Physical Exam of Abd/ Motivational Interviewing/Male GU Exam Flashcards
Dysphagia
Trouble swallowing
Hematemesis
Vomiting blood
Melana
Black stool
Visceral Pain
Colic pain - hollow organ caused by distention or stretching, crescendo/decrescendo pattern, not well localized
Parietal Pain
Caused by inflammation of the peritoneum, steady aching pain that is usually well localized
Referred Pain
From a distant site: Gallbladder: Right Shoulder Spleen: Left Shoulder Pancreas or Aorta: Back Kidney: Loin to groin
Components and order of the abdominal exam
Inspection, auscultation, percussion, palpation, rectal exam, special techniques
How far should you expose in the abd exam?
Form xiphoid to pubis
Where is the best place to auscultate the abd?
RLQ - best place to listen to cecum
What are normal bowel sounds?
High pitched tinkle
When do you report absent bowel sounds?
After no sounds for 2 min
Borborygmi
Increased hyperactive bowel sounds, low pitched rumbling, hyperperistalisis
Abdominal bruits and locations
Soft sound made by disrupted arterial flow through a narrowed artery "hissing sound" Aortic: btw umbilicus and xiphoid Renal a.: Lateral to aorta Iliac: lateral to umbilicus Femoral a.: along inguinal ligament
Percussion evaluates the presence of
Gaseous distention, fluid, solid masses, size and location of liver and spleen
Tympany
Most common, indicates presence of gas in the stomach and small bowel
Liver Percussion
Right mid clavicular line - resonant (lungs) to dull (liver) to tympanic (intestine)
Normal/Abnormal Liver Size
Normal 10cm
Fluid wave and shifting dullness indicates
ascites
Describe fluid wave
Assistants hands placed midline - tap on one flank while palpating the other, easily palpable impulse suggests ascites
Describe shifting dullness
Percuss pt abd on their back and then on their side - note where the sound changes form tympany to dull and the shift of the sound when the pt turns on their side (organs move to top and fluid shifts to bottom)
Light palpation
Looks for tenderness and areas of muscular spasm or rigidity - use finger tips with gentle motion
Deep palpation
Evaluates organ size, abnormal masses, aorta, deep pain - one hand on the other
Rebound tenderness
Evaluates for peritoneal tenderness and inflammation - slowly gently and deeply palpate, if there is pain test is +, includes rovings sign
Roving’s sign
Referred rebound tenderness, press on the LLQ and release, positive if pain in the RLQ
Is the spleen palpated under normal conditions?
No
Palpation of Aorta - Normal Size
Normal aorta 2.5-3 cm wide
Aortic aneurysm
Pathologic dilation, can be associated with bruit, assessed with ultrasound and CT
Percussion of kidney - Lloyds Sign
At level TV12 - gently hit over costovertebral angle on either side of the spine - pain over the kidney indicates inflammatory or infectious process
What if a pt FOBT is +?
Requires thorough evaluation for colorectal cancer (CRC). Preferable colonoscopy but sigmoidoscopy and air contrast barium enema are also acceptable
Obturator sign
Place right leg in figure 4 - press the right knee while holding down the left hip
What signs will be positive in appendicitis?
Rovings, Psoas, and Obturator
What imaging test is most sensitive to appendicitis?
CT scan - 90-98% sensitive
If you expect appendicitis in a female pt what MUST you do?
Perform a pregnancy test
Acute cholecystitis
Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm
What symptoms are indicative of acute cholecystitis? What sign is +?
Biliary colic pain, pain radiation to right shoulder
Fat, female, fertile, fair flatulent
Murphys sign
What is the diagnostic triad for acute cholecystisis?
RUQ pain, fever and leukocytosis
What is Murphys sign?
RUQ pain, sudden arrest of inspiration during palpation of the liver and GB
What will lab tests of an acute cholecystisis pt reveal?
Leukocytosis with left shift, serum bilirubin may be mildly elevated, AST/ALT can be elevated, Ultrasound detects stones, thickening of GB wall, dilated bile duct and fluid, HIDA scan (radionuclide biliary scan)
Role of Expert
Provide information in a manner pt can hear without feeling offensive, validates all perspectives, costs and benefits, then allows pt to make decision for themselves
Why do people change behavior?
Because they decide it is what they want to do - benefits outweigh the costs
What are the six stages of change?
Precotemplation, contemplation, preparation, action, maintenance, relapse
Describe precontemplation
Pt not thinking about change, may be resigned to behavior, may have tried to change in the past but failed so gives up, denial, believes the consequences aren’t serious
Describe contemplation
Pt weighing cost/benefits, ambivalence about change, giving up something enjoyable makes them feel a loss, barriers and benefits, I know I need to but
Describe preparation
Experimenting with small change, prepare to make specific change, small dietary changes, brand of cigarettes, decrease in drinking
Describe action
Taking definitive action, much praise necessary to maintain
Describe maintenance
Maintaining over time, ongoing support and encouragement, continued appreciation of gains
Describe relapse
Normal part of the process of change, pt usually feels demoralized, not starting back at zero, recognized continued attempts to try not focus on the sense of failure
Define motivational interviewing
Directive, client centered counseling style for eliciting behavior change by helping clients explore and resolve ambivalence
General principles of motivational interviewing
Express empathy - pt feels heard and validated, less defensive
Support self-efficacy - pt is in control of their lives
Roll with resistance
Develop discrepancy - change occurs when a pt wants to be someplace other than where they are
Name 5 behaviors inclusive in motivational interviewing
Seeking to understand the persons frame of reference
Expressing affirmation and acceptance Exploring without prejudice pt options
Monitoring the pt readiness to change
Affirming the clients freedom of choice and self direction
Is direct persuasion an effective method for resolving ambivalence?
No
T/F Readiness to change is not a patient trait but a fluctuating product of interpersonal interaction
True
Name and describe the 3 columns of vascular erectile tissue
Corpus spongiosum - contains the urethra
Corpora cavernoas - two bilateral
tunica vaginalis
serous membrane covering the testes
vas deferens
cordlike tube, transports sperm from epididymis to urethra
Spermatic cord
Contains vas deferens, blood vessels, nerves, and muscle fibers
Prostate lobe has how many lobes and where is prostate cancer most common?
5 lobes - anterior, posterior, middle and two later
Most common in posterior lobe
Indirect hernia
Most common in men and women
Above the inguinal ligament
Often into the scrotum
Direct hernia
Less common, usually in men, rare in women
Above the inguinal ligament
Rarely into the scrotum
Femoral hernia
Least common but more common in men than women
Below inguinal ligament
Never into scrotum
Components of the Male GU Exam
Penis, scrotum, hernias, prostate and special techniques
Inspection of Penis involves
Skin, hair, foreskin, glans (tip) and meatus - compression of glans to check for discharge
Describe the prostate gland
Bi-lobed, heart shaped, constancy of your nose, about the size of a walnut, inferior aspect of the posterior lobe is best palpated on a DRE
Hypospadias
Congenital displacement of the urethral meatus on the inferior surface of the penis along the urethral groove - important in new born exam - also associate with congenital renal abnormalities
Phimosis
Foreskin can’t retract over the penis, very painful in erection, hygiene issues - circumcise
Paraphimosis
Foreskin cannot be retracted back over the glans - circumcise
Hydrocele
Fluid filled mass within the tunica vaginalis - transilluminates with light
Cryptorchidism
Undescended testicle, usually atrophies, increased risk for cancer
