Week 5 - Abdomen Flashcards
Visceral pain
- Caused when hollow organs are forcefully distended or stretched
- Difficult to localize, felt midline
- Gnawing, cramping, aching (start)
- Symptoms may progress to nausea, sweating, restlessness, pallor, vomiting
Somatic pain
- Caused by inflammation of the peritoneum (peritonitis)
- Localized over structure involved
- Sharp, steady, intense, localized,
- aggravated by movement or coughing
- Patient prefers to lie still
Referred pain
- Pain caused at sites that are innervated at same level but distant from primary problem
- Palpation does not results in tenderness
- pain usually at same spinal level as disordered structure
- pain starts in one area and becomes stronger and then may radiate
Pain with pyelonephritis or UTI
dull, achy, steady
Pain from renal colic
- sharp, comes and goes, radiates around the trunk or abdomen
- patient usually moving to try and find a comfortable position
Steps of assessing the abdomen
- inspect
- auscultate
- palpate
- percuss
Murphy’s sign
Patient pulls away sharply when palpating the gallbladder
McBurney’s Point
press on this point and quickly release, rebound pain can indicate appendicitis
Hep A
is a highly contagious short-term liver infection spread from person to person or by consuming contaminated food or drinks.
Hep B
Transmitted through contact with infectious blood or body fluids through sex, puncture through the skin
Hep C
illicit IV drug use or blood transfusion
Steps for anorectal and prostate exam
- Properly position the patient for the exam (left side)
- Inspect sacrococcygeal and perianal areas (lesions, ulcers, inflammation, rash, excoriation)
- Inspect the anus (lesion, mass, skin breakdown)
- Perform a digital rectal examination
- Assess anal sphincter tone
- Palpate the anal canal and rectal surface (mass, tenderness, mucosal breaks, nodules, irregularities, induration)
- In person with prostates, palpate the prostate gland (size, shape, mobility, consistency, nodule tenderness)
Prostate is comprised of
Right and left lateral lobes that are palpable. Posterior, anterior and medial lobes (non palpable).
Lies around the urethra.
Anorectal cancer - what does palpating feel like
Firm, nodular with rolled edge on examination
Prostate cancer screening recommendation
USPSTF recommendations
- Age 55-69
ACS recommendation -
- age 50 to <10 years life expectancy
AUA
- age 55 to <10 years life expectancy
PSA test
Shared decision making
Risk factors for prostate cancer
- Age
- Ethnicity
- Family history (having it or early diagnosis – before 55)
- Smoking
- Diets high in animal fat
- Obesity
- Cadmium exposure
- Possibly agent orange exposure
Examination findings for prostate cancer
- Hardness or gland,
- Distinct nodules for firmness
Symptoms of proctitis
- anorectal pain
- feeling of incomplete evacuation
- discharge
- bleeding
Can feel anal fissures, pain on exam
What generally causes proctitis?
STDs
Murphy’s sign
Palpation of gallbladder that results in swift patient retraction. Assess for cholecystitis.
McBurney’s Point
Point between the umbilicus and right iliac crest that is tender when palpated or during rebound that assesses for appendicitis.
Steps for abdominal examination
- Inspect
- Auscultate
- Palpate
- Percuss
Steps of the abdominal exam
- Inspect the surface, contours, and movements of the abdomen including skin temperature, color, and presence of scars or striae.
- Prior to palpation or percussion, place the diaphragm of your stethoscope in one abdominal region and listen for bowel sounds (presence, characteristics, bruits).
- Percuss the abdomen lightly in all four quadrants (tympany, dullness, area of change).
- Palpate lightly with one hand in all four quadrants (masses, tenderness, guarding).
- Palpate deeply with two hands in all four quadrants (liver edge, masses, tenderness, pulsations).
- Check for signs of peritonitis (guarding, rigidity, rebound tenderness).
Liver assessment
Estimate size along the right midclavicular line using percussion
Spleen assessment
Percuss for splenic enlargement along Traube space
Palpate for splenic edge with the patient supine in right lateral decubitis position.
Kidney assessment
Check for tenderness at costovertebral angle using fist percussion.
Urinary Bladder assessment
Percuss bladder for distention and tenderness
Dyspepsia
chronic or recurrent discomfort or pain centered in the upper abdomen, characterized by epigastric pain or burning, fullness or early satiety (or both), excessive postprandial pain
Functional (Non-Ulcer) dyspepsia
a 3-month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease (PUD)
Heartburn
Rising retrosternal burning pain or discomfort occurring weekly or more often. Aggravated by foods like alcohol, citrus, chocolate, coffee, onions, pepperming or positions like lying down.
RLQ conditions
- appendicitis
- peptic ulcer disease
- ruptured ovarian follicle
- ectopic pregnancy
LLQ conditions
- Accompanied by diarrhea –> diverticulitis
- Diffuse abdo pain, distention, nausea, emesis –> obstruction
- Severe diffuse abdo pain with guarding and rigidity on exam–> peritonitis
Chronic lower abdo pain can be caused by….
Change in bowel habits –> colon cancer
Intermittent pain for 12 weeks in preceding 12 months with relieve from defecation, change in bowel habits, change in stool formation –> IBS
Indigestion
General distress associated with eating that may have many meanings
- Pregnancy
- DKA
- Adrenal insufficiency
- Hypercalcemia
- Uremia
- Liver disease
- Emotional state
- Adverse drug reactions
Nausea and vomiting
- W/obstipation (severe constipation with inability to pass gas/stool) –> obstruction
- hematemesis – brownish black, possibly coffee ground emesis –> esophageal or gastric varices?
What can cause early satiety?
- Gastroparesis
- anticholinergic medications
- gastric outlet obstruction
- gastric CA
Dysphagia
- Xerostomia – insufficient saliva
- Can be structural (esphageal stricture), neurologic (stroke, parkinson’s), muscular (muscular dystrophy, myasthenia gravis)
Diarrhea
- Acute – less than 14 days, usually foodborne caused by infection
- Persistent – 14-30 days
- Chronic – more than 30 days (IBS, crohns, UC, C Diff)
Jaundice
Yellowish discoloration of the skin and sclera caused by elevated levels of bilirubin from the breakdown of hemoglobin
Carotenemia
(orange pigment in carrots) increased carotene in the blood causes discoloration of skin but not sclera or mucous membranes
Peptic ulcer disease
Mucosal ulcer in the stomach or duodenum >5mm (H.pylori/NSAIDS)
Epigastric pain that may radiate to the back
o Gnawing, burning, aching, hunger like pain – 20% have no symptoms
Duodenal ulcer – pain at night
o Relief with food and antacids (duodenal)
Gastroesophageal reflux disease (GERD)
Prolonged exposure of the esophagus to gastric acid due to impaired esophageal motility of excess relaxation of sphincter muscle
o Chest or epigastric pain that burns
o Happens after meals,
o Happens with spicy foods, lying down, bending over
o Better with PPIs and antacids
Symptoms associated with GERD
- Wheezing
- Chronic cough
- SOB
- Hoarseness
- Choking sensation
- Dysphagia
- Halitosis
- Sore throat
Symptoms associated with PUD
- N&V
- Belching
- Bloating
- Heartburn
- dyspepsia
Special assessment techniques for Appendicitis
- McBurney’s point tenderness RLQ
- Rovsing sign - rebound tenderness in LLQ
- Psoas sign - raise right thigh against hand, causes pain in RLQ
- Obturator - flex right thigh at hip, bend knee, rotate leg internally - pain RLQ
- Rectal exam - right sided rectal tenderness
- Pelvic exam - palpable inflamed appendix
Diverticulitis
Acute inflammation of colonic diverticula, outpouching usually in sigmoid or descending colon
- LLQ pain
- diarrhea (with hx constipation then diverticulitis )
- Cramping then steady pain
- Gradual onset
- Better with analgesia, bowel rest, ABX
Symptoms associated with diverticulitis
- Anorexia
- Fever
- Diarrhea
- Urinary symptoms
Biliary colic
Intermittent obstruction of the cystic duct by a gallstone
o Intermittent pain that resolves
o RUQ or epigastric pain, may radiate to shoulder
o Rapid onset, lasts hours and subsides gradually
o Worse with large fatty meals
Ulcerative colitis
- Muscosal inflammation from the recutm to colon with microperforations and possibly polyps
- Frequent diarrhea, watery, bloody
- Abrupt onset, recurrent, persistent, may awaken at night
Symptoms associated with ulcerative colitis
- Cramping with urgency
- Fever
- Fatigue
- Weakness
- abdo pain
Hepatitis A
- Fecal oral spread or contaminated food
- HVA vaccine at age 1
- Immune globulin single dose for treatment
- Not fatal unless other liver conditions
Hepatitis B
- Spread through body fluids
- Most cases self limited pt develops immunity
- Chronic infection in diabetic and immunosuppressed patients
- Vaccination & antiviral treatment
Hepatitis C
- Most prevalent bloodborne pathogen in the US
- IV drug use, needlestick injuries, transfusion/transplantation prior to 1992
Inflammatory bowel disease (IBS)
o Characterized by bloating
o Increases the risk for colorectal cancer
- Intermittent pain for 12 weeks in preceding 12 months with relieve from defecation, change in bowel habits, change in stool formation
Hepatomegaly
o Enlarged liver
o A palpable liver edge does not indicate hepatomegaly
Colon cancer and screening recommendations
For adults 50 to 75. All of these are options:
o Colonoscopy every 10 years
o Stool based test annually
o Sigmoidoscopy every 5 years
o Flexible sigmoidoscopy every 10 years
Structures of the RUQ
Gallbladder
Pylorus
Duodenum
Hepatic flexure of colon
Head of pancreas
Structures of the LUQ
Spleen
Splenic flexure of colon
Stomach
Body and tail of pancreas
Structures of the LLQ
Sigmoid colon
Descending colon
Left ovary
Structures of the RLQ
Cecum
Appendix
Ascending colon
Terminal ileum
Right ovary
Obstipation
Severe constipation that prevents passage of stool and gas, indicates bowel obstruction, is a medical emergency.
Diarrhea
lose or watery stool for at least 75% of the stools being passed
Constipation
- Less than 3 BM per week,
- at least 25% involve straining or feeling incomplete emptying,
- lumpy or hard,
- requires manual facilitation to pass
Acute abdominal pain causes
- appendicitis
- cholecystitis
- GERD
- INtestinal obstruction
- UTI
- Peritonitis
Chronic abdominal pain causes
- IBS
- IBD
- GERD
- PUD
- Cancer
Melena
Black tarry stools
Hematochezia
bright red bloody stools
Pencil thin stools
colon cancer
Mucus in stools
Adenoma, infection, IBD, IBS
Black stool
- ate licorice
- taking bismuth?
- bleeding in UGI tract?
Pale, white, clay colored stools
bile duct may be blocked
Yellow stool
Too much fat, malabsorption, celiac disease
Red stools
- ate red things
- hemorrhoids
- bleeding LGI tract
Symptoms of Viral hepatitis
Affects the liver and may cause
- n/v
- abdo pain
- dark urine
- light colored stools
What is proctitis?
Inflammation of the last 6” of the cololn
Risk factors for proctitis
- unsafe sex practices
- inflammatory bowel disease
- radiation therapy
Concerns for
- anemia, fistulas
Risk factors for anorectal cancer
- age
- adenomatous polyps
- IBD
- family history
Anorectal cancer screening guidelines
USPSTF
50-75
- colonoscopy every 10 years
- FIT annually
- FIT/DNA every 3 years
Cause of Anal Cancer?
HPV infection
At risk
- immunocomprimised
- HIV
- medication
- prior transplants
- homosexual men
Treatment is chemo and radiation
