters connected to a portion of small bowel and then to the abdominal wall –> Usually in the RIGHT iliac fossa –> Bag will contain urine.

152
Q

Stomas - Nephrostomy?

A
  1. Drainage of urine from the kidney pelvis to the exterior.
  2. Usually a temporary measure following operative procedures to the renal tract or to decompress an obstructed system - usually at the flank –> Bag will contain urine.
153
Q

Light palpation of the abdomen?

A

Use finger-tips and palmar aspects of the fingers.

  1. If there is pain on light palpation –> attempt to determine whether the pain is worse when you press down or when you release the pressure - rebound tenderness.
  2. If the abdominal muscles seem tense, determine whether it is localized or generalized.
  3. It may be helpful for the patient to bend their knees slightly - relaxing the abdominal muscles.
  4. Involuntary tension in the abdominal muscles –> guarding.
154
Q

Signs of peritonitis?

A
  1. Pain on light palpation
  2. Rebound tenderness
  3. Involuntary guarding
  4. Pain recurring with slight movement of the examining hand
  5. Absent bowel sounds
155
Q

Liver - normal borders?

A

Extends from the 5th intercostal space on the right of the midline to the costal margin - hiding under the ribs so is often not normally palpable - don’t worry if you can’t feel one!

156
Q

Liver - how to palpate?

A
  1. Using the flat of your right hand, start palpation from the right iliac fossa.
  2. You should angle the hand such that the index is aligned with the costal margin.
  3. Exert gentle pressure and ask the patient to take a deep breath.
  4. With each inward breath –> your fingers should drift slightly superiorly as the liver moves inferiorly with the diaphragm.
  5. Relax the pressure on your hand slightly at the height of inspiration.
157
Q

If the liver is felt you should note:

A
  1. How FAR below the costal margin.
  2. Nature of the liver edge - smooth surface or irregular.
  3. Presence of tenderness
  4. Whether the liver is pulsatile
158
Q

Liver palpation - findings?

A
  1. Often possible to palpate live just below costal margin in normal, healthy, thin people AT THE HEIGHT OF INSPIRATION.
  2. Enlarged liver - many causes.
  3. Normal liver may be palpable in patients with COPD/asthma - hyper-expanded chest or in subdiaphragmatic collection.
  4. Palpable liver - when Riedel’s lobe is present.
159
Q

Riedel’s lobe?

A
  1. Normal variant in which a projection of the liver arises from the inferior surface of the right lobe.
  2. More common in females.
  3. Commonly mistaken for a right kidney or enlarged gallbladder.
160
Q

Gallbladder - position?

A
  1. Lies at the right costal margin at the tip of the 9th rib at the lateral border of the rectus abdominis.
  2. Normally only palpable when enlarged due to biliary obstruction or acute cholecystitis.
161
Q

Palpable gallbladder - findings?

A
  1. Felt as a bulbous, focal, rounded mass which moves with inspiration.
  2. Position the right hand perpendicular to the costal margin and palpate in a medial –> lateral direction.
162
Q

Murphy sign:

A

Sign of cholecystitis - pain on palpation over the gallbladder during deep inspiration - ONLY POSITIVE if there is NO pain on the left at the sam position.

163
Q

Courvoisier’s law?

A

In the presence of jaundice, a palpable gallbladder is probably NOT caused by gallstones.

164
Q

Spleen - size?

A

Largest lymphatic organ - varies in size + shape between individuals.
Roughly the size of a clenched fist 12x7.

165
Q

Inferior edge of the spleen?

A

May have a palpable notch centrally which will help you differentiate it from any other abdominal mass.

166
Q

Important to keep in mind about impalpable spleen?

A

May sometimes become palpable by repositioning the patient - ask them to roll onto their right hand side and repeat the examination.

167
Q

Hepatomegaly - some causes:

A
  1. Alcohol
  2. RHF
  3. Neoplasia (primary cancer, metastases, myeloproliferative disorders, leukemia, lymphoma)
  4. Chronic liver disease - Cirrhosis causes a small shrunken liver.
  5. Infections - viral hep, brucellosis, TB.
  6. Amyloidosis
  7. Hemochromatosis
  8. Biliary obstruction
168
Q

Splenomegaly - some causes:

A

Massive –> >8cm: Malaria, Kala-azar, Gaucher’s.
Moderate –> 4-8cm: Portal HTN secondary to cirrhosis - lymphoproliferative disorders and many others.
Mild –> Lymphoproliferative disorders, portal HTN, infectious hep, glandular fever (IM), subacute IE, sarco, RA, connective tissue diseases, hematological disorders (idiopathic thrombocytopenia, hereditary spherocytosis, polycythemia rubra vera).

169
Q

Hepatosplenomegaly - some causes?

A
  1. Myeloproliferative diseases
  2. Lymphoproliferative disorders
  3. Chronic liver disease + portal HTN
  4. Infection (Acute hep, brucellosis, Weil’s disease, toxo, CMV)
  5. SLE
  6. Amyloidosis
  7. Sarco
  8. Thyrotoxicosis
  9. Acromegaly
  10. Pernicious anemia
  11. SCA
170
Q

Kidneys - Position?

A
  1. Retroperitoneal - posterior abdominal wall either side of the vertebral column between T12 and L3 vertebrae.
  2. They move slightly inferiorly with inspiration.
  3. Right is LOWER than left.
171
Q

Kidney palpation?

A

Bimanual (both hands) - you may be able to feel the lower pole of the right kidney in normal thin people.

172
Q

Kidney palpation - steps:

A
  1. Place your left hand behind the patient at the right loin.
  2. Place your right hand below the right costal margin at the lateral border of the rectus abdominis.
  3. Keeping the fingers of your right hand together, flex them at the MCP joint pushing deep into the abdomen.
  4. Ask the patient to take a deep breath - you may be able to feel the rounder lower pole of the kidney between your hands, slipping away when the patient exhales.
173
Q

How is the bimanual technique for palpating the kidney called?

A

Renal ballottement.

174
Q

Features of an enlarged spleen?

A
  1. Impossible to feel above the organ
  2. Central notch on the leading edge
  3. Moves easily on inspiration
  4. Moves inferio-medially on inspiration
  5. Not ballotable
  6. Dullness to percussion
  7. May enlarge toward the umbilicus
175
Q

Features of an enlarged kidney?

A
  1. Can feel above the organ
  2. No notch - but you may feel the central hilar notch.
  3. Moves late on inspiration
  4. Moves inferiorly on inspiration
  5. Ballotable
  6. Resonant percussion due to overlying bowel gas
  7. Enlarges inferiorly lateral to the midline.
176
Q

Unilateral palpable kidney - etiology?

A
  1. Hydronephrosis
  2. PKD
  3. RCC
  4. Acute renal VEIN thrombosis
  5. Renal abscess
  6. Acute pyelonephritis
177
Q

Bilateral palpable kidney - etiology?

A
  1. Bilateral hydronephrosis
  2. Bilateral RCC
  3. PKD
  4. Nephrotic syndrome
  5. Amyloidosis
  6. Lymphoma
  7. Acromegaly
178
Q

Bladder - palpable?

A

Not when empty.

179
Q

The full bladder will be?

A
  1. Palpable, rounded mass arising from behind the pubic symphysis
  2. Dull to percussion
  3. You will be unable to feel below it.
  4. Pressure on the full bladder will make the patient feel the need to urinate.
180
Q

Aorta - where to palpate?

A

May be palpated in the midline above the umbilicus, felt as a longitudinal pulsatile mass –> particularly palpable in thin people.

181
Q

Aorta - if felt?

A
  1. Position the fingers of each hand either side of the outermost palpable margins.
  2. Measure the distance between your fingers - Normal diameter 2-3cm.
  3. Decide whether the mass you feel is pulsatile/expansile in itself (in which case your fingers will move outwards) or whether the pulsation is transmitted through other tissue (in which case your fingers will move upwards).
182
Q

2 specific ascites tests?

A
  1. Shifting dullness

2. Fluid thrill

183
Q

How to perform shifting dullness test?

A
  1. Percuss centrally –> laterally until dullness is detected –> Marks air-fluid level in the abdomen.
  2. Keep your finger pressed there as you…
  3. Ask the patient to hold the new position for half a minute.
  4. Repeat percussion moving laterally to central over your mark.
  5. If the dullness truly was an air-fluid level, the fluid will now be moved by gravity away from the marked spot and the previously dull area will be resonant.
184
Q

Fluid thrill - what to detect?

A

A wave transmitted across the peritoneal fluid –> Only possible with MASSIVE ascites.

185
Q

Percussion - importance in kidneys?

A
  1. Useful in differentiating an enlarged kidney from an enlarged spleen or liver.
  2. Kidneys lie deep in the abdomen and are surrounded by perinephric fat which makes them resonant to percussion.
  3. Splenomegaly or hepatomegaly will appear dull.
186
Q

Bladder - Percussion?

A

Dullness to percussion in the suprapubic regionmay be helpful in determining whether an ill-defined mass is an enlarged bladder (dull) or distended bowel (resonant).

187
Q

Bowel sounds?

A
  1. Low-pitched gurgling sounds produced by normal gut peristalsis.
  2. Intermittent but will vary in time depending on when the last meal was eaten.
  3. Practice listening to as many abdomens as possible to understand the normal range of sounds.
188
Q

Normal bowel sounds?

A
  1. Low-pitched gurgling

2. Intermittent

189
Q

High-pitched bowel sounds?

A
  1. Often called “tinkling”.

2. Suggestive of partial or total bowel obstruction.

190
Q

Borborygmus?

A

This is loud low-pitched gurgling that can even be heard without a stethoscope - typical of diarrheal states or abnormal peristalsis.

191
Q

Absent bowel sounds?

A

If no sounds are heard for 2min, there may be a complete lack of peristalsis –> Paralytic ileus or peritonitis.

192
Q

Bruits?

A

Sounds produced by turbulent flow of blood through a vessel - similar to heart murmurs.

193
Q

Where to hear looking for bruits?

A
  1. Just above the umbilicus over the aorta - AAA
  2. Either side of the midline just above the umbilicus (renal artery stenosis)
  3. At the epigastrium - mesenteric stenosis.
  4. Over the liver - AV malformations, acute alcoholic hepatitis, HCC.
194
Q

Friction rubs?

A

Creaking sounds like that of pleural rub heard when inflamed peritoneal surfaces move against each other with respiration.

195
Q

Friction rubs - where to listen?

A

Over:

  1. Liver
  2. Spleen
196
Q

Friction rubs - etiology?

A
  1. HCC
  2. Liver abscess
  3. Recent percutaneous liver biopsy
  4. Splenic infarction
  5. STD-associated perihepatitis (Fitz-Hugh-Curtis)
197
Q

Venous hums?

A

Rarely - possible to hear the hum of venous blood flow in the upper abdomen over a caput medusa.

198
Q

Per rectum exam - what to look for?

A
  1. Rashes
  2. Excoriations
  3. Skin tags
  4. Anal warts
  5. Fistulous openings
  6. Fissures
  7. External Hemorrhoids
  8. Abscesses
  9. Fecal soiling
  10. Blood
  11. Mucus
199
Q

Per rectum exam - hints:

A
  1. If the patient experience severe pain, with gentle pressure on the anal opening, consider… anal fissure, ischiorectal abscess, anal ulcer, thrombosed hemorrhoid, or prostatitis.
  2. In this situation, you may have to apply anesthetic gel to the anal margin before proceeding. If in doubt, ask a senior.
200
Q

Feature of most abdominal hernias?

A

Have an expansile cough impulse - asking the patient to cough will increase the intra-abdominal pressure causing a visible or palpable impulse.

201
Q

Strangulation of hernias?

A

Hernias that cannot be reduced (irreducible) may become fixed or swollen as their blood supply is occluded causing ischemia and necrosis of the herniated organ.

202
Q

An approach to hernias?

A
  1. Determine characteristics as you would any lump –> Including position, temperature, tenderness, shape, size, tension, and composition.
  2. Make a note of the characteristics of the overlying skin.
  3. Palpate the hernia and feel for a cough impulse.
  4. Attempt reduction of hernia.
  5. Percuss and auscultate the hernia - listening to bowel sounds or bruits.
  6. Always remember to examine the same site on the opposite side.
203
Q

Internal inguinal ring is?

A

An opening in the transversalis fascia lying at the mid-inguinal point, halfway between the anterior superior iliac spine and the pubic symphysis –> About 1.5cm above the femoral pulse.

204
Q

External inguinal ring?

A

An opening of the external oblique aponeurosis and is immediately above and medial to the pubic tubercle.

205
Q

Direct inguinal hernia?

A

Herniation at the site of the external inguinal ring.

206
Q

Indirect inguinal hernia?

A

85% of all hernias.
Herniation is through the internal ring with bowel or omentum travelling down the inguinal canal and may protrude through the external ring into the scrotum.
More likely to strangulate than direct inguinal hernias.

207
Q

Examination of hernias?

A
  1. Patient should be examined standing-up and undressed from the waist down (some hernias may spontaneously reduce when supine).
  2. Palpate especially for tenderness and consistency of the lump.
  3. Herniated omentum will appear rubbery, non fluctuant and dull to percussion.
  4. Herniated gut will be resonant, fluctuant. You may be able to hear bowel sounds within the hernia.
  5. With 2 fingers on the mass, ask the patient to cough and feel for an expansile cough impulse.
  6. Attempt to reduce the hernia by massaging it back towards it suspected site of origin.
  7. Once reduced, the hernia should NOT reappear until you release the pressure.
  8. With the hernia reduced, try pressing over the site of the internal ring and asking the patient to cough.
  9. Indirect hernia will remain reduced whereas a direct hernia will protrude once more.
208
Q

Features of INDIRECT inguinal hernia?

A
  1. Can descend into scrotum
  2. Reduces upwards, laterally backwards
  3. Remains reduced with pressure at the internal ring
  4. Causative defect is NOT palpable
  5. Reappears at the internal ring and flows medially
209
Q

Features of DIRECT inguinal hernia?

A
  1. Very rarely descends to scrotum
  2. Reduces upwards and backwards
  3. Not controlled by pressure over the internal ring
  4. Defect in the abdominal wall is palpable
  5. Reappears in the same position as before reduction
210
Q

Inspection of the abdomen - Look especially for?

A
  1. Scars
  2. Abdominal distention
  3. Focal swellings
  4. Divarication of the recti
  5. Prominent vasculature
  6. Obvious pulsations
  7. Peristaltic waves
  8. Striae
  9. Skin discoloration
  10. Stomas
211
Q

Inspection of the abdomen - scars?

A
  1. Trauma or surgery.
  2. Recent scars –> Pink and vascular.
  3. Old scars –> White and may be indurated.
212
Q

Inspection of the abdomen - Divarication of the recti?

A

Particularly in the elderly + patients who had abdominal surgery –> twin rectus abdominis muscles may separate laterally on contraction –> causing underlying organs to bulge through the resultant mid-line gap.

213
Q

Inspection of the abdomen - Prominent vasculature?

A

Note the exact location:

  1. Inferior flow of blood suggests SVC obstruction.
  2. Superior flow of blood suggests IVC obstruction.
  3. Flow radiating out from the umbilicus - caput medusae –> Indicates portal HTN.
214
Q

Inspection of the abdomen - peristaltic waves?

A

Usually seen in thin, fit, young individuals –> A very obvious bowel peristalsis is seen as rippling movements beneath the skin and may indicate intestinal obstruction.

215
Q

Inspection of the abdomen - striae?

A
  1. May be normal in rapidly growing pubescent teens.
  2. Obesity
  3. Pregnancy (“Striae gravidarum”)
  4. Ascites
  5. Following rapid weight loss or abdominal paracentesis.
  6. Pink/purple in Cushing’s
216
Q

Inspection of the abdomen - Skin discoloration?

A

2 Classical patterns seen:
Bruising/discoloration –> Presence of retroperitoneal blood (esp. in pancreatitis).
Cullen sign –> Discoloration at the umbilicus and surrounding skin.
Grey-Turner sign –> Discoloration at the flanks.

217
Q

Stomas - colostomy?

A

Usually seen in the left iliac fossa and will be flush to the skin - bag may contain semi-solid to formed stool.

218
Q

Stomas - Ileostomy?

A

Usually in the right iliac fossa and formed as a “spout” of bowel mucosa extending from the abdominal wall to prevent the luminal contents harming the abdominal wall –> Bag will contain semi-formed and liquid stool.

219
Q

Stomas - Urostomy?

A

Often formed as an ileal conduit with ureters connected to a portion of small bowel and then to the abdominal wall –> Usually in the RIGHT iliac fossa –> Bag will contain urine.

220
Q

Stomas - Nephrostomy?

A
  1. Drainage of urine from the kidney pelvis to the exterior.
  2. Usually a temporary measure following operative procedures to the renal tract or to decompress an obstructed system - usually at the flank –> Bag will contain urine.
221
Q

Light palpation of the abdomen?

A

Use finger-tips and palmar aspects of the fingers.

  1. If there is pain on light palpation –> attempt to determine whether the pain is worse when you press down or when you release the pressure - rebound tenderness.
  2. If the abdominal muscles seem tense, determine whether it is localized or generalized.
  3. It may be helpful for the patient to bend their knees slightly - relaxing the abdominal muscles.
  4. Involuntary tension in the abdominal muscles –> guarding.
222
Q

Signs of peritonitis?

A
  1. Pain on light palpation
  2. Rebound tenderness
  3. Involuntary guarding
  4. Pain recurring with slight movement of the examining hand
  5. Absent bowel sounds
223
Q

Liver - normal borders?

A

Extends from the 5th intercostal space on the right of the midline to the costal margin - hiding under the ribs so is often not normally palpable - don’t worry if you can’t feel one!

224
Q

Liver - how to palpate?

A
  1. Using the flat of your right hand, start palpation from the right iliac fossa.
  2. You should angle the hand such that the index is aligned with the costal margin.
  3. Exert gentle pressure and ask the patient to take a deep breath.
  4. With each inward breath –> your fingers should drift slightly superiorly as the liver moves inferiorly with the diaphragm.
  5. Relax the pressure on your hand slightly at the height of inspiration.
225
Q

If the liver is felt you should note:

A
  1. How FAR below the costal margin.
  2. Nature of the liver edge - smooth surface or irregular.
  3. Presence of tenderness
  4. Whether the liver is pulsatile
226
Q

Liver palpation - findings?

A
  1. Often possible to palpate live just below costal margin in normal, healthy, thin people AT THE HEIGHT OF INSPIRATION.
  2. Enlarged liver - many causes.
  3. Normal liver may be palpable in patients with COPD/asthma - hyper-expanded chest or in subdiaphragmatic collection.
  4. Palpable liver - when Riedel’s lobe is present.
227
Q

Riedel’s lobe?

A
  1. Normal variant in which a projection of the liver arises from the inferior surface of the right lobe.
  2. More common in females.
  3. Commonly mistaken for a right kidney or enlarged gallbladder.
228
Q

Gallbladder - position?

A
  1. Lies at the right costal margin at the tip of the 9th rib at the lateral border of the rectus abdominis.
  2. Normally only palpable when enlarged due to biliary obstruction or acute cholecystitis.
229
Q

Palpable gallbladder - findings?

A
  1. Felt as a bulbous, focal, rounded mass which moves with inspiration.
  2. Position the right hand perpendicular to the costal margin and palpate in a medial –> lateral direction.
230
Q

Murphy sign:

A

Sign of cholecystitis - pain on palpation over the gallbladder during deep inspiration - ONLY POSITIVE if there is NO pain on the left at the sam position.

231
Q

Courvoisier’s law?

A

In the presence of jaundice, a palpable gallbladder is probably NOT caused by gallstones.

232
Q

Spleen - size?

A

Largest lymphatic organ - varies in size + shape between individuals.
Roughly the size of a clenched fist 12x7.

233
Q

Inferior edge of the spleen?

A

May have a palpable notch centrally which will help you differentiate it from any other abdominal mass.

234
Q

Important to keep in mind about impalpable spleen?

A

May sometimes become palpable by repositioning the patient - ask them to roll onto their right hand side and repeat the examination.

235
Q

Hepatomegaly - some causes:

A
  1. Alcohol
  2. RHF
  3. Neoplasia (primary cancer, metastases, myeloproliferative disorders, leukemia, lymphoma)
  4. Chronic liver disease - Cirrhosis causes a small shrunken liver.
  5. Infections - viral hep, brucellosis, TB.
  6. Amyloidosis
  7. Hemochromatosis
  8. Biliary obstruction
236
Q

Splenomegaly - some causes:

A

Massive –> >8cm: Malaria, Kala-azar, Gaucher’s.
Moderate –> 4-8cm: Portal HTN secondary to cirrhosis - lymphoproliferative disorders and many others.
Mild –> Lymphoproliferative disorders, portal HTN, infectious hep, glandular fever (IM), subacute IE, sarco, RA, connective tissue diseases, hematological disorders (idiopathic thrombocytopenia, hereditary spherocytosis, polycythemia rubra vera).

237
Q

Hepatosplenomegaly - some causes?

A
  1. Myeloproliferative diseases
  2. Lymphoproliferative disorders
  3. Chronic liver disease + portal HTN
  4. Infection (Acute hep, brucellosis, Weil’s disease, toxo, CMV)
  5. SLE
  6. Amyloidosis
  7. Sarco
  8. Thyrotoxicosis
  9. Acromegaly
  10. Pernicious anemia
  11. SCA
238
Q

Kidneys - Position?

A
  1. Retroperitoneal - posterior abdominal wall either side of the vertebral column between T12 and L3 vertebrae.
  2. They move slightly inferiorly with inspiration.
  3. Right is LOWER than left.
239
Q

Kidney palpation?

A

Bimanual (both hands) - you may be able to feel the lower pole of the right kidney in normal thin people.

240
Q

Kidney palpation - steps:

A
  1. Place your left hand behind the patient at the right loin.
  2. Place your right hand below the right costal margin at the lateral border of the rectus abdominis.
  3. Keeping the fingers of your right hand together, flex them at the MCP joint pushing deep into the abdomen.
  4. Ask the patient to take a deep breath - you may be able to feel the rounder lower pole of the kidney between your hands, slipping away when the patient exhales.
241
Q

How is the bimanual technique for palpating the kidney called?

A

Renal ballottement.

242
Q

Features of an enlarged spleen?

A
  1. Impossible to feel above the organ
  2. Central notch on the leading edge
  3. Moves easily on inspiration
  4. Moves inferio-medially on inspiration
  5. Not ballotable
  6. Dullness to percussion
  7. May enlarge toward the umbilicus
243
Q

Features of an enlarged kidney?

A
  1. Can feel above the organ
  2. No notch - but you may feel the central hilar notch.
  3. Moves late on inspiration
  4. Moves inferiorly on inspiration
  5. Ballotable
  6. Resonant percussion due to overlying bowel gas
  7. Enlarges inferiorly lateral to the midline.
244
Q

Unilateral palpable kidney - etiology?

A
  1. Hydronephrosis
  2. PKD
  3. RCC
  4. Acute renal VEIN thrombosis
  5. Renal abscess
  6. Acute pyelonephritis
245
Q

Bilateral palpable kidney - etiology?

A
  1. Bilateral hydronephrosis
  2. Bilateral RCC
  3. PKD
  4. Nephrotic syndrome
  5. Amyloidosis
  6. Lymphoma
  7. Acromegaly
246
Q

Bladder - palpable?

A

Not when empty.

247
Q

The full bladder will be?

A
  1. Palpable, rounded mass arising from behind the pubic symphysis
  2. Dull to percussion
  3. You will be unable to feel below it.
  4. Pressure on the full bladder will make the patient feel the need to urinate.
248
Q

Aorta - where to palpate?

A

May be palpated in the midline above the umbilicus, felt as a longitudinal pulsatile mass –> particularly palpable in thin people.

249
Q

Aorta - if felt?

A
  1. Position the fingers of each hand either side of the outermost palpable margins.
  2. Measure the distance between your fingers - Normal diameter 2-3cm.
  3. Decide whether the mass you feel is pulsatile/expansile in itself (in which case your fingers will move outwards) or whether the pulsation is transmitted through other tissue (in which case your fingers will move upwards).
250
Q

2 specific ascites tests?

A
  1. Shifting dullness

2. Fluid thrill

251
Q

How to perform shifting dullness test?

A
  1. Percuss centrally –> laterally until dullness is detected –> Marks air-fluid level in the abdomen.
  2. Keep your finger pressed there as you…
  3. Ask the patient to hold the new position for half a minute.
  4. Repeat percussion moving laterally to central over your mark.
  5. If the dullness truly was an air-fluid level, the fluid will now be moved by gravity away from the marked spot and the previously dull area will be resonant.
252
Q

Fluid thrill - what to detect?

A

A wave transmitted across the peritoneal fluid –> Only possible with MASSIVE ascites.

253
Q

Percussion - importance in kidneys?

A
  1. Useful in differentiating an enlarged kidney from an enlarged spleen or liver.
  2. Kidneys lie deep in the abdomen and are surrounded by perinephric fat which makes them resonant to percussion.
  3. Splenomegaly or hepatomegaly will appear dull.
254
Q

Bladder - Percussion?

A

Dullness to percussion in the suprapubic regionmay be helpful in determining whether an ill-defined mass is an enlarged bladder (dull) or distended bowel (resonant).

255
Q

Bowel sounds?

A
  1. Low-pitched gurgling sounds produced by normal gut peristalsis.
  2. Intermittent but will vary in time depending on when the last meal was eaten.
  3. Practice listening to as many abdomens as possible to understand the normal range of sounds.
256
Q

Normal bowel sounds?

A
  1. Low-pitched gurgling

2. Intermittent

257
Q

High-pitched bowel sounds?

A
  1. Often called “tinkling”.

2. Suggestive of partial or total bowel obstruction.

258
Q

Borborygmus?

A

This is loud low-pitched gurgling that can even be heard without a stethoscope - typical of diarrheal states or abnormal peristalsis.

259
Q

Absent bowel sounds?

A

If no sounds are heard for 2min, there may be a complete lack of peristalsis –> Paralytic ileus or peritonitis.

260
Q

Bruits?

A

Sounds produced by turbulent flow of blood through a vessel - similar to heart murmurs.

261
Q

Where to hear looking for bruits?

A
  1. Just above the umbilicus over the aorta - AAA
  2. Either side of the midline just above the umbilicus (renal artery stenosis)
  3. At the epigastrium - mesenteric stenosis.
  4. Over the liver - AV malformations, acute alcoholic hepatitis, HCC.
262
Q

Friction rubs?

A

Creaking sounds like that of pleural rub heard when inflamed peritoneal surfaces move against each other with respiration.

263
Q

Friction rubs - where to listen?

A

Over:

  1. Liver
  2. Spleen
264
Q

Friction rubs - etiology?

A
  1. HCC
  2. Liver abscess
  3. Recent percutaneous liver biopsy
  4. Splenic infarction
  5. STD-associated perihepatitis (Fitz-Hugh-Curtis)
265
Q

Venous hums?

A

Rarely - possible to hear the hum of venous blood flow in the upper abdomen over a caput medusa.

266
Q

Per rectum exam - what to look for?

A
  1. Rashes
  2. Excoriations
  3. Skin tags
  4. Anal warts
  5. Fistulous openings
  6. Fissures
  7. External Hemorrhoids
  8. Abscesses
  9. Fecal soiling
  10. Blood
  11. Mucus
267
Q

Per rectum exam - hints:

A
  1. If the patient experience severe pain, with gentle pressure on the anal opening, consider… anal fissure, ischiorectal abscess, anal ulcer, thrombosed hemorrhoid, or prostatitis.
  2. In this situation, you may have to apply anesthetic gel to the anal margin before proceeding. If in doubt, ask a senior.
268
Q

Feature of most abdominal hernias?

A

Have an expansile cough impulse - asking the patient to cough will increase the intra-abdominal pressure causing a visible or palpable impulse.

269
Q

Strangulation of hernias?

A

Hernias that cannot be reduced (irreducible) may become fixed or swollen as their blood supply is occluded causing ischemia and necrosis of the herniated organ.

270
Q

An approach to hernias?

A
  1. Determine characteristics as you would any lump –> Including position, temperature, tenderness, shape, size, tension, and composition.
  2. Make a note of the characteristics of the overlying skin.
  3. Palpate the hernia and feel for a cough impulse.
  4. Attempt reduction of hernia.
  5. Percuss and auscultate the hernia - listening to bowel sounds or bruits.
  6. Always remember to examine the same site on the opposite side.
271
Q

Internal inguinal ring is?

A

An opening in the transversalis fascia lying at the mid-inguinal point, halfway between the anterior superior iliac spine and the pubic symphysis –> About 1.5cm above the femoral pulse.

272
Q

External inguinal ring?

A

An opening of the external oblique aponeurosis and is immediately above and medial to the pubic tubercle.

273
Q

Direct inguinal hernia?

A

Herniation at the site of the external inguinal ring.

274
Q

Indirect inguinal hernia?

A

85% of all hernias.
Herniation is through the internal ring with bowel or omentum travelling down the inguinal canal and may protrude through the external ring into the scrotum.
More likely to strangulate than direct inguinal hernias.

275
Q

Examination of hernias?

A
  1. Patient should be examined standing-up and undressed from the waist down (some hernias may spontaneously reduce when supine).
  2. Palpate especially for tenderness and consistency of the lump.
  3. Herniated omentum will appear rubbery, non fluctuant and dull to percussion.
  4. Herniated gut will be resonant, fluctuant. You may be able to hear bowel sounds within the hernia.
  5. With 2 fingers on the mass, ask the patient to cough and feel for an expansile cough impulse.
  6. Attempt to reduce the hernia by massaging it back towards it suspected site of origin.
  7. Once reduced, the hernia should NOT reappear until you release the pressure.
  8. With the hernia reduced, try pressing over the site of the internal ring and asking the patient to cough.
  9. Indirect hernia will remain reduced whereas a direct hernia will protrude once more.
276
Q

Features of INDIRECT inguinal hernia?

A
  1. Can descend into scrotum
  2. Reduces upwards, laterally backwards
  3. Remains reduced with pressure at the internal ring
  4. Causative defect is NOT palpable
  5. Reappears at the internal ring and flows medially
277
Q

Features of DIRECT inguinal hernia?

A
  1. Very rarely descends to scrotum
  2. Reduces upwards and backwards
  3. Not controlled by pressure over the internal ring
  4. Defect in the abdominal wall is palpable
  5. Reappears in the same position as before reduction
278
Q

Femoral canal?

A

Small component of the femoral sheath medial to femoral vessels and contains loose connective tissue + lymphatic vessels + lymph nodes.

279
Q

Femoral canal - borders?

A

Anteriorly –> inguinal ligament.
Posteriorly –> pectineal ligament.
Laterally –> femoral vein.
Medially –> Lacunar ligament.

280
Q

Femoral hernias?

A

Protrusions of bowel or omentum through this space.

281
Q

Femoral hernias - target group?

A

More common in middle-aged and elderly women and can easily strangulate due to small - easily strangulate due to small, rigid opening they pass through.

282
Q

Examination of femoral hernia:

A
  1. Examine with the patient standing up and undressed from the waist down.
  2. Examine as you would any other hernia and attempt reduction.
  3. If present, a femoral hernia will appear as lump just lateral and inferior to the pubic tubercle, about 2cm medial to femoral pulse.
283
Q

Differential diagnosis of a femoral hernia?

A
  1. Inguinal hernia
  2. Very large lymph node
  3. Ectopic testicle
  4. Psoas bursa or abscess
  5. Lipoma
284
Q

Umbilical/paraumbilical hernia?

A

Herniation through a defect near the umbilicus (considered congenital if identified in children).

285
Q

Epigastric hernia?

A

Herniation through the linea alba above the umbilicus.

286
Q

Spigalean hernia?

A

Herniation through the linea semilunaris (lateral to the rectus sheath) - usually below and lateral to the umbilicus - rare.

287
Q

Obturator hernia?

A

Herniation through the obturator canal - associated with increasing age and multiparity.

288
Q

Perineal hernia?

A

Herniation through the pelvic floor diaphragm - rare.

289
Q

Incisional hernia?

A

Herniation through the site of previous surgery - bulge is usually seen underlying a surface surgical scar - Increasing incidence with advanced age but can be caused by wound infection and associated fasciitis or muscle necrosis.

290
Q

Chronic liver disease - features?

A
  1. Jaundice
  2. Palmar erythema
  3. Leuconychia
  4. Clubbing
  5. Spider naevi
  6. Telangiectasia
  7. Hepatomegaly
  8. Ascites
  9. Variceal bleeding
  10. Purpura
  11. Easy bruising
  12. Epistaxis
  13. Menorrhagia
  14. Loss of libido
  15. Hair loss
  16. Bilateral parotid swelling
  17. Encephalopathy
291
Q

Chronic liver disease - males?

A
  1. Gynecomastia
  2. Testicular atrophy
  3. Impotence
292
Q

Chronic liver disease - females?

A
  1. Breast atrophy
  2. Irregular menses
  3. Amenorrhea
293
Q

Alcoholic hepatitis - features?

A

Hepatocellular inflammation with lymphocyte infiltration, steatosis, cholestasis, fibrosis, and necrosis.

  1. Fever
  2. Jaundice
  3. Tender hepatomegaly
  4. May hear a bruit over the liver
294
Q

Hepatic encephalopathy - mechanism?

A

Shunting of blood away from the portal circulation, seen in chronic liver disease –> allows potentially neurotoxic substances absorbed in the gut to bypass the liver where they would normally be removed.

295
Q

Grading of hepatic encephalopathy?

A

Grade 0 - normal mental state.
Grade I - altered mood or behavior (Decr. Attention span, difficulty with numbers and lack of awareness).
Grade II - Incr. Drowsiness, slurred speech, mild/mod confusion.
Grade III - stupor but responsive to stimuli, significant confusion, restlessness.
Grade IV - coma

296
Q

General causes of malabsorption?

A
  1. Pancreatic insufficiency
  2. Bile salt malabsorption
  3. Small bowel mucosa defects (celiac D, tropical sprue, giardiasis, disaccharidase deficiency, Whipple D, short bowel syndrome)
  4. Bacterial overgrowth
  5. Specific delivery defects.
297
Q

General symptoms of malabsorption include?

A
  1. Muscle wasting
  2. Weight loss
  3. Pallor
  4. Diarrhea (watery)
  5. Steatorrhea
  6. Glossitis
  7. Angular stomatitis (B2, B12, folate)
  8. Intra-oral purpura + easy bruising (vitK)
  9. Follicular keratitis - hyperkeratotic white patches (vitA deficiency).
298
Q

Acute pancreatitis - symptoms?

A
  1. Pain - central abdomen or epigastric, radiating through to the back.
  2. Sometimes relieved slightly by sitting forwards.
  3. Vomiting.
299
Q

Acute pancreatitis - Signs?

A
  1. Tachycardia
  2. Fever
  3. Jaundice (rarely)
  4. Peritonitis (bowel ileus, very tender abdomen, guarding)
  5. Retroperitoneal bleed - Cullen’s, Grey-Turner’s signs.
300
Q

Chronic pancreatitis - MCC?

A

Chronic heavy alcohol intake.

301
Q

Cholangitis - Biliary sepsis?

A 
Suggested by Charcot-triad:
1. RUQ pain.
2. Fever
3. Jaundice
You may also be able to elicit Murphy's sign.
302
Q

Celiac disease - incidence?

A

UK - 1/2000

Ireland - 1/300

303
Q

Celiac disease - pathogenesis?

A

T-cell mediated autoimmune disease of the small bowel mucosa characterized by VILLOUS ATROPHY and incr. intra-epithelial lymphocytosis in response to ingestion of gluten.

304
Q

Gluten?

A

High-molecular weight compound containing gliadins and peptides - Found in a huge number of founds containing wheat, barley and rye.

305
Q

Celiac disease - Symptoms?

A
  1. Tiredness
  2. Malaise
  3. Diarrhea/Steatorrhea
  4. Abdominal discomfort and bloating
  5. Weight loss
  6. Anxiety
  7. Depression
  8. Peripheral paresthesia
306
Q

Celiac disease - Signs?

A
  1. Muscle wasting
  2. Mouth ulceration
  3. Angular stomatitis
  4. Ankle edema (low serum albumin)
  5. Polyneuropathy
  6. Muscle weakness
  7. Tetany
307
Q

Celiac disease - associations?

A
  1. Autoimmune thyroid disorders
  2. Chronic liver disease
  3. Fibrosing alveolitis
  4. Ulcerative colitis
  5. Insulin-dependent DM
308
Q

Celiac disease - Possible complications to be aware of?

A
  1. Small bowel lymphoma (rare)
  2. Small bowel adenocarcinoma (rarest)
  3. Ulcerative jejunitis
  4. Splenic atrophy
  5. Anemia
  6. Osteomalacia
  7. Osteoporosis
  8. Secondary lactose intolerance
309
Q

UC - symptoms?

A
  1. Diarrhea - often with blood/mucus
  2. Weight loss
  3. Fever
  4. Abdominal pain
  5. Proctitis may cause rectal bleeding, mucus, tenesmus, and constipation.
310
Q

UC - complications to be aware of?

A
  1. Toxic megacolon
  2. Iron def. anemia
  3. Incr. risk of colorectal carcinoma
  4. Fistula-formation (rare)
311
Q

Crohn - symptoms?

A

If disease is limited to the colon, symptoms may be identical to UC.

  1. Loose stools or diarrhea (usually NOT BLOODY)
  2. Anorexia
  3. Malaise
  4. Weight loss
  5. Abdominal pain (insidious, often in the RLQ)
  6. Perianal pain
  7. Joint pains
312
Q

Crohn - Note on examination…(these can ALSO occur in UC):

A
  1. Aphthous mouth ulcers.
  2. Uveitis
  3. Anemia
  4. Arthropathy
313
Q

Active Crohn’s disease?

A
  1. Colicky pain in the right iliac fossa.
  2. May have diarrhea with blood and mucus
  3. Weight loss
  4. Borborygmus
  5. May be a palpable inflammatory mass in the right iliac fossa
  6. Abdominal distention
  7. +/- Bowel obstruction
314
Q

Active Crohn’s colitis?

A
  1. Similar presentation to UC

2. Perianal disease more likely to produce fissuring and fistula formation.

315
Q

CD - Complications to be aware of?

A
  1. Fistula formation (from the bowel to any other abdominal organ or the exterior).
  2. Small incr. risk of colorectal carcinoma.
  3. VitB12 def.
  4. Iron def.
  5. Abscess formation
  6. Stricture formation
  7. Systemic infection
316
Q

Extraintestinal features of IBD?

A
  1. Sero-negative arthropathy of large or small joint (peripheral non-deforming, particularly at the knees, ankles, wrists).
  2. Sacroiliitis
  3. Anterior uveitis
  4. Erythema nodosum
  5. Pyoderma gangrenosum
  6. Ureteric calculi
  7. Gallstones
  8. Sclerosing cholangitis
  9. Cholangiocarcinoma
  10. Nutritional def. (Osteoporosis? Osteomalacia?)
  11. Bile salt malabsorption
  12. Osteoporosis secondary to long-term steroid use or malabsorption.
  13. Systemic amyloidosis.
317
Q

Irritable bowel syndrome - Rome II diagnostic criteria?

A

At least 12wk, which need NOT to be consecutive, in the preceding 12 months of abdominal discomfort or pain that has 2 out of 3 features:

  1. Relief with defecation
  2. Onset associated with a change in frequency of stool
  3. Onset associated with a change in form stool
318
Q

Other symptoms which support the diagnosis of IBS?

A
  1. Abnormal stool frequency - >3/day or <3/wk.
  2. Abnormal stool form - Lumpy/hard, loose/watery.
  3. Abnormal stool passage - straining, urgency, feeling of incomplete evacuation.
  4. Passage of mucus
  5. Bloating or feeling of abdominal distention
319
Q

Applied anatomy - Boundaries?

A

Anterior abdominal wall is bounded by the 7th to 12th costal cartilages and the xiphoid process of the sternum superiorly and the inguinal ligaments and pelvic bones inferiorly.

Internal Medicine (106 decks)

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