Week 8 - Abdomen

Question 1

To which location the pancreatic and biliary tree pain are usually referred?

Answer 1

Pain of duodenal or pancreatic origin may be referred to the back.

Pain from the biliary tree may be referred to the right shoulder or right posterior chest.

Question 2

What are the causes of doubling over with cramping, colicky pain, sudden knifelike epigastric pain?

Answer 2

Doubling over with cramping, colicky pain indicates renal stone.

Sudden knifelike epigastric pain occurs in gallstone pancreatitis.

Question 3

What are the causes and characteristics of heartburn?

Answer 3

Heartburn: a burning sensation in the epigastric area radiating into the throat, often associated with regurgitation.

It is typically aggravated by food such as alcohol, chocolate, citrus fruits, coffee, onions, and peppermint; or positions like bending over, exercising, lifting, or lying supine.

Question 4

What are the characteristics of pain in appendicitis and diverticulitis? What are the sign symptoms of colon cancer?

Answer 4

Appendicitis pain is in RLQ or migrates from periumbilical region, combined with abdominal wall rigidity on palpation.

Diverticulitis pain is in LLQ with a palpable mass.

Colon cancer will show a change in bowel habits with mass lesion.

Question 5

What are the causes of regurgitation of gastric contents? What are the causes of hematemesis? What are the causes of early satiety? What is the location of esophageal dysphagia?

Answer 5

Regurgitation occurs in GERD, esophageal stricture, and esophageal cancer.

Hematemesis may accompany esophageal or gastric varices, gastritis, or peptic ulcer disease.

Early satiety may be due to diabetic gastroparesis, anticholinergic medication, gastric outlet obstruction, gastric cancer, and hepatitis.

Patients with esophageal dysphagia will point to below the sternoclavicular notch.

Question 6

What are the usual causes of acute diarrhea and of chronic diarrhea? What are the causes of steatorrhea?

Answer 6

Acute diarrhea is usually caused by infection; chronic diarrhea is typically noninfectious in origin, as in Crohn’s disease and ulcerative colitis.

Steatorrhea causes include celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.

Question 7

What are the causes of constipation and obstipation? Define melena and hematochezia. What are the causes?

Answer 7

Constipation causes include anticholinergic agents, calcium channel blockers, iron supplements, and opiates. Constipation also occurs with diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, Parkinson’s disease, and systemic sclerosis.

Obstipation signifies intestinal obstruction.
Melena is black, tarry stools due to upper GI bleeding.

Hematochezia is stool that is red or maroon-colored due to lower GI bleeding.

Question 8

Define acholic stool. What is its common cause? What is the cause of jaundice with itching?

Answer 8

Acholic stools are gray or light colored due to obstructed bile excretion.

Jaundice with itching is due to obstructive jaundice.

Question 9

What are the causes of suprapubic pain, painful urination, and difficulty in voiding?

Answer 9

Suprapubic pain is due to bladder disorders.
Painful urination accompanies cystitis or urethritis.

Difficulty voiding may be due to bladder stones, foreign bodies, tumors, or acute prostatitis.

Question 10

What are the features of acute pyelonephritis? What is the location of flank pain? What is the character of ureteral pain?

Answer 10

Kidney pain, fever, and chills occur in acute pyelonephritis.

Flank pain is at or below the posterior costal margin near the costovertebral angle.

Ureteral pain is severe and colicky and radiates from the costovertebral angle around the trunk to the groin.

Question 11

Define caput medusa? What are the other classic findings of alcohol abuse?

Answer 11

Caput medusa is a collateral pathway of recanalized umbilical veins radiating up the abdomen that decompresses portal vein hypertension.

Other classic findings of alcohol abuse include hepatosplenomegaly, ascites, spider angiomas, palmar erythema, and peripheral edema.

Question 12

What are the cutoffs for hazardous alcohol drinking in men and women?

Answer 12

Men ≥ 4 drinks per occasion and ≥ 14 drinks per week.

Women ≥ 3 drinks per occasion and ≥ 7 drinks per week.

Question 13

What are the recommendations for screening of colorectal cancer in persons with average risk?

Answer 13

One of the following five options:
▪ Fetal Occult Blood Test every year.
▪ Flexible sigmoidoscopy every 5 years.
▪ Combined of the above two.
▪ Colonoscopy every 10 years.
▪ Double-contrast barium enema every 5 years.

Question 14

What is the sequence of abdominal examinations?

Answer 14

Inspection, Auscultation, Percussion, (Light, then Deep) Palpation.

Question 15

What are the causes of pink, purple striae, dilated veins, bulging flanks and suprapubic bulge on the abdomen?

Answer 15

Pink, purple striae is Cushing’s syndrome.

Dilated veins is hepatic cirrhosis or inf. vena cava obstruction.

Bulging flanks is ascites.

Suprapubic bulge on the abdomen is distended bladder, pregnant uterus, or hernia.

Question 16

What are the causes of increased peristaltic waves and increased pulsations visible on the abdomen? Where will you listen bruits of renal artery stenosis?

Answer 16

Increased peristaltic waves due to intestinal obstruction.

Increased pulsations visible on the abdomen due to aortic aneurysm.

Listen for bruits of renal artery stenosis in the RUQ and LUQ.

Question 17

What are the causes of friction rubs over the liver? What are the shape and percussion notes in intestinal obstruction?

Answer 17

Friction rubs in liver are due to tumor, gonococcal infection around the liver, splenic infarction.

Intestinal obstruction will present with protuberant abdomen with tympany.

Question 18

What is the palpation finding of peritoneal inflammation? What is the significance of rebound tenderness? How rebound tenderness is elicited?

Answer 18

Peritoneal inflammation presents with involuntary abdominal rigidity.

Rebound tenderness elicited from the examiner decreases pressure against the abdomen signifies peritoneal inflammation.

Question 19

In which condition the liver dullness may be displaced downward?

Answer 19

Liver dullness may be displaced downward by COPD.

Question 20

How will you palpate the liver? What is the site at which liver is palpable?

Answer 20

Using the left hand to support the back at the level of the 11th and 12th rib, the right hand presses on the abdomen inferior to the border of the liver and continues to palpate superiorly until the liver border is palpated. Ask the patient to take a deep breath. This can illicit pain in liver or gallbladder disease and also makes it easier to find the inferior border of the liver (the diaphragm lowering during deep inspiration forces the liver downward).

On inspiration, the liver is palpable about 3cm below the right costal margin in the midclavicular line.

Question 21

What are the causes of tenderness over the liver? What are the directions of enlargement of spleen?

Answer 21

Tenderness over the liver suggest inflammation as in hepatitis or congestion as in heart failure. Directions of enlargement of spleen are anteriorly, downward, and medially.

Question 22

What are the causes of splenomegaly?

Answer 22

Splenomegaly may be due to portal HTN, hematologic malignancies, HIV, and splenic infarct or hematoma.

Question 23

What are the causes of enlarged kidney? What are the findings on pressure and percussion in pyelonephritis?

Answer 23

Causes of kidney enlargement include hydronephrosis, cysts, and tumors. Pyelonephritis will elicit pain with pressure or percussion.

Question 24

What are the causes of bladder outlet obstruction? What are the risk factors of abdominal aortic aneurysm (AAA)? What are the exam findings in (AAA)?

Answer 24

Bladder outlet obstruction is found in urethral stricture, prostatic hyperplasia, medication, stroke, and MS.

AAA risk factors are age > 65, history of smoking, male, and first-degree relative with AAA.

Question 25

What are the causes of ascites? What happens to dullness and tympany with position change of a patient with ascites?

Answer 25

Ascites may be due to cirrhosis, congestive heart failure, constrictive pericarditis, inf. vena cava or hepatic vein obstruction, nephrotic syndrome, malnutrition, and ovarian cancer.

Dullness will shift towards the floor; tympany will shift towards the ceiling.

Question 26

What is the characteristic of pain in appendicitis? Describe Ronsig’s sign, referred rebound tenderness, psoas sign, and obturator sign.

Answer 26

Appendicitis pain classically begins near the umbilicus, then shifts to the RLQ that is increased by coughing.

Rovsing’s sign is rebound tenderness in the left lower quadrant.

Referred rebound tenderness is RLQ pain on quick withdrawal.

Psoas sign is pain when the patient flexes his thigh against the examiner’s hand.

Obturator sign is pain when you flex the patient’s thigh and rotate the leg internally at the hip.

Question 27

How Murphy’s sign is elicited? When is it positive? How will you distinguish a mass on the abdominal wall from an intraabdominal mass?

Answer 27

Murphy’s sign is elicited by hooking your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Ask the patient to take a deep breath. A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy’s sign of acute cholecystitis.

Abdominal wall mass vs. intraabdominal mass: Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again. A mass in the abdominal wall remains palpable; an intraabdominal mass is obscured by muscular contraction.

Question 28

What the location, radiation of pain, aggravating and relieving factors of acute pancreatitis? What are the location and radiation of pain of acute cholecystitis?

Answer 28

Acute Pancreatitis Location: Epigastric pain that may radiate to the back or abdomen.

Acute Pancreatitis A/A Factors: Food aggravates, not relieved by food or antacids.

Acute Cholecystitis Location: RUQ or upper abdominal pain that may radiate to right scapular area.

Question 29

What are the causes of stress incontinence in both men and women?

Answer 29

Female causes of stress incontinence: weakness of pelvic floor muscles due to childbirth, surgery, post- menopausal atrophy of mucosa or urethral infection.

Male causes of stress incontinence: prostate surgery.