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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
Very localized abdominal pain?
May originate from the parietal peritoneum
26
Abdominal pain - radiation examples?
1. Right scapula --> Gallbladder 2. Shoulder-tip --> Diaphragmatic irritation 3. Mid-back --> Pancreas
27
Abdominal pain - character?
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.
28
Renal colic?
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.
29
Bladder pain?
Diffuse severe pain in the suprapubic region.
30
Prostatic pain?
Dull ache which may be felt in the lower abdomen, rectum, perineum or anterior thighs.
31
Urethral pain?
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!
32
Small bowel obstruction pain?
Colicky central pain associated with vomiting, abdominal distention +/- constipation.
33
Colonic pain?
As above under "small bowel" but sometimes temporarily relieved by defecation or passing flatus.
34
Bowel ischemia pain?
Dull, severe, constant, RUQ/Epigastric pain that can last hours and is often worse after eating fatty foods.
35
Pancreatic pain?
Epigastric, radiating to the back and partly relieved by sitting up + leaning forward.
36
Peptic ulcer pain?
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.
37
Normal bowel habit?
Ranges from 3 times/day to once every 3 days.
38
Constipation is?
Passage of stool <3 times/week or stools that are hard or difficult to pass.
39
Thorough history of constipation should include?
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
40
Drugs associated with constipation?
1. Codeine 2. Antidepressants 3. Aluminium 4. Calcium antacids
41
Constipation - met. or endocrine causes?
1. Thyroid disorders 2. Hypercalcemia 3. Diabetes 4. Pheochromocytoma 5. Hirschsprung disease
42
Constipation - neurological problems?
1. Autonomic neuropathy 2. Spinal cord injury 3. MS
43
Diarrhea - definition?
Incr. in stool volume (>200mL daily) and frequency (3/day). Also a change in consistency to semi-formed or liquid stool.
44
Acute diarrhea is suggestive of?
Infection
45
Diarrhea - ask specifically?
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
46
Constipation - etiology?
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
47
Diarrhea - etiology - malabsorption?
May cause steatorrhea - fatty, pale stool, EXTREMELY ODOROUS and difficult to flush.
48
Diarrhea - etiology - Incr. intestinal motility?
1. Hyperthyroidism | 2. Irritable bowel syndrome
49
Diarrhea - etiology - exudative?
Inflammation of the bowel causes small volume, frequent stools, often with blood or mucus (e.g. colonic carcinoma, Crohn, UC).
50
Diarrhea - etiology - osmotic?
Large volume of stool which disappears with fasting. | Causes: Lactose intolerance, gastric surgery.
51
Diarrhea - etiology - secretory?
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
52
Rectal bleeding - determine?
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).
53
Melena - bleed where?
Upper GI or right side of the colon.
54
Melena - what to ask about?
Do you take iron supplements/bismuth containing compounds?
55
Mucus - what is it?
Clear viscoid secretion of the mucus membranes. | Contains mucus, epithelial cells, leukocytes and various salts suspended in water.
56
Mucus - may indicate?
1. IBD 2. Solitary rectal ulcer 3. Small or large bowel fistula 4. Colonic villous adenoma 5. Irritable bowel syndrome
57
Excessive flatus - feature of?
1. Hiatus hernia 2. Peptic ulceration 3. Chronic gallbladder disease 4. Air-shallowing (aerophagy) 5. High-fibre diet
58
Causes of lower GI bleeding?
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
59
Hemobilia?
Bleeding into the biliary tree.
60
Fat malabsorption?
1. Pancreatic insufficiency - Chronic pancreatitis, CF. 2. Celiac disease 3. IBD 4. Blind bowel loops 5. Short bowel syndrome
61
Fat malabsorption - what does the patient tell?
1. Pale stool 2. Offensive smelling 3. Poorly formed 4. Difficult to flush (floats)
62
Jaundice - ask about?
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).
63
Jaundice - ask especially about?
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
64
Jaundice - PREhepatic etiology?
1. Hemolysis 2. Gilbert 3. Dubin-Johnson 4. Rotor 5. Hemodialysis
65
Jaundice - HEPATOCELLULAR etiology?
1. Cirrhosis 2. Acute hep - viral, alcoholic, autoimmune, drug-induced. 3. Liver tumors 4. Cholestasis from drugs - chlorpromazine.
66
Jaundice - Posthepatic etiology?
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.
67
5 causes of abdominal swelling - 5 F's + 1:
``` Fat Fluid Flatus Feces Fetus + Tumor. ```
68
5 types of urinary incontinence?
1. "True" 2. Giggle 3. Stress 4. Urge 5. Dribbling or overflow
69
True urinary incontinence?
Total lack of control of urinary excretion --> Suggestive of a fistula between the urinary tract and the exterior or a neurological condition.
70
Giggle urinary incontinence?
Incontinence during bouts of laughter - Common in young girls.
71
Stress urinary incontinence?
Leakage associated with a sudden Incr. in intra-abdominal pressure of any cause --> coughing, laughing, sneezing.
72
Urge urinary incontinence?
Intense urge to urinate such that the patient is unable to get to the toilet in time.
73
Causes of urge urinary incontinence?
1. Over-activity of the detruser muscle 2. Urinary infection 3. Bladder stones 4. Bladder cancer
74
Dribbling or overflow?
Continual loss of urine from a chronically distended bladder. Typically in elderly males with prostate disease.
75
Terminal dribbling?
Male complaint - usually indicative of prostate disease.
76
Dysuria?
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").
77
Incomplete emptying suggests?
Detruser dysfunction or prostatic disease.
78
Intermittency?
Stop-start manner of urine flow. | Suggests --> BPH, bladder stones, ureteroceles
79
Oliguria - definition?
Scanty or low-volume urination and is defined as the excretion of <300mL urine in 24h.
80
Causes of oliguria?
Physiological --> Dehydration | Pathological --> Intrinsic renal disease, shock, or obstruction.
81
Polyuria should be differentiated from???
Urinary frequency - In polyuria we got LARGE volumes.
82
Causes of polyuria?
1. Hysterical polydipsia 2. DM 3. Diabetes insipidus - failure of ADH 4. Chronic renal failure --> defective urine concentration.
83
Polyuria - remember to ask?
Use of diuretics!
84
Weight loss in a patient with ascites?
BEWARE --> Ascites weighs 1kg/L and some patients with liver failure may have 10-20L of ascites - MASKING any "dry weight" loss.
85
Weight loss - try to determine?
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.
86
Weight loss - ALSO ask about?
1. Color and consistency of stools (steatorrhea) 2. Urinary symptoms 3. Recent change in temperature tolerance
87
Combination of weight loss with incr. appetite may suggest?
May suggest malabsorption or thyrotoxicosis (or other hypermetabolic state).
88
The abdomen - PMH - Ask specifically?
1. Previous surgeries --> including peri- and postoperative and anesthetic complications. 2. Chronic bowel disease --> IBD 3. Possible associated conditions --> diabetes with hemochromatosis.
89
The abdomen - DHx - Drugs that precipitate hepatitis?
1. Halothane 2. Phenytoin 3. Chlorothiazides 4. Pyrazinamide 5. Isoniazid 6. Methyl dopa 7. Statins 8. Sodium valproate 9. Amiodarone 10. Antibiotics 11. NSAIDs
90
The abdomen - DHx - Drugs that precipitate cholestasis?
1. Chlorpromazine 2. Sulfonamides 3. Sulfonylureas 4. Rifampin 5. Nitrofurantoin 6. Anabolic steroids 7. OCPs
91
The abdomen - DHx - Drugs that precipitate fatty liver?
1. Tetracycline 2. Sodium valproate 3. Amiodarone
92
Drug that precipitate acute liver necrosis?
Paracetamol
93
The rest of history - Smoking?
1. Incr. risk for peptic ulceration, esophageal cancer, colorectal cancer. 2. Detrimental effect in Crohn 3. Protect against UC
94
Rest of history - Family history?
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
95
Rest of the history - SHx?
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
96
Rest of history - Dietary history?
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.
97
The CAGE questionnaire?
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?
98
Framework for the abdominal examination?
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
99
General inspection - Look especially for?
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
100
Nails - examine for?
1. Leukonychia 2. Koilonychia 3. Muerhrcke's lines 4. Clubbing 5. Blue lunulae
101
Leukonychia?
Whitening of the nail bed due to hypoalbuminemia (eg malnutrition, malabsorption, hepatic disease, nephritic syndrome).
102
Koilonychia?
"Spooning" of the nails making a concave shape instead of the normal convexity.
103
Koilonychia - Causes?
Congenital/Chronic iron deficiency.
104
Muehrcke's lines?
Transverse white lines --> Seen in hypoalbuminemic states including severe liver cirrhosis.
105
Clubbing - abdominal causes?
1. Cirrhosis 2. IBD 3. Celiac disease
106
Blue lanulae?
Bluish discoloration of the normal lanulae seen in Wilson.
107
Palmar erythema?
"Liver palms": Blotchy reddening of the palms of the hands --> thenar/hypothenar. Can also affect soles of feet.
108
Palmar erythema - associated with?
1. Chronic liver disease 2. Pregnancy 3. Thyrotoxicosis 4. RA 5. Polycythemia 6. Chronic leukemia (rarely) It can also be a normal finding.
109
Dupuytren contracture?
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.
110
Dupuytren contracture - causes?
Seen especially in alcoholic liver disease but may also be seen in manual workers (or may be familial).
111
Hepatic flap - associated with?
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
112
Examine the upper limb for any signs of?
1. Bruising 2. Petechiae 3. Muscle wasting 4. Scratch marks (excoriations)
113
Bruising may be a sing of?
1. Hepatocellular damage --> coagulation disorder. 2. Thrombocytopenia --> hypersplenism. 3. Marrow suppression with alcohol.
114
Petechia may be a sign of?
Pin-prick bleeds which do not blanche with pressure --> Sign of THROMBOCYTOPENIA.
115
Upper limb - be careful not to miss?
1. AV fistulae | 2. Hemodialysis catheters
116
Axillae - examine for?
1. Lymphadenopathy | 2. Acanthosis nigricans
117
Acanthosis nigricans?
Thickened, blackening of the skin. Velvety in appearance --> May be associated with INTRA-ABDOMINAL malignancy.
118
Eyes - look especially for?
1. Jaundice 2. Anemia 3. Kayser-Fleischer rings 4. Xanthelasma
119
Kayser-Fleischer rings?
Greenish-yellow pigmented ring just inside the cornea-scleral margin - due to Cu deposition.
120
Mouth - look for?
1. Angular stomatitis 2. Circumoral pigmentation 3. Dentition 4. Telangiectasia 5. Gums 6. Breath 7. Tongue 8. Candidiasis
121
Angular stomatitis - sign of?
``` Reddening and inflammation at the corners of the mouth --> A sign of: 1. Thiamine 2. B12 3. Iron deficiencies :). ```
122
Circumoral pigmentation - seen in?
Hyperpigmented areas around the mouth - Peutz-Jegher's syndrome.
123
Dentition?
Note false teeth or if there is evidence of tooth decay.
124
Telangiectasia - seen in?
Osler-Weber-Rendu syndrome.
125
Gums - look for?
1. Ulcers --> Celiac disease/IBD/Behcet/Reiter. | 2. Hypertrophy --> Pregnancy/Phenytoin/Leukemia/Scurvy/Gingivitis
126
Breath - especially for?
1. Fetor hepaticus - sweet-smelling breath. 2. Ketosis - sickly sweet pear-drop smelling breath. 3. Uremia - a fishy smell.
127
Tongue - look especially for?
1. Glossitis 2. Macroglossia 3. Leukoplakia 4. Geographical tongue
128
Glossitis?
Smooth, erythematous swelling of the tongue.
129
Glossitis - causes?
Iron/B12/Folate def
130
Macroglossia - etiology?
1. Amyloidosis 2. Hypothyroidism 3. Acromegaly 4. Down 5. Neoplasia
131
Leukoplakia?
White-colored thickening of the tongue and oral mucus membranes - PREMALIGNANT condition.
132
Leukoplakia - etiology?
1. Smoking 2. Poor dental hygiene 3. Alcohol 4. Sepsis 5. Syphilis
133
Geographical tongue?
Painless red rings and lines on the surface of the tongue looking rather like a map.
134
Geographical tongue - etiology?
B2 deficiency or may be a normal variant.
135
Candidiasis - etiology?
1. Immunosuppression 2. Antibiotic use 3. Poor oral hygiene 4. Fe def. 5. Diabetes
136
Neck - examine?
Cervical + supraclavicular lymph nodes.
137
Chest - examine for?
1. Spider naevi | 2. Gynecomastia
138
Spider nevi - where to find?
In the distribution of SVC.
139
Spider nevi - allowed how many nevi?
Up to 5.
140
Spider nevi etiology?
1. Chronic liver disease | 2. Estrogen excess
141
Gynecomastia - etiology?
1. Alcoholic liver disease 2. Congenital adrenal hyperplasia 3. Several commonly used drugs - spironolactone/digoxin/cimetidine.
142
Inspection of the abdomen - Look especially for?
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
Inspection of the abdomen - scars?
1. Trauma or surgery. 2. Recent scars --> Pink and vascular. 3. Old scars --> White and may be indurated.
144
Inspection of the abdomen - Divarication of the recti?
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
Inspection of the abdomen - Prominent vasculature?
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
Inspection of the abdomen - peristaltic waves?
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
Inspection of the abdomen - striae?
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
Inspection of the abdomen - Skin discoloration?
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
Stomas - colostomy?
Usually seen in the left iliac fossa and will be flush to the skin - bag may contain semi-solid to formed stool.
150
Stomas - Ileostomy?
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
Stomas - Urostomy?
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
Stomas - Nephrostomy?
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
Light palpation of the abdomen?
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
Signs of peritonitis?
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
Liver - normal borders?
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
Liver - how to palpate?
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
If the liver is felt you should note:
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
Liver palpation - findings?
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
Riedel's lobe?
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
Gallbladder - position?
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
Palpable gallbladder - findings?
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
Murphy sign:
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
Courvoisier's law?
In the presence of jaundice, a palpable gallbladder is probably NOT caused by gallstones.
164
Spleen - size?
Largest lymphatic organ - varies in size + shape between individuals. Roughly the size of a clenched fist 12x7.
165
Inferior edge of the spleen?
May have a palpable notch centrally which will help you differentiate it from any other abdominal mass.
166
Important to keep in mind about impalpable spleen?
May sometimes become palpable by repositioning the patient - ask them to roll onto their right hand side and repeat the examination.
167
Hepatomegaly - some causes:
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
Splenomegaly - some causes:
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
Hepatosplenomegaly - some causes?
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
Kidneys - Position?
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
Kidney palpation?
Bimanual (both hands) - you may be able to feel the lower pole of the right kidney in normal thin people.
172
Kidney palpation - steps:
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
How is the bimanual technique for palpating the kidney called?
Renal ballottement.
174
Features of an enlarged spleen?
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
Features of an enlarged kidney?
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
Unilateral palpable kidney - etiology?
1. Hydronephrosis 2. PKD 3. RCC 4. Acute renal VEIN thrombosis 5. Renal abscess 6. Acute pyelonephritis
177
Bilateral palpable kidney - etiology?
1. Bilateral hydronephrosis 2. Bilateral RCC 3. PKD 4. Nephrotic syndrome 5. Amyloidosis 6. Lymphoma 7. Acromegaly
178
Bladder - palpable?
Not when empty.
179
The full bladder will be?
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
Aorta - where to palpate?
May be palpated in the midline above the umbilicus, felt as a longitudinal pulsatile mass --> particularly palpable in thin people.
181
Aorta - if felt?
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
2 specific ascites tests?
1. Shifting dullness | 2. Fluid thrill
183
How to perform shifting dullness test?
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
Fluid thrill - what to detect?
A wave transmitted across the peritoneal fluid --> Only possible with MASSIVE ascites.
185
Percussion - importance in kidneys?
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
Bladder - Percussion?
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
Bowel sounds?
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
Normal bowel sounds?
1. Low-pitched gurgling | 2. Intermittent
189
High-pitched bowel sounds?
1. Often called "tinkling". | 2. Suggestive of partial or total bowel obstruction.
190
Borborygmus?
This is loud low-pitched gurgling that can even be heard without a stethoscope - typical of diarrheal states or abnormal peristalsis.
191
Absent bowel sounds?
If no sounds are heard for 2min, there may be a complete lack of peristalsis --> Paralytic ileus or peritonitis.
192
Bruits?
Sounds produced by turbulent flow of blood through a vessel - similar to heart murmurs.
193
Where to hear looking for bruits?
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
Friction rubs?
Creaking sounds like that of pleural rub heard when inflamed peritoneal surfaces move against each other with respiration.
195
Friction rubs - where to listen?
Over: 1. Liver 2. Spleen
196
Friction rubs - etiology?
1. HCC 2. Liver abscess 3. Recent percutaneous liver biopsy 4. Splenic infarction 5. STD-associated perihepatitis (Fitz-Hugh-Curtis)
197
Venous hums?
Rarely - possible to hear the hum of venous blood flow in the upper abdomen over a caput medusa.
198
Per rectum exam - what to look for?
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
Per rectum exam - hints:
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
Feature of most abdominal hernias?
Have an expansile cough impulse - asking the patient to cough will increase the intra-abdominal pressure causing a visible or palpable impulse.
201
Strangulation of hernias?
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
An approach to hernias?
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
Internal inguinal ring is?
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
External inguinal ring?
An opening of the external oblique aponeurosis and is immediately above and medial to the pubic tubercle.
205
Direct inguinal hernia?
Herniation at the site of the external inguinal ring.
206
Indirect inguinal hernia?
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
Examination of hernias?
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
Features of INDIRECT inguinal hernia?
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
Features of DIRECT inguinal hernia?
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
Inspection of the abdomen - Look especially for?
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
Inspection of the abdomen - scars?
1. Trauma or surgery. 2. Recent scars --> Pink and vascular. 3. Old scars --> White and may be indurated.
212
Inspection of the abdomen - Divarication of the recti?
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
Inspection of the abdomen - Prominent vasculature?
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
Inspection of the abdomen - peristaltic waves?
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
Inspection of the abdomen - striae?
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
Inspection of the abdomen - Skin discoloration?
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
Stomas - colostomy?
Usually seen in the left iliac fossa and will be flush to the skin - bag may contain semi-solid to formed stool.
218
Stomas - Ileostomy?
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
Stomas - Urostomy?
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
Stomas - Nephrostomy?
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
Light palpation of the abdomen?
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
Signs of peritonitis?
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
Liver - normal borders?
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
Liver - how to palpate?
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
If the liver is felt you should note:
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
Liver palpation - findings?
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
Riedel's lobe?
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
Gallbladder - position?
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
Palpable gallbladder - findings?
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
Murphy sign:
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
Courvoisier's law?
In the presence of jaundice, a palpable gallbladder is probably NOT caused by gallstones.
232
Spleen - size?
Largest lymphatic organ - varies in size + shape between individuals. Roughly the size of a clenched fist 12x7.
233
Inferior edge of the spleen?
May have a palpable notch centrally which will help you differentiate it from any other abdominal mass.
234
Important to keep in mind about impalpable spleen?
May sometimes become palpable by repositioning the patient - ask them to roll onto their right hand side and repeat the examination.
235
Hepatomegaly - some causes:
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
Splenomegaly - some causes:
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
Hepatosplenomegaly - some causes?
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
Kidneys - Position?
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
Kidney palpation?
Bimanual (both hands) - you may be able to feel the lower pole of the right kidney in normal thin people.
240
Kidney palpation - steps:
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
How is the bimanual technique for palpating the kidney called?
Renal ballottement.
242
Features of an enlarged spleen?
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
Features of an enlarged kidney?
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
Unilateral palpable kidney - etiology?
1. Hydronephrosis 2. PKD 3. RCC 4. Acute renal VEIN thrombosis 5. Renal abscess 6. Acute pyelonephritis
245
Bilateral palpable kidney - etiology?
1. Bilateral hydronephrosis 2. Bilateral RCC 3. PKD 4. Nephrotic syndrome 5. Amyloidosis 6. Lymphoma 7. Acromegaly
246
Bladder - palpable?
Not when empty.
247
The full bladder will be?
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
Aorta - where to palpate?
May be palpated in the midline above the umbilicus, felt as a longitudinal pulsatile mass --> particularly palpable in thin people.
249
Aorta - if felt?
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
2 specific ascites tests?
1. Shifting dullness | 2. Fluid thrill
251
How to perform shifting dullness test?
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
Fluid thrill - what to detect?
A wave transmitted across the peritoneal fluid --> Only possible with MASSIVE ascites.
253
Percussion - importance in kidneys?
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
Bladder - Percussion?
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
Bowel sounds?
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
Normal bowel sounds?
1. Low-pitched gurgling | 2. Intermittent
257
High-pitched bowel sounds?
1. Often called "tinkling". | 2. Suggestive of partial or total bowel obstruction.
258
Borborygmus?
This is loud low-pitched gurgling that can even be heard without a stethoscope - typical of diarrheal states or abnormal peristalsis.
259
Absent bowel sounds?
If no sounds are heard for 2min, there may be a complete lack of peristalsis --> Paralytic ileus or peritonitis.
260
Bruits?
Sounds produced by turbulent flow of blood through a vessel - similar to heart murmurs.
261
Where to hear looking for bruits?
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
Friction rubs?
Creaking sounds like that of pleural rub heard when inflamed peritoneal surfaces move against each other with respiration.
263
Friction rubs - where to listen?
Over: 1. Liver 2. Spleen
264
Friction rubs - etiology?
1. HCC 2. Liver abscess 3. Recent percutaneous liver biopsy 4. Splenic infarction 5. STD-associated perihepatitis (Fitz-Hugh-Curtis)
265
Venous hums?
Rarely - possible to hear the hum of venous blood flow in the upper abdomen over a caput medusa.
266
Per rectum exam - what to look for?
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
Per rectum exam - hints:
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
Feature of most abdominal hernias?
Have an expansile cough impulse - asking the patient to cough will increase the intra-abdominal pressure causing a visible or palpable impulse.
269
Strangulation of hernias?
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
An approach to hernias?
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
Internal inguinal ring is?
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
External inguinal ring?
An opening of the external oblique aponeurosis and is immediately above and medial to the pubic tubercle.
273
Direct inguinal hernia?
Herniation at the site of the external inguinal ring.
274
Indirect inguinal hernia?
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
Examination of hernias?
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
Features of INDIRECT inguinal hernia?
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
Features of DIRECT inguinal hernia?
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
Femoral canal?
Small component of the femoral sheath medial to femoral vessels and contains loose connective tissue + lymphatic vessels + lymph nodes.
279
Femoral canal - borders?
Anteriorly --> inguinal ligament. Posteriorly --> pectineal ligament. Laterally --> femoral vein. Medially --> Lacunar ligament.
280
Femoral hernias?
Protrusions of bowel or omentum through this space.
281
Femoral hernias - target group?
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
Examination of femoral hernia:
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
Differential diagnosis of a femoral hernia?
1. Inguinal hernia 2. Very large lymph node 3. Ectopic testicle 4. Psoas bursa or abscess 5. Lipoma
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Umbilical/paraumbilical hernia?
Herniation through a defect near the umbilicus (considered congenital if identified in children).
285
Epigastric hernia?
Herniation through the linea alba above the umbilicus.
286
Spigalean hernia?
Herniation through the linea semilunaris (lateral to the rectus sheath) - usually below and lateral to the umbilicus - rare.
287
Obturator hernia?
Herniation through the obturator canal - associated with increasing age and multiparity.
288
Perineal hernia?
Herniation through the pelvic floor diaphragm - rare.
289
Incisional hernia?
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
Chronic liver disease - features?
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
Chronic liver disease - males?
1. Gynecomastia 2. Testicular atrophy 3. Impotence
292
Chronic liver disease - females?
1. Breast atrophy 2. Irregular menses 3. Amenorrhea
293
Alcoholic hepatitis - features?
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
Hepatic encephalopathy - mechanism?
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
Grading of hepatic encephalopathy?
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
General causes of malabsorption?
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
General symptoms of malabsorption include?
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
Acute pancreatitis - symptoms?
1. Pain - central abdomen or epigastric, radiating through to the back. 2. Sometimes relieved slightly by sitting forwards. 3. Vomiting.
299
Acute pancreatitis - Signs?
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
Chronic pancreatitis - MCC?
Chronic heavy alcohol intake.
301
Cholangitis - Biliary sepsis?
``` Suggested by Charcot-triad: 1. RUQ pain. 2. Fever 3. Jaundice You may also be able to elicit Murphy's sign. ```
302
Celiac disease - incidence?
UK - 1/2000 | Ireland - 1/300
303
Celiac disease - pathogenesis?
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
Gluten?
High-molecular weight compound containing gliadins and peptides - Found in a huge number of founds containing wheat, barley and rye.
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Celiac disease - Symptoms?
1. Tiredness 2. Malaise 3. Diarrhea/Steatorrhea 4. Abdominal discomfort and bloating 5. Weight loss 6. Anxiety 7. Depression 8. Peripheral paresthesia
306
Celiac disease - Signs?
1. Muscle wasting 2. Mouth ulceration 3. Angular stomatitis 4. Ankle edema (low serum albumin) 5. Polyneuropathy 6. Muscle weakness 7. Tetany
307
Celiac disease - associations?
1. Autoimmune thyroid disorders 2. Chronic liver disease 3. Fibrosing alveolitis 4. Ulcerative colitis 5. Insulin-dependent DM
308
Celiac disease - Possible complications to be aware of?
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
UC - symptoms?
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
UC - complications to be aware of?
1. Toxic megacolon 2. Iron def. anemia 3. Incr. risk of colorectal carcinoma 4. Fistula-formation (rare)
311
Crohn - symptoms?
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
Crohn - Note on examination...(these can ALSO occur in UC):
1. Aphthous mouth ulcers. 2. Uveitis 3. Anemia 4. Arthropathy
313
Active Crohn's disease?
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
Active Crohn's colitis?
1. Similar presentation to UC | 2. Perianal disease more likely to produce fissuring and fistula formation.
315
CD - Complications to be aware of?
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
Extraintestinal features of IBD?
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
Irritable bowel syndrome - Rome II diagnostic criteria?
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
Other symptoms which support the diagnosis of IBS?
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
Applied anatomy - Boundaries?
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.

.► ABORDAGEM SINDRÔMICA (41 decks)

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