(11) Abdomen tables

Question 1

GERD:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 1

Process: Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or excess relaxations of the lower esophageal sphincter; Helicobacter pylori may be present

Location: chest or epigastric

Quality: heartburn, regurgitation

Timing: After meals, especially spicy
foods

Aggravating Factors: Lying down, bending over; physical activity; diseases such as scleroderma, gastroparesis; drugs like nicotine that relax the lower esophageal sphincter

Relieving Factors: Antacids, proton pump inhibitors;
avoiding alcohol, smoking, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers

Associating Symptoms/Setting: Wheezing, chronic cough, shortness of breath, hoarseness, choking
sensation, dysphagia, regurgitation, halitosis, sore throat; increases risk of Barrett esophagus and esophageal cancer

Question 2

Peptic Ulcer Disease:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 2

Process: Mucosal ulcer in stomach or duodenum >5 mm, covered with fibrin, extending through the muscularis mucosa; H. pylori infection present in 90% of peptic ulcers

Location: epigastric, may radiate straight to the back

Quality: Variable: epigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike; No symptoms in up to 20%

Timing: Intermittent; duodenal ulcer is
more likely than gastric ulcer
or dyspepsia to cause pain that
(1) wakes the patient at night,
and (2) occurs intermittently
over a few wks, disappears for
months, then recurs

Aggravating Factors: variable

Relieving Factors: Food and antacids may bring relief
(less likely in gastric ulcers)

Associating Symptoms/Setting: Nausea, vomiting, belching, bloating;
heartburn (more common in duodenal
ulcer); weight loss (more common in
gastric ulcer); dyspepsia is more common
in the young (20–29 yrs), gastric
ulcer in those over 50 yrs, and duodenal
ulcer in those 30–60 yrs

Question 3

Gastric Cancer:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 3

Process:Adenocarcinoma in 90%–95%, either
intestinal (older adults) or diffuse
(younger adults, worse prognosis)

Location: increasingly in “cardia” and GE junction; also in distal stomach

Quality: variable

Timing: Pain is persistent, slowly progressive;
duration of pain is typically
shorter than in peptic ulcer

Aggravating Factors: Often food; H. pylori infection

Relieving Factors: Not relieved by food or antacids

Associating Symptoms/Setting: Anorexia, nausea, early satiety, weight
loss, and sometimes bleeding; most
common in ages 50–70 yrs

Question 4

Acute Appendicitis:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 4

Process: Acute inflammation of the appendix
with distention or obstruction

Location: Poorly localized periumbilical pain,
usually migrates to the right lower
quadrant

Quality: Mild but increasing, possibly
cramping; Steady and more severe

Timing: Lasts roughly 4–6 hrs, depending
on intervention

Aggravating Factors: Movement or cough

Relieving Factors: If it subsides temporarily,
suspect perforation of the
appendix.

Associating Symptoms/Setting: Anorexia, nausea, possibly vomiting,
which typically follow the onset of
pain; low fever

Question 5

Acute Cholecystitis:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 5

Process:Acute inflammation of the gallbladder with distention or obstruction

Location: Right upper quadrant or epigastrium; may radiate to right shoulder or interscapular
area

Quality: steady, aching

Timing: Gradual onset; course longer
than in biliary colic

Aggravating Factors: Jarring, deep breathing

Relieving Factors: none

Associating Symptoms/Setting: Anorexia, nausea, vomiting, fever;
no jaundice

Question 6

Biliary Colic:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 6

Process:Sudden obstruction of the cystic duct
or common bile duct by a gallstone

Location: Epigastric or right upper quadrant;
may radiate to the right scapula and
shoulder

Quality: Steady, aching; not colicky;
Usually last longer than 3 hrs

Timing: Rapid onset over a few min, lasts
one to several hrs and subsides
gradually; often recurrent

Aggravating Factors: Fatty meals but also fasting;
often precedes cholecystitis,
cholangitis, pancreatitis

Relieving Factors: none

Associating Symptoms/Setting: Anorexia, nausea, vomiting, restlessness

Question 7

Acute Pancreatitis:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 7

Process:Intrapancreatic trypsinogen activation
to trypsin and other enzymes, resulting
in autodigestion and inflammation
of the pancreas

Location: Epigastric, may radiate straight to the back or other areas of the abdomen;
20% with severe sequelae of organ
failure

Quality: usually steady

Timing: Acute onset, persistent pain

Aggravating Factors: Lying supine; dyspnea if pleural
effusions from capillary leak syndrome;
selected medications,
high triglycerides may exacerbate

Relieving Factors: Leaning forward with trunk
flexed

Associating Symptoms/Setting: Nausea, vomiting, abdominal distention,
fever; often recurrent; 80%
with history of alcohol abuse or
gallstones

Question 8

Chronic Pancreatitis:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 8

Process: Irreversible destruction of the pancreatic
parenchyma from recurrent inflammation
of either large ducts or small ducts

Location: epigastric, radiating to back

Quality: severe, persistent, deep

Timing: Chronic or recurrent course

Aggravating Factors: Alcohol, heavy or fatty meals

Relieving Factors: Possibly leaning forward with
trunk flexed; often intractable

Associating Symptoms/Setting: Pancreatic enzyme insufficiency,
diarrhea with fatty stools (steatorrhea)
and diabetes mellitus

Question 9

Acute Diverticulitis:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 9

Process: Acute inflammation of colonic diverticula,
outpouchings 5–10 mm in diameter,
usually in sigmoid or descending
colon

Location: LLQ

Quality: may be cramping at 1st then steady

Timing: often gradual onset

Aggravating Factors: none

Relieving Factors: analgesia, bowel rest, antibiotics

Associating Symptoms/Setting: Fever, constipation. Also nausea,
vomiting, abdominal mass with
rebound tenderness

Question 10

Acute Bowel Obstruction:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 10

Process: Obstruction of the bowel lumen, most
commonly caused by (1) adhesions or
hernias (small bowel), or (2) cancer or
diverticulitis (colon)

Location: Small bowel: periumbilical or upper abdominal; Colon: lower abdominal or generalized

Quality: cramping

Timing: Paroxysmal; may decrease as
bowel mobility is impaired
Paroxysmal, though typically
milder

Aggravating Factors: Ingestion of food or liquids

Relieving Factors: none

Associating Symptoms/Setting: Vomiting of bile and mucus (high
obstruction) or fecal material (low
obstruction); obstipation develops
(early); vomiting late if at all; prior
symptoms of underlying cause

Question 11

Mesenteric Ischemia:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 11

Process: Occlusion of blood flow to small
bowel, from arterial or venous thrombosis
(especially superior mesenteric
artery), cardiac embolus, or hypoperfusion;
can be colonic

Location: May be periumbilical at first, then diffuse; may be postprandial,
classically inducing “food fear”

Quality: Cramping at first, then
steady; pain disproportionate
to examination findings

Timing: Usually abrupt in onset, then
persistent

Aggravating Factors: underlying cardiac disease

Relieving Factors: none

Associating Symptoms/Setting: Vomiting, bloody stool, soft distended
abdomen with peritoneal
signs, shock; age >50 yrs

Question 12

Pancreatic Cancer:

Process
Location
Quality
Timing
Aggravating Factors
Relieving Factors
Associating Symptoms/Setting

Answer 12

Process: Predominantly adenocarcinoma (95%); 5% 5-yr survival

Location: If cancer in body or tail, epigastric, in either upper quadrant, often radiates to the back

Quality: steady, deep

Timing: Persistent pain; relentlessly progressive illness

Aggravating Factors: smoking, chronic pancreatitis

Relieving Factors: Possibly leaning forward with trunk flexed; often intractable

Associating Symptoms/Setting: Painless jaundice, anorexia, weight loss; glucose intolerance, depression

Question 13

Oropharngeal Dysphagia:

Timing
Aggravating Factors
Associated Symptoms/Conditions

Answer 13

Timing: acute or gradual onset & variable course, depending on underlying disorder

Aggravating Factors: attempts to start swallowing process

Associated Symptoms/Conditions: aspiration into the lungs or regurgitation into the nose w/ attempts to swallow; from motor disorders affecting the pharyngeal muscles such as stroke, bulbar palsy, or other neuromuscular conditions

Question 14

Esophageal Dysphagia (mechanical narrowing):
Mucosal rings and webs

Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions

Answer 14

Timing: intermittent

Aggravating Factors: solid food

Relieving Factors: regurgitation of the bolus of food

Associated Symptoms/Conditions: usually none

Question 15

Esophageal Dysphagia (mechanical narrowing):
Esophageal stricture

Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions

Answer 15

Timing: intermittent, may become slowly progressive

Aggravating Factors: solid foods

Relieving Factors: regurgitation of the food bolus

Associated Symptoms/Conditions: long history of heartburn and regurgitation

Question 16

Esophageal Dysphagia (mechanical narrowing):
Esophageal cancer

Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions

Answer 16

Timing: may be intermittent at first, progressive over months

Aggravating Factors: solid foods w/ progression to liquids

Relieving Factors: regurgitation of food bolus

Associated Symptoms/Conditions: pain in chest and back, weight loss - especially late in course of illness

Question 17

Motor Disorders: Diffuse esophageal spasm

Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions

Answer 17

Timing: intermittent

Aggravating Factors: solids or liquids

Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver, sometimes nitroglycerin

Associated Symptoms/Conditions: chest pain that mimics angina pectoris or MI and lasts min to hrs, possibly heartburn

Question 18

Motor Disorders: Scleroderma

Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions

Answer 18

Timing: intermittent, may progress slowly

Aggravating Factors: solids or liquids

Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver

Associated Symptoms/Conditions: heartburn, other manifestations of scleroderma

Question 19

Motor Disorders: Achalasia

Timing
Aggravating Factors
Relieving Factors
Associated Symptoms/Conditions

Answer 19

Timing: intermittent, may progress

Aggravating Factors: solids or liquids

Relieving Factors: repeated swallowing, movements such as straightening the back, raising the arms, Valsalva maneuver

Associated Symptoms/Conditions: regurgitation often at night when lying down with nocturnal cough, possibly chest pain precipitated by eating

Question 20

Acute Diarrhea: Secretory Infection (non-inflammatory)

process
characteristics of stool
timing
associated symptoms
setting/person @ risk

Answer 20

process: infection by virus, preformed bacterial toxins, cryptosporidium, rotavirus, Giardia lamblia

characteristics of stool: watery, w/o blood, pus, mucus

timing: few days

associated symptoms: N/V, periumbilical pain, temp normal or slightly elevated

setting/person @ risk: travel, food source, epidemic

Question 21

Acute Diarrhea: Inflammatory Infection

process
characteristics of stool
timing
associated symptoms
setting/person @ risk

Answer 21

process: colonization of invasion of intentional mucosa

characteristics of stool: loose to watery, often w/ blood, pus, or mucus

timing: acute illness of varying duration

associated symptoms: lower abd cramping pain and often rectal urgency, tenesmus, fever

setting/person @ risk: travel, contaminated food or water, frequent anal intercourse

Question 22

Drug-induced Diarrhea

process
characteristics of stool
timing
associated symptoms
setting/person @ risk

Answer 22

process: action of many drugs (Mg antacids, Abs, chemo, laxatives)

characteristics of stool: loose to watery

timing: actor, recurrent, chronic

associated symptoms: nausea, usually little to no pain

setting/person @ risk: prescribed or OTC meds

Question 23

Chronic Diarrhea: Irritable Bowel Syndrome

process
characteristics of stool
timing
associated symptoms
setting/person @ risk

Answer 23

process: altered motility ot secretion from liminal and mucosal irritants that change mucosal permeability; immune activation, and colonic transit, including maldigested carbs, fats, excess bile acids, gluten intolerance, enteroendocrine signaling, and changes in microbiomes

characteristics of stool: loose, 50% w/ mucus; small-moderate volume; small hard stools w/ constipation; may be mixed patten

timing: worse in am, rarely at night

associated symptoms: cramps lower abdominal pain, abd distention, flatulence, nausea; urgency, pain relieved w/ defecation

setting/person @ risk: young-middle aged, women

Question 24

Chronic Diarrhea: fecal impaction/motility disorders

process
characteristics of stool
timing
associated symptoms
setting/person @ risk

Answer 24

process: partial obstruction by impacted stool only allowing passage of loose feces

characteristics of stool: loose, small volume

timing: variable

associated symptoms: campy abd pain, incomplete evacuation

setting/person @ risk: older adults, immobilized/institutionalized pts, medications

Question 25

Chronic Diarrhea: cancer of sigmoid colon ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 25

process: partial obstruction by malignant neoplasm characteristics of stool: may be blood streaked timing: variable associated symptoms: change in usual bowel habits, cramps lower abd pain, constipation setting/person @ risk: >55y/o

Question 26

Ulcerative Colitis ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 26

process: mucosa; inflammation typically extending proximally from rectum to varying lengths of colon, w/ microulcerations and if chronic inflammatory polyps characteristics of stool: frequent, eatery, often contain blood timing:onset typically abrupt, often recurrent, persistent, may awaken at night associated symptoms: cramping w/ urgency, tenesmus, fever, fatigue, weakness, abd pain if complicated by toxic megacolon; may include episcleritis, uveitis, arthritis, erythema nodosum setting/person @ risk: young adults, Ashkenazi Jew, altered CD+ T cell Th2 response (increased colon CA risk)

Question 27

Crohn Disease of small bowel or colon ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 27

``` process: Chronic transmural inflammation of the bowel wall, with skip pattern involving the terminal ileum and/ or proximal colon (and rectal sparing); may cause strictures ``` characteristics of stool: Small, soft to loose or watery, with bleeding if colitis, obstructive symptoms, if enteritis timing: More insidious onset; chronic or recurrent ``` associated symptoms: Crampy periumbilical, right lower quadrant (enteritis) or diffuse (colitis) pain, with anorexia, fever, and/ or weight loss; perianal or perirectal abscesses and fistulas; may cause small or large bowel obstruction ``` ``` setting/person @ risk: Often teens or young adults, but also adults of middle age; more common in Ashkenazi Jewish descendants; linked to altered CD4+ Tcell helper Th1 and 17 response; increases risk of colon cancer ```

Question 28

Chronic Diarrhea: malabsorption syndrome ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 28

``` process: Defective membrane transport or absorption of intestinal epithelium (Crohn, celiac disease, surgical resection); impaired luminal digestion (pancreatic insufficiency); epithelial defects at brush border (lactose intolerance) ``` ``` characteristics of stool: Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in toilet (steatorrhea) ``` timing: Onset of illness typically insidious ``` associated symptoms: Anorexia, weight loss, fatigue, abdominal distention, often crampy lower abdominal pain. Symptoms of nutritional deficiencies such as bleeding (vitamin K), bone pain and fractures (vitamin D), glossitis (vitamin B), and edema (protein) ``` setting/person @ risk: Variable, depending on cause

Question 29

Chronic Diarrhea: osmotic - lactose intolerance ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 29

process: intestinal lactase deficiency characteristics of stool: watery diarrhea of large volume timing: follow the ingestion of milk and milk products; relieved by fasting associated symptoms: crampy abd pain, abd distention, flatulence setting/person @ risk: African Americans, native Americans, Hispanics (lower risk in Caucasians)

Question 30

Chronic Diarrhea: abuse of osmotic purgatives ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 30

process: laxative habit, often surreptitious characteristics of stool: watery diarrhea of large volume timing: variable associated symptoms: often none setting/person @ risk: persons w/ anorexia or bulimia

Question 31

Chronic Diarrhea: secretory diarrhea ``` process characteristics of stool timing associated symptoms setting/person @ risk ```

Answer 31

process: Variable: bacterial infection, secreting villous adenoma, fat or bile salt malabsorption, hormone-mediated conditions (gastrin in Zollinger–Ellison syndrome, vasoactive intestinal peptide) characteristics of stool: watery diarrhea of large volume timing: variable associated symptoms: Weight loss, dehydration, nausea, vomiting, and cramping, abdominal pain setting/person @ risk: Variable depending on cause

Question 32

Constipation: inadequate time or setting for the defecation reflex Process Associated Setting/Symptoms

Answer 32

Process: Ignoring the sensation of a full rectum inhibits the defecation reflex Associated Setting/Symptoms: Hectic schedules, unfamiliar surroundings, bed rest

Question 33

Constipation: False Expectations of Bowel Habits Process Associated Setting/Symptoms

Answer 33

Process: Expectations of “regularity” or more frequent stools than a person’s norm Associated Setting/Symptoms: Beliefs, treatments, and advertisements that promote the use of laxatives

Question 34

Constipation: Diet Deficient in Fiber Process Associated Setting/Symptoms

Answer 34

Process: decreased fecal bulk Associated Setting/Symptoms: Other factors such as debilitation and constipating drugs may contribute

Question 35

Irritable Bowel Syndrome: Process Associated Setting/Symptoms

Answer 35

Process: Functional change in frequency or form of bowel movement without known pathology; possibly from change in intestinal bacteria. ``` Associated Setting/Symptoms: Three patterns: diarrhea—predominant, constipation—predominant, or mixed. Symptoms present ≥6 mo and abdominal pain for ≥3 mo plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) ```

Question 36

Cancer of Rectum or Sigmoid Colon: Process Associated Setting/Symptoms

Answer 36

Process: Progressive narrowing of the bowel lumen from adenocarcinoma Associated Setting/Symptoms: Change in bowel habits; often diarrhea, abdominal pain, bleeding, occult blood in stool; in rectal cancer, tenesmus and pencil-shaped stools; weight loss

Question 37

Fecal Impaction: Process Associated Setting/Symptoms

Answer 37

Process: A large, firm, immovable fecal mass, most often in the rectum ``` Associated Setting/Symptoms: Rectal fullness, abdominal pain, and diarrhea around the impaction; common in debilitated, bedridden, and often elderly and institutionalized patients ```

Question 38

Constipation causing obstructing lesions - diverticulitis, volvulus, intussusception, hernia: Process Associated Setting/Symptoms

Answer 38

Process: Narrowing or complete obstruction of the bowel Associated Setting/Symptoms: Colicky abdominal pain, abdominal distention, and in intussusception, often “currant jelly” stools (red blood and mucus)

Question 39

Constipation: Painful Anal Lesions Process Associated Setting/Symptoms

Answer 39

Process: Pain may cause spasm of the external sphincter and voluntary inhibition of the defecation reflex Associated Setting/Symptoms: Anal fissures, painful hemorrhoids, perirectal abscesses

Question 40

Constipation:drugs Process Associated Setting/Symptoms

Answer 40

Process: A variety of mechanisms Associated Setting/Symptoms: Opiates, anticholinergics, antacids containing calcium or aluminum, and many others

Question 41

Constipation: depression Process Associated Setting/Symptoms

Answer 41

Process: a disorder of mood Associated Setting/Symptoms: Fatigue, anhedonia, sleep disturbance, weight loss

Question 42

Constipation: Neurologic Disorders Process Associated Setting/Symptoms

Answer 42

Process: Interference with the autonomic innervation of the bowel Associated Setting/Symptoms: Spinal cord injuries, multiple sclerosis, Hirschsprung disease, and other conditions

Question 43

Constipation: metabolic conditions Process Associated Setting/Symptoms

Answer 43

Process: Interference with bowel motility Associated Setting/Symptoms: Pregnancy, hypothyroidism, hypercalcemia

Question 44

Melena: problem selected causes w/ associated symptoms/setting

Answer 44

Problem: Refers to passage of black tarry stool Fecal blood tests are positive Involves loss ≥60 mL of blood into the gastrointestinal tract (less in children), usually from the esophagus, stomach, or duodenum with transit time of 7–14 hrs Less commonly, if slow transit, blood loss originates in the jejunum, ileum, or ascending colon In infants, melena may result from swallowing blood during the birth Gastritis, GERD, peptic ulcer (gastric or duodenal) - Usually epigastric discomfort from heartburn, dysmotility; if peptic ulcer, pain after meals delay of 2–3 hrs if duodenal ulcer; may be asymptomatic Gastritis or stress ulcers - Recent ingestion of alcohol, aspirin, or other anti-inflammatory drugs; recent bodily trauma, severe burns, surgery, or increased intracranial pressure Esophageal or gastric varices - Cirrhosis of the liver or other causes of portal hypertension Reflux esophagitis, Mallory-Weiss tear in esophageal mucosa due to retching and vomiting - Retching, vomiting, often recent ingestion of alcohol

Question 45

Black Stool: problem selected causes w/ associated symptoms/setting

Answer 45

Problem: Black stool from other causes with negative fecal blood tests; stool change has no pathologic significance Selected Causes: ingestions of iron, bismuth salts, licorice, or even chocolate cookies - asymptomatic

Question 46

Stool with Red Blood (Hematochezia) problem selected causes w/ associated symptoms/setting

Answer 46

``` Problem: Usually originates in the colon, rectum, or anus; much less frequently from the jejunum or ileum Upper gastrointestinal hemorrhage may also cause red stool, usually with large blood loss ≥1 L Rapid transit leaves insufficient time for the blood to turn black from oxidation of iron in hemoglobin ``` Colon cancer - Often a change in bowel habits, weight loss Hyperplasia or adenomatous polyps - Often no other symptoms Diverticula of the colon - Often no symptoms unless inflammation causes diverticulitis Proctitis (various causes including anal intercourse) - rectal urgency, tenesmus ischemic colitis - lower abdominal pain, sometimes fever or shock on older adults, abdomen typically soft to palpation hemmorhoids - blood on toilet paper, on surface of the stool, dripping into toilet anal fissure - blood on toilet paper or on surface of stool, anal pain

Question 47

Reddish but non bloody stool: causes & symptoms

Answer 47

ingestion of beets - pink urine usually pecans reddish stool, from poor metabolism of betacyanin

Question 48

Urinary Frequency: mechanisms

Answer 48

- decreased bladder capacity | - impaired bladder emptying w/ residual urine in the bladder

Question 49

urinary frequency - decreased bladder capacity mechanism-cause-symptoms (3)

Answer 49

1. increased bladder sensitivity to stretch b/c of inflammation - infection, stones, tumor, foreign body in bladder - burning on urination, urinary urgency, sometimes gross hematuria 2. decreased elasticity of the bladder wall - infiltration by scar tissue or tumor - burning on urination, urinary urgency, sometimes gross hematuria 3. decreased cortical inhibition of bladder contractions - motor disorders of the CNS (stroke) - urinary urgency, near sx: weakness, paralysis

Question 50

urinary frequency - impaired bladder emptying w/ residual urine in the bladder mechanism-cause-symptoms (2)

Answer 50

1. partial mechanism obstruction of the bladder neck/proximal urethra - BPH, urethral stricture, obstructive lesion of bladder/prostate - hesitancy in starting stream, strain to void, reduced size/force of stream, dribbling during or at end of urination 2. loss of S2-S4 innervation to the bladder - near dz affecting sacral nerves or nerve roots, diabetic neuropathy - weakness or sensory deficits

Question 51

Nocturia w/ high volumes: mechanisms/causes/symptoms (3)

Answer 51

1. decreased concentrating ability of he kidney w/ loss of normal drop in nocturnal urine output - chronic renal insufficiency - other sx of renal insufficiency 2. excessive fluid intake before bed - habit, esp. ETOH/coffee 3. fluid-retaining, edematous states, daytime accumulation of dependent edema that is excreted when pt supine - heart failure, nephrotic syndrome, hepatic cirrhosis w/ ascites, chronic venous insufficiency - edema, reduced UOP during day

Question 52

Nocturia w/ low volumes mechanisms/causes/symptoms

Answer 52

urinary frequency, voiding while up at night w/o real urge "pseudo frequency" - insomnia - variable symptoms

Question 53

Polyuria mechanisms/causes/symptoms

Answer 53

1. deficiency of ADH (DI) - disorder of posterior pituitary and hypothalamus - thirst, polydipsia (severe, persistent), nocturne 2. renal unresponsiveness to ADH (nephrogenic DI) - kidney diseases (hypoercalcemic and hypokalemic nephropathy), drug toxicity (lithium) - thirst, polydipsia, (severe, persistent), nocturne 3. solute diuresis: - electrolytes (Na) - large saline infusions, potent diuretics, kidney diseases - variable sx - non electrolytes (glucose) - uncontrolled DM - thirst, polydipsia, nocturne 4. excessive water intake - primary polydipsia - polydipsia episodic, thirst may not be present, nocturne usually absent

Question 54

Stress Incontinence

Answer 54

urethral sphincter is weakened so that transient increased in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance

Question 55

Stress incontinence: mechanisms

Answer 55

women: - pelvic floor weakness - inadequate muscular and ligamentous support of bladder neck and proximal urethra change the angle between bladder and urethra - causes: childbirth and surgery - local conditions affecting the internal urethral sphincter (postmenopausal atrophy of mucosa and urethral infection) men: prostate surgery

Question 56

stress incontinence: symptoms

Answer 56

momentary leakage of small amounts of urine w/ coughing, laughing, sneezing while person is upright -urine loss unrelated to conscious urge to urinate

Question 57

stress incontinence: physical signs

Answer 57

may be demonstrable if examined before voiding and in standing position - atrophic vaginitis may be evident - bladder distention is absent

Question 58

Urge incontinence

Answer 58

detrusor muscles are stronger than normal and overcome the normal urethral resistance -bladder is typically small

Question 59

urge incontinence: mechanisms/symptoms/physical signs (3)

Answer 59

1. decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, lesions of spinal cord above sacral level - involuntary urine loss proceeded by urge to void, moderate volume - small bladder not detectable on abd exam 2. hyper excitability of sensory pathways (bladder infections, tumors, fecal impaction) - urgency, frequency, nocturne w/ small to moderate volumes (if acute inflammation present: pain on urination) - when cortical inhibition decreased, mental deficits or motor signs of CNS dz present 3. reconditioning of voiding reflexes as in frequent voluntary voiding at low bladder volumes - "pseudo-stress incontinence": voiding 10-21 sec after stresses such as position change, stairs, cough/laugh/sneeze - when sensory pathways are hyper excitable signs of local pelvic problems or fecal impaction present

Question 60

urinary overflow incontinence

Answer 60

detrusor contractions are insufficient to overcome urethral resistance causing urinary retention - bladder typically flaccid and large even after effort to void

Question 61

urinary overflow incontinence: mechanisms/symptoms/physical signs (3)

Answer 61

1. obstruction of bladder outlet (BPH, tumor) - intravascular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues 2. weakness of detrusor muscle associated w/ peripheral nerve dz at S2-S4 level - decreased force of urinary stream 3. impaired bladder sensation that interrupts reflex arc (diabetic neuropathy) - prior sx of partial urinary obstruction or other symptoms of peripheral nerve disease may be present Physical signs: enlarged, tender bladder, prostate enlargement, motor signs of peripheral nerve disease, decrease in perineal sensation, diminished/absent reflexes

Question 62

Functional Urinary Incontinence

Answer 62

patient is functionally unable to reach toilet in time b/c of impaired health or environmental conditions

Question 63

Functional urinary Incontinence: mechanisms/symptoms/physical signs

Answer 63

mechanisms: - problems in mobility resulting from weakness, arthritis, poor vision, or other conditions - environmental factors such as unfamiliar setting, distant bathroom facilities, bed rails, physical restraints symptoms: incontinence on the way to toilet or only in the early morning physical signs: bladder not detectable on exam, look for environmental causes

Question 64

Urinary Incontinence s/t medications

Answer 64

drugs may contribute to any type of incontinence -sedatives, tranquilizers, sympathetic blockers, potent diuretics

Question 65

Umbilical Hernia

Answer 65

protrusion through a defective umbilical ring | -most common in infants (usually closes spontaneously in 1-2 years) but occurs in adults

Question 66

Incisional Hernia

Answer 66

protrusion through an operative scare - palpate to detect length and width of defect in abdominal wall - small defect, through which a large hernia has passed, has a greater risk for complications than a large defect

Question 67

Epigastric Hernia

Answer 67

small midline protrusion through a defect in the lines alba occurs between the diploid process and the umbilicus - w/ pt coughing or performing valsalva maneuver palpate by running fingered down line laba

Question 68

Diastasis Recti

Answer 68

separation of 2 rectus abdomens muscles through which abdominal contents form a midline ridge typically extending from the xiphoid to the umbilicus and seen only when pt raises head and shoulders - often present w/ repeated pregnancies, obesity, chronic lung disease - clinically benign

Question 69

Abdominal Lipoma

Answer 69

common, benign, fatty tumors usually in SQ tissues anywhere on body including abdominal wall -small or large -soft and lobulated press finger down on edge, tumor usually slips out from under finger and is well demarcated, nonreducible, nontender

Question 70

Types of Protuberant Abdomens

Answer 70

1. Fat - most common, thickens abdominal wall, mesentery, omentum, umbilicus sunken, pannus (apron of fatty tissue) may extend below inguinal ligaments - lift to look for skin inflammation or hidden hernia 2. Gas - distention may be localized or generalized, tympanic percussion, caused by foods, obstruction, paralytic ileum, note location (more marked in colon than small bowel) 3. Tumor - usually rising out of pelvis, dull to percussion, airfilled bowel displaced to periphery (ovarian tumor, uterine fibroids), don't mistake for distended bladder 4. Pregnancy - listen for fetal heart 5. Ascites - seeks lowest point in abdomen producing bulging flanks that are dull to percussion, umbilicus may protrude, turn pt to side to look for shift

Question 71

increased bowel sounds

Answer 71

diarrhea, early intestinal obstruction

Question 72

decreased then absent bowel sounds

Answer 72

dynamic ileum and peritonitis | listen at least 2 min

Question 73

high pitched tinkling bowel sounds

Answer 73

intestinal fluid | air under tension in dilated bowel

Question 74

rushes of high pitched bowel sounds w/ abdominal cramp

Answer 74

intestinal obstruction

Question 75

hepatic bruit suggests

Answer 75

carcinoma of liver | cirrhosis

Question 76

arterial bruits w/ both systolic and diastolic components suggest

Answer 76

partial obstruction of aorta or large arteries

Question 77

epigastrium bruits suggest

Answer 77

renal artery stenosis or renovascular hypertension

Question 78

abdominal venous hum

Answer 78

rare soft humming noise w/ both systolic and diastolic components - points to increased collateral circulation between portal and systemic system as in hepatic cirrhosis

Question 79

abdominal friction rubs

Answer 79

area grating sounds w/ respiratory variation - indicate inflammation of peritoneal surface of an organ as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct - when systolic bruit accompanies hepatic friction rub, suspect carcinoma of liver

Question 80

abdominal wall tenderness

Answer 80

may originate in abdominal wall when pt raised head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion protected by the tightened muscles) decreases

Question 81

visceral tenderness

Answer 81

usually the discomfort is dull w/ no muscular rigidity or rebound tenderness may be tender to deep palpation: enlarged liver, normal aorta, normal cecum, normal or spastic colon

Question 82

tenderness from disease in chest and pelvis: acute pleurisy

Answer 82

may cause abdominal pain and tenderness - when unilateral can mimic acute cholecystitis or appendicitis - chest signs usually present, rebound tenderness and rigidity less common

Question 83

tenderness from disease in chest and pelvis: acute salpingitis

Answer 83

frequently bilateral, the tenderness of inflamed Fallopian tubes is usually maximal just above inguinal ligaments - rebound tenderness and rigidity may be present - on pelvic exam: motion of cervix and uterus causes pain

Question 84

tenderness of peritoneal inflammation

Answer 84

tenderness more sever than visceral tenderness - muscular rigidity and rebound tenderness are frequently but not necessarily present - generalized peritonitis causes exquisite tenderness throughout the abdomen w/ board-like muscular rigidity

Question 85

local causes of peritoneal inflammation:

Answer 85

acute cholecystitis (Murphy's sign, signs maximal in RUQ) acute pancreatitis (epigastric tenderness and rebound tenderness present, soft abdominal wall) acute appendicitis (RLQ but may be absent early, McBurney's point) acute diverticulitis (confined inflammatory process, LLQ sigmoid colon, may have suprapubic or right sided pain, localized peritoneal signs and tender underlying mass, micro perforation, access, obstruction may occur)

Question 86

Downward displacement of liver by low diaphragm

Answer 86

common when diaphragm flattened and low (COPD) - liver edge may be palpable well below costal margin - percussion reveals low upper edge, vertical span of liver normal

Question 87

Normal variations in liver shape

Answer 87

right lobe may be elongated and easily palpable as it projects downward toward the iliac crest (Riedel lobe)

Question 88

Smooth large liver

Answer 88

- cirrhosis may produce enlarged liver w/ firm, nontender edge (may also be scarred and contracted), also seen w/ hemochromatosis, amyloidosis, lymphoma - suggests inflammation (hepatitis, venous congestion: right heart failure)

Question 89

Irregular large liver

Answer 89

- enlarged liver that is firm or hard w/ irregular edge or surface suggests hepatocellular carcinoma - may be one or more nodules - liver may/may not be tender