When assessing the abdomen for descriptive purposes you want to break it up into 4 or 9 ______ is used as the center 4 quadrants: 9 quadrants:

Umbilicus RLQ, RUQ, LUQ, LLQ Epigastric, Umbilical, Hypogastric or Suprapubic

Palpable structures in the Abdomen Firm narrow tube in LLQ Part of ascending colon; softer wider tube in RLQ (lower margins), below right costal margin Pulsations can normally be seen in thinner person, should be palpable in upper abdomen Pulsations of these may be felt in the lowre quadrants

Sigmoid colon Cecum Liver Abdominal aorta Iliac arteries

When examining organs, you want to move in a _____ motion RUQ ____: is mostly protected under the rib cage cage but the edge can be palpated at the right costal margin ______: which rests against the liver and the duodenum are not palpable ________: can be palpated in very thin individuals with relaxed muscles….not always easy to come by when you are trying to examine an abd _________: you have the , the LUQ is lateral to and behind the stomach, just above the kidney in the left mid axillary line. The tip of the spleen maybe palpable below the left costal margin in a small percentage of people…not common _P_ cannot be detected LLQ _,_ only palpated in bimanual exam _Lower midline_: and normally a pelvic organ in pregnant women can be a palpable abdominal finding RLQ _A_ and _loop_ not palpable ______: in women not palpable

Clockwise RUQ Liver Gallbladder Lower pole of kidney Upper midline: Xyphoid process, aorta LUQ Spleen Pancreas LLQ Sigmoid colon, ovaries bladder, uterus RLQ Appendix and bowel loop Ovaries

History GI Abdominal _____, acute vs. chronic I______ N___/V____ A_____, early _____ D_____, or O______ Change in bowel _____ D____, C_____ J_____ _MH _MH

pain Indigestion Nausea/Vomiting Anorexia, satiety Dysphagia, Odynophagia function Diarrhea, Constipation Jaundice PMH FMH

History Urinary and Renal S_____ pain Dys____, urgency, frequency H_____, decreased stream in men ____uria or ___turia Urinary ______ ___turia Kidney or ____ pain Uretral ____ PMH

Suprapubic Dysuria Hesitancy Polyuria, Nocturia Incontinence Hematuria Flank Colic

1. Acute, subacute, chronic pain: acute \ _ _m 2. Abdominal ______: and hospitalizations for abdominal or bladder issues 3. Current ______: if a person says that have no GI issues but are taking ____ or ____ then you have a clue that at one time they had _____..ask about ___ they take the medication 4. Fam hx of _______: ask about colon____, screening starts at age ___ unless fam hx then age ___, Colorectal cancer screening 5. _______: Any change in appetite? L___ of appetite? Any change in ____? How much gained or lost? Over what time period? Is the weight loss due to ____? Dy_____. Any difficulty _____? When did you first notice this? 6. Food ______: Are there any foods you cannot eat? What happens if you do eat them: ____ reaction, h_____, belching, bloating, indigestion? Do you use ____? Any abdominal pain? Please ____ to it. 7. Nausea/vomiting: Any nausea or vomiting? How often? How much comes up? What is the color? Is there an odor? Is it bloody? Is the nausea and vomiting associated with colicky pain, diarrhea, fever, chills? What foods did you eat in the last 24 hours? Where? At home, school, restaurant? _Is there anyone in the family: ?_ 8. _____ habits: How often do you have a bowel movement? What is the color? Consistency? Any diarrhea or constipation? How long? Any recent change in bowel habits? Use laxatives? Which ones? How often do you use them? 9. Past ________ history. Any past history of gastrointestinal problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia? Ever had any operations in the abdomen? Please describe. Any problems after surgery? Any abdominal x-ray studies? How were the results? 10. ________: What medications are you currently taking? 11. _______ – How much would you say you drink each day? Each week? When was you last alcoholic drink? 12. _______: Do you smoke? How many packs per day? For how long? 13. _______________: Now I would like to ask you about your diet. Please tell me all the food you ate yesterday, starting with breakfast._

1. 4, 1-3 months, \>/- 4 months 2. Surgery 3. Medications: Prevacid, Prilosec, gastritis, why 4. Colon CA: colonscopy, 50, 45 5. Appetite: Loss, weight, diet, Dysphagia, swallowing 6. Intolerance: Allergic, heartburn, antacids, point 7. with same symptoms in last 24 hrs? 8. Bowel 9. Abdominal 10. Medications 11. Alcohol 12. Cigarettes 13. Nutritional Assessment

Colorectal Cancer Screening High Risk _____ hx of colorectal cancer or adenoma _____ hx with colorectal cancer or adenoma Personal hx of _____ to abdomen or pelvis to treat prior CA PMH of (2) ___MH of familial adenomatous _____; hereditary __-polposis colorectal CA

High Risk Personal First degree relative Radiation UC or Crohns FMH: polyposis, non-polyposis

Colorectal Screening Average Risk Age ___-___ Age ___-___ based on individual \> ___ do not screen, competing causes of mortality preclude, mortality benefit ____ based test q__-__ years ____ exam q__-__ years

Average Risk 45-75 76-85 \>85 Stool, 1-3 Visual, 5-10

Colorectal Cancer Screening In your history if you find the person is at high risk for colorectal cancer than you are going to make sure they are followed by a _________ and as their PCP during their annual exam you are going to make sure that you evaluate to see if they are up to date on their screening Greater than ___ if not screened need to outweigh the benefits to the risk, of colonoscopy, polyps take about ___ years to turn into cancer FIT DNA stool sample once every _- yrs Virtual colonoscopy CT colonoscopy_ Should be screened __ -__

Gastroenterologist 76, 10 1-3 45-75

Visceral Pain Occurs from _______ or stretching of ____ ______ to localize ______ can stimulate visceral pain fiber _____ in quality Described as g____, b_____, c_____ or a_____ _____ can be associated with sweating, pallor, n/v

distention, organs Difficult Ischemia Varies gnawing, burning, cramping, aching Severe

Parietal Pain ______ in the parietal _______ It is _____ aching pain More _____ than visceral Located over affected ______ ______ with movement or coughing Patient prefers to lie ____

Inflammation, peritoneum steady severe structure worse still Visceral periumbilical pain may signify acute appendicitis from distention of the inflamed appendix, which gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum Visceral pain- comes from structure in the abdomen. Peritoneum can get worse and lead to parietal pain.

Referred Pain When a person gives a history of abdominal pain, the pains location may not necessarily be directly over the involve organ. This is because the human brain has no ___ ____ for internal organs. Rather, the pain is often referred to a site where the organ was located in ____ development. Although the organ ______ during fetal development, its _____ persist in referring sensations from the _____ location. Right shoulder/scapula: (2) Left scapula: ______ along with lower thoracic Back/ right flank pain: _______

felt image fetal, migrates, nerves, former liver, duodenal ulcer Pancreatitis, Cholecystitis

RUQ Differentials Acute ______, _____ colic Acute _____ Perforated _____ ulcer

cholecystitis, biliary Hepatitis Duodenal

RLQ Differentials A_______ Small Bowel ______ ____ Calculi _______ enteritis Female (3)

Appendicitis SBO Renal Mesenteric PID, Ectopic Pregnancy, Ovarian Torsion

LUQ Differentials Acute ______ ____ ulcer ____tritis _____ enlargement

Pancreatitis Gastric Gastritis Splenic

LLQ Differentials D______ C______ Bowel ______ ____ calculi _____ enteritis Female (3) When a patient is describing their abdominal pain, you will start to build a differential in your mind based on the location and history of the pain Mesenteric adenitis, inflammation of the mesenteric lymph nodes usually caused by viral or bacterial infection, most commonly occurs on the ____ side and can often mimic an ______, ___ is performed to eval the nodes as well as the appendix

Diverticulitis Constipation Bowel Obstruction Renal Mesenteric PID, Ectopic Pregnancy, Ovarian Torsion right, appendicitis, US

Periumbilical _____enteritis _____citis ____ bowel obstruction

Gastroenteritis Appendicitis Early

Suprapubic Bladder _____ C_____ Bladder _____ P______

Bladder infetion Constipation CA Prostatitis

Diffuse Pain Acute _______ Mesenteric ______ ____enteritis Dissecting or rupture _____ ______ obstruction

Pancreatitis thrombosis Gastroenteritis aneurysm Intestinal

Abdomen Flashcards by Felita Salim

When assessing the abdomen for descriptive purposes you want to break it up into 4 or 9

______ is used as the center
4 quadrants:
9 quadrants:

Umbilicus
RLQ, RUQ, LUQ, LLQ
Epigastric, Umbilical, Hypogastric or Suprapubic

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Palpable structures in the Abdomen

Firm narrow tube in LLQ
Part of ascending colon; softer wider tube in RLQ
(lower margins), below right costal margin
Pulsations can normally be seen in thinner person, should be palpable in upper abdomen
Pulsations of these may be felt in the lowre quadrants

Sigmoid colon
Cecum
Liver
Abdominal aorta
Iliac arteries

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When examining organs, you want to move in a _____ motion

RUQ
- ____: is mostly protected under the rib cage cage but the edge can be palpated at the right costal margin
- ______: which rests against the liver and the duodenum are not palpable
- ________: can be palpated in very thin individuals with relaxed muscles….not always easy to come by when you are trying to examine an abd
- _________: you have the , the
LUQ
- is lateral to and behind the stomach, just above the kidney in the left mid axillary line. The tip of the spleen maybe palpable below the left costal margin in a small percentage of people…not common
- P cannot be detected
LLQ
- , only palpated in bimanual exam
- Lower midline: and normally a pelvic organ in pregnant women can be a palpable abdominal finding
RLQ
- A and loop not palpable
- ______: in women not palpable

Clockwise

RUQ
- Liver
- Gallbladder
- Lower pole of kidney
- Upper midline: Xyphoid process, aorta
LUQ
- Spleen
- Pancreas
LLQ
- Sigmoid colon, ovaries
- bladder, uterus
RLQ
- Appendix and bowel loop
- Ovaries

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__________ organs are the kidneys
______ by the rib cage (______ portions)
The costovertebral angle is made up of the _____ rib and the _______ process
Helps assess for kidney ______.

Posterior
Protected, upper
12th, vertebral
tenderness

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History GI

Abdominal _____, acute vs. chronic
I______
N___/V____
A_____, early _____
D_____, or O______
Change in bowel _____
D____, C_____
J_____
_MH
_MH

pain
Indigestion
Nausea/Vomiting
Anorexia, satiety
Dysphagia, Odynophagia
function
Diarrhea, Constipation
Jaundice
PMH
FMH

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History Urinary and Renal

S_____ pain
Dys____, urgency, frequency
H_____, decreased stream in men
____uria or ___turia
Urinary ______
___turia
Kidney or ____ pain
Uretral ____
PMH

Suprapubic
Dysuria
Hesitancy
Polyuria, Nocturia
Incontinence
Hematuria
Flank
Colic

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Acute, subacute, chronic pain: acute < __ wks, subacute _-_m, chronic > _m
Abdominal ______: and hospitalizations for abdominal or bladder issues
Current ______: if a person says that have no GI issues but are taking ____ or ____ then you have a clue that at one time they had _____..ask about ___ they take the medication
Fam hx of _______: ask about colon____, screening starts at age ___ unless fam hx then age ___, Colorectal cancer screening
_______: Any change in appetite? L___ of appetite? Any change in ____? How much gained or lost? Over what time period? Is the weight loss due to ____? Dy_____. Any difficulty _____? When did you first notice this?
Food ______: Are there any foods you cannot eat? What happens if you do eat them: ____ reaction, h_____, belching, bloating, indigestion? Do you use ____? Any abdominal pain? Please ____ to it.
Nausea/vomiting: Any nausea or vomiting? How often? How much comes up? What is the color? Is there an odor? Is it bloody? Is the nausea and vomiting associated with colicky pain, diarrhea, fever, chills? What foods did you eat in the last 24 hours? Where? At home, school, restaurant? Is there anyone in the family: ?
_____ habits: How often do you have a bowel movement? What is the color? Consistency? Any diarrhea or constipation? How long? Any recent change in bowel habits? Use laxatives? Which ones? How often do you use them?
Past ________ history. Any past history of gastrointestinal problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia? Ever had any operations in the abdomen? Please describe. Any problems after surgery? Any abdominal x-ray studies? How were the results?
________: What medications are you currently taking?
_______ – How much would you say you drink each day? Each week? When was you last alcoholic drink?
_______: Do you smoke? How many packs per day? For how long?
______________: Now I would like to ask you about your diet. Please tell me all the food you ate yesterday, starting with breakfast.

4, 1-3 months, >/- 4 months
Surgery
Medications: Prevacid, Prilosec, gastritis, why
Colon CA: colonscopy, 50, 45
Appetite: Loss, weight, diet, Dysphagia, swallowing
Intolerance: Allergic, heartburn, antacids, point
with same symptoms in last 24 hrs?
Bowel
Abdominal
Medications
Alcohol
Cigarettes
Nutritional Assessment

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Colorectal Cancer Screening

High Risk
- _____ hx of colorectal cancer or adenoma
- _____ hx with colorectal cancer or adenoma
- Personal hx of _____ to abdomen or pelvis to treat prior CA
- PMH of (2)
- ___MH of familial adenomatous _____; hereditary __-polposis colorectal CA

High Risk
- Personal
- First degree relative
- Radiation
- UC or Crohns
- FMH: polyposis, non-polyposis

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Colorectal Screening

Average Risk
- Age ___-___
- Age ___-___ based on individual
- > ___ do not screen, competing causes of mortality preclude, mortality benefit
- ____ based test q__-__ years
- ____ exam q__-__ years

Average Risk
- 45-75
- 76-85
- >85
- Stool, 1-3
- Visual, 5-10

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Colorectal Cancer Screening

In your history if you find the person is at high risk for colorectal cancer than you are going to make sure they are followed by a _________ and as their PCP during their annual exam you are going to make sure that you evaluate to see if they are up to date on their screening
Greater than ___ if not screened need to outweigh the benefits to the risk, of colonoscopy, polyps take about ___ years to turn into cancer
FIT DNA stool sample once every - yrs Virtual colonoscopy CT colonoscopy
Should be screened __ -__

Gastroenterologist
76, 10
1-3
45-75

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Abdominal Pain

Take a careful, orderly _____
_____ of the pain: have patient describe in ___ words
_____ of pain: have patient _____ to the pain
______ of the pain
Factors p_____ and ______ abdominal pain- f___?
Patient assessment of pain ______– 0-10
Assess if the patient looks as uncomfortable as they are rating the pain

history
Character, own
Location, point
Radiation
precipitating, relieving, food?
severity

Pain is subjective…so if the person is rating themselves a 9/10 yet they seem perfectly comfortable, you will want to ask about their pain tolerance…have they had a great deal of pain in the past, what has worked, have you been told in the past that you have a high or low pain tolerance. People will often tell you…ya I broke my arm once and I did not realize it for a day or so when I still couldn’t use it…

Remember our oldcart (Onset Location Duration Context Associated symptoms Radiation of pain, timing)

Have them point to it.

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Visceral Pain

Occurs from _______ or stretching of ____
______ to localize
______ can stimulate visceral pain fiber
_____ in quality
Described as g____, b_____, c_____ or a_____
_____ can be associated with sweating, pallor, n/v

distention, organs
Difficult
Ischemia
Varies
gnawing, burning, cramping, aching
Severe

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Parietal Pain

______ in the parietal _______
It is _____ aching pain
More _____ than visceral
Located over affected ______
______ with movement or coughing
Patient prefers to lie ____

Inflammation, peritoneum
steady
severe
structure
worse
still
Visceral periumbilical pain may signify acute appendicitis from distention of the inflamed appendix, which gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum*
Visceral pain- comes from structure in the abdomen. Peritoneum can get worse and lead to parietal pain.*

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Referred Pain

Felt in ____ sites:
- Which are _____ at approximately the ___ spinal levesl as the disordered structure
Develops as pain _____
Usually _____

distant
- innervated, same
intensifies
localized

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Referred Pain

When a person gives a history of abdominal pain, the pains location may not necessarily be directly over the involve organ. This is because the human brain has no ___ ____ for internal organs.
Rather, the pain is often referred to a site where the organ was located in ____ development. Although the organ ______ during fetal development, its _____ persist in referring sensations from the _____ location.
Right shoulder/scapula: (2)
Left scapula: ______ along with lower thoracic Back/ right flank pain: _______

felt image
fetal, migrates, nerves, former
liver, duodenal ulcer
Pancreatitis, Cholecystitis

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RUQ Differentials

Acute ______, _____ colic
Acute _____
Perforated _____ ulcer

cholecystitis, biliary
Hepatitis
Duodenal

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RLQ Differentials

A_______
Small Bowel ______
____ Calculi
_______ enteritis
Female (3)

Appendicitis
SBO
Renal
Mesenteric
PID, Ectopic Pregnancy, Ovarian Torsion

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LUQ Differentials

Acute ______
____ ulcer
____tritis
_____ enlargement

Pancreatitis
Gastric
Gastritis
Splenic

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LLQ Differentials

D______
C______
Bowel ______
____ calculi
_____ enteritis
Female (3)
When a patient is describing their abdominal pain, you will start to build a differential in your mind based on the location and history of the pain*
Mesenteric adenitis, inflammation of the mesenteric lymph nodes usually caused by viral or bacterial infection, most commonly occurs on the ____ side and can often mimic an ______, ___ is performed to eval the nodes as well as the appendix*

Diverticulitis
Constipation
Bowel Obstruction
Renal
Mesenteric
PID, Ectopic Pregnancy, Ovarian Torsion

right, appendicitis, US

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Epigastric

_ _ D
G____
Abominal ____ _____
_____ pain

PUD
GERD
AAA
Pancreatic

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Periumbilical

_____enteritis
_____citis
____ bowel obstruction

Gastroenteritis
Appendicitis
Early

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Suprapubic

Bladder _____
C_____
Bladder _____
P______

Bladder infetion
Constipation
CA
Prostatitis

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Diffuse Pain

Acute _______
Mesenteric ______
____enteritis
Dissecting or rupture _____
______ obstruction

Pancreatitis
thrombosis
Gastroenteritis
aneurysm
Intestinal

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**Associated Sx with Pain** **(3)**

**Nausea** **Vomiting** **Anorexia**

**Nausea** * Nausea: * Assocaited with disorders of the ____ and ____ especially _____ gastric emptying * _____ symptoms - perspiration, salivation, skin pallor and vagal discharge that may cause _____ and \_\_\_\_\_ * Ask about? Association with f\_\_\_, m\_\_\_\_\_, stooling \_\_\_\_\_, change in \_\_\_\_, du\_\_\_\_

* Unpleasant feeling or sensation that person will vomit * stomach, duodenum, delayed * Autonomic, bradycardia, hypotension * food, medicine, pattern, diet, duration

Nausea * *You are going to ask about how ____ you feel nauseous is it related to certain \_\_\_\_* * *With vomiting, ask about what ____ it is, how often it occurs how much is coming up…what does it ____ like, ____ odor present with sbo or gastrocolic fistula,* * *Is there _____ in it?..gastric juice is clear and mucoid, small amounts of yellow or greenish bile is common, brown or black "\_\_\_\_\_ \_\_\_\_\_\_” blood altered by gastric juices* * *\_\_\_\_\_\_\_\_\_ associated with esophageal or gastric varices, gastritis, peptic ulcer disease (frank red)* * *Ask about \_\_\_\_\_, last time urinated, color, remember that in diabetic ketoacidosis, anorexia, n/v are present, obtaining urine to assess for _______ for dehydration and \_\_\_\_\_for diabetes a good idea*

* *often, foods* * *color, smell, fecal* * *blood, "coffee ground"* * *Hematemesis* * *dehydration, ketones, glucose*

**Vomiting** * Ask about association with f\_\_\_\_, d\_\_\_\_, s\_\_\_ symptoms * Is it the ____ symptom? * If Emesis is B\_\_\_\_\_, F\_\_\_\_, F\_\_\_\_\_, B\_\_\_\_\_, C\_\_\_\_\_ G\_\_\_\_\_ * Association with pain * Pain prior to vomiting, concern for: * Pain after vomiting: non-surgical emergency such as: * Gastric acid with make food or milk curl and smell \_\_\_* * Bilious emesis with the first episode is concern for \_\_\_\_\_\_, 2-3 hours after forceful wretching is \_\_\_\_* * Food with emesis when the food was consumed 12 hours ago or longer, concern for: \_\_\_\_\_\_\_\_\_* * \_\_\_\_ may come from a tear from mucosal surface or maybe a bleed from an ulcer* * Coffee grounds _____ of blood by gastric \_\_\_\_*

* fever, diarrhea, systemic * only * Bilious, Food, Fecal, Blood, Coffee Ground * Pain * Acute Abdomen * Acute gastroenteritis * foul* * obstruction, common* * delayed gastric emptying* * Blood* * digestion, acid*

**Anorexia** * ****Anorexia or loss of appetite is important but _____ symptom * Seen with neo\_\_\_\_, de\_\_\_\_, anorexia nervosa, r\_\_\_\_ failure, viral \_\_\_\_\_, m\_\_\_\_, ____ diseases * _Is it related to food_ (e.g. ____ deficiency) or reluctance to eat because of anticipated \_\_\_\_\_ * Ask about early \_\_\_\_ * seen with \_\_\_\_\_ * Ask about abdominal \_\_\_\_\_ * Gastric _____ obstruction, gastric \_\_\_\_, _____ meds, diabetic gastro\_\_\_\_\_ * Is important but nonspecific* * Often related to some type of food \_\_\_\_\_\_* * Is it because you're getting full very \_\_\_\_? Like after 2-3 bites* * Or do you feel your abdomen is ____ or full?*

* nonspecifc * neoplasm, depression, renal, hepatitis, medications, chronic * _intolerance_ (eg lactase), pain * Satiety * Hepatitis * Fullness * outlet, CA, anticholinergics, gastroparesis * intolerance* * quickly* * distended*

**Swallowing** * **Dysphagia** * ****Food seems to ____ "not go down right" * Suggests ______ disorder or ______ anomalies, can be __ or \_\_\_\_ * Ask about ____ of food associated with dysphagia * Solids that progress to _____ concern for _____ cancer

* **Dysphagia** * ****stick * motility, structural, CA or GERD * types * liquids, esophageal

**Swallowing** * **Odynophagia** * ****\_\_\_\_\_ with swallowing * Can be medication induced from (2) * Consider esophageal \_\_\_\_\_\_ * *Mouth ______ can cause or they swallow something too \_\_\_*

* **Odynophagia** * ****Pain * NSAIDs or ASA * Ulceration * *dryness, big*

**Bowel Function** * Ask about f\_\_\_\_\_, c\_\_\_\_, c\_\_\_, st\_\_\_\_, __ of constipation or diarrhea, ____ in bowel function, is it associated with abdominal \_\_\_? * If complaining of diarrhea; ask about recent t\_\_\_\_, f\_\_\_\_, m\_\_\_\_ exposure to \_\_\_\_, s\_\_\_\_ symptoms * Diarrhea- ask about presence of m\_\_\_\_, occurs at \_\_\_\_, is it g\_\_\_ or o\_\_\_, does the stool f\_\_\_\_ * Any blood in stool (2) * Is the blood in stool or on the toilet paper - on paper consider \_\_\_\_\_\_

* frequency, consistency, color, straining, hx, change, pain * travel, food, medications, ill, systemic * mucus, night, greasy, oily, float * Melena or Hematochezia * hemorrhoids

Bowel Function * *\_\_\_ color stools ____ the excretion of bile into the intestine, occur with \_\_\_\_\_* * *_Acute diarrhea \_\_\_weeks, Chronic diarrhea \_\_\_weeks or more_* * *Acute usually \_\_\_\_\_\_* * *Chronic usually non-infectous and is related to (2) _Changes in stooling related to abdominal pain can mean \_\_\_\__* * *Diarrhea with mucus can be \_\_\_\_\_\_cause* * *Oily or frothy can mean ____ diarrheal stools known as streatorrhea, due to malabsorptions as seen in ____ disease, ______ insufficiency, small bowel _____ overgrowth* * *Black tarry stool means _____ …black stool can also be from ____ supplements or use of \_\_\_\_\_* * *_Bright red blood in stool = \_\_\_\_\_\_\_\__*

* Grey, lack, bile, hepatitis * 2, 4 * infectious * UC or Crohns, IBS * inflammatory * fatty, celiac, pancreatic, bacterial * melena, iron, bismuth * hematochezia

**Jaundice** * Extrahepatic * ____ obstruction * _____ cell * Intrahepatic * _____ hepatitis * _____ hepatitis * D\_\_\_\_ * S\_\_\_\_ * M\_\_\_\_\_\_\_

* Extrahepatic * Biliary * Sickle * Intrahepatic * Viral * Alcoholic * Drugs * Sepsis * Malignancy

**Jaundice** * Risk Factors for liver disease * Hepatitis A: * Hepatits B: * Hepatitis C: * ____ use * M\_\_\_ * ____ surgery or disease * Remember other diseases besides the A, B and C can cause hepatitis, such as ___ ior in gallbladder any surgery or illness can cause ______ obstruction* * Normal bili = \_\_\_-\_\_\_ mg/dl* * Serum bili needs to be \_\_-\_\_\_ mg/dl before jaundice is clinical 1st visible in the \_\_\_\_*

* Risk factors * recent travel with poor sanitation * expsoure to infectious bodily fluids * IV drug use, blood transfusion * Alcohol * Meds * Gallbladder ## Footnote * EBV, extrahepatic* * 0.1-1.2* * 2-3, sclera*

**Urinary Tract** * Ask about difficulty \_\_\_\_\_, f\_\_\_\_\_, dy\_\_\_\_, u\_\_\_\_, n\_\_\_\_, altered urinary \_\_\_\_, associated \_\_\_\_ * H\_\_\_\_\_ * K\_\_\_\_ * Trouble with in\_\_\_\_\_ * *Kidney pain can be _____ dt distention of kidney such as in acute ____ or it can be ____ with ____ of ureter from s\_\_\_ or \_\_\_\_*

* passing, frequency, dysuria, urgency, nocturia, stream, pain * Hematuria * Kidney * Incontinence * *visceral, pyelonephritis, parietal, obstruction, stones, clots*

Incontinence * **Stress:** increased abdominal \_\_\_\_\_, increases bladder pressure to exceed urethral sphincter \_\_\_\_, dt ___ urethral sphincter tone or poor ____ of bladder * **Urge**; (\_\_\_\_\_ bladder) urgency is immediately followed involuntary ____ dt uncontrolled ____ muscle * **Overflow**: n\_\_\_\_\_ disorder or _____ limits emptying until bladder is over distended * **Functional:** impaired \_\_\_\_\_, m\_\_\_\_, or mo\_\_\_\_

* pressure, tone, poor, support * overactive, leaking, detrusor * neurologic, obstruction * cognition, mask, mobility

**Physical Exam** * Inspect abdomen * De\_\_\_\_\_ * Co\_\_\_\_ * S\_\_\_ and s\_\_\_\_\_ * E\_\_\_\_ veins * Visible p\_\_\_\_\_\_ * Visible p\_\_\_\_\_\_ * Hair \_\_\_\_\_\_ * Evidence of \_\_\_\_\_\_ * Auscultate * ____ sounds * A\_\_\_\_\_ (4) * Percuss * (3) * Palpate * (3) *\_\_\_\_\_\_\_ before percussion and palpation can change \_\_\_\_\_, which would give a ___ interpretation of bowel and ____ sounds - also if patient is in pain, palpation will ___ exam*

* Inspect * Demeanor * Contour * Scars, Striae * Engorged * Peristalsis * Pulsation * Distribution * Hernia * Auscultate * Bowel * Arteries (Abdominal aorta, Renal, Iliac, Femoral) * Percuss * Abdomen, Liver, Spleen * Palpate * Abdomen, Liver, Spleen ## Footnote *Auscultation, peristalsis, false, vascular, end*

**Inspection** * *\_\_\_\_ pulse in epigastric area is \_\_\_\_\_, especially in ____ persons* * *The amplitude is increased with \_\_\_\_\_, ____ pulse pressure, or t\_\_\_\_\_ aorta. If you feel a \_\_\_\_, get an \_\_\_\_\_.* * *Feeling a pulsatile mass raises the question of an ____ or a ___ struture adjacent to the aorta. A ____ suggests aneurysm. ____ is diagnostic* * *Visible peristalsis (normal in \_\_\_\_). Borborygymi (intenstinal ____ heard without stethoscope) and visible peristalsis are highly suggestive of ____ associated with pain* * *During inspection you can ask pt to \_\_\_\_, evaluate for p\_\_\_\_ or appearance or appearance of ____ indicating hernia*

* *Aortic, normal, thin* * *aneurysm, widened, tortuous. murmur, US* * *Aneurysm, solid. murmur. US* * *thin, rumbling, obstruction* * *cough, pain, buldges*

**Excess Abdominal Hair in Females** *Causes (4)*

* *Polycystic ovarian syndrome* * *Cushings* * *Adrenal Problems* * *Medications*

**Striae in Obese Female** * *Stretch marks* * *Are they dangerous?* * *Can be seen post ____ or \_\_\_\_\_* * *From ____ \_\_\_\_\_ of skin* * *\_\_\_\_\_ quality* * *Differ from Cushings becuase they will have a \_\_\_/\_\_\_/\_\_\_ hue*

* *Benign* * *Pregnancy, Obesity* * *Rapid expansion* * *Silver* * *pink/purplish/blue*

**Hernias** * **\_\_\_\_** hernias result from ____ in the abdominal wall * Hernias are typically classified by e\_\_\_\_ and l\_\_\_\_ * Incisional hernias result from prior \_\_\_\_\_ * Epigastric, Umbilical, Femoral, and Inguinal are \_\_\_\_\_

* Ventral, defects * etiology, location * surgery * spontaneous

Hernias * *Localized bulges in the abdominal wall include ventral hernia (defects in the wall through which tissue protrudes) and subcutaneous tumors such as \_\_\_\_\_.* * ***Umbilical** hernias protrude through a _____ umbilical \_\_\_\_\_. They are most common in _____ but also occur in adult. Usually close spontaneously within \_\_-\_\_\_ years in infants.* * ***Incisional*** *hernias protrude through an operative \_\_\_\_. By palpation, note the length an width of the defect in the abdominal wall. A \_\_\_\_defect, through which a large hernia has passed, has a _____ risk of ______ than a large defect.* * ***Epigastric** hernia small midline protrusion through a defect in the ____ \_\_\_, somewhere ____ the xiphoid process and the umbilicus. With the patient’s head and shoulder raise, look for it and run your fingerpad down the linea alba to feel it* * *You can assess for possible hernias by having the patient _____ while they are in the _____ position, the increased abdominal pressure will cause a bulging or a lump to appear in any of the areas noted above*

* *lipomas* * *defect, ring, infants, 1-2* * *scare, small, greater, complication* * *linea alba, between* * *cough, supine*

**Inguinal and Femoral Hernias** * *Femoral hernia: occurs ____ the inguinal ligament* * *Inguinal hernia: occurs ___ the inguinal ligament* * *Female inguianal and femoral hernias are much ____ to identify and often have to be evaluated by \_\_\_\_\_*

* *below* * *above* * *harder, US*

**Lipomas** * **\_\_\_\_\_\_ tumors** * **B\_\_\_\_\_ f\_\_\_\_ tumors** * Size? * How do they feel? * Can they move? * *In order to differentiate between lipoma from hernia* * *Look at the _____ and then try to \_\_\_\_\_\* it* * *If you can reduce it then it is a \_\_\_\_\_* * *They are benign but has ____ concerns so they can be ____ resected*

* **Subcutaneous** * **Benign fatty** * small or large * soft and lobulated * Moveable under the skin * *location, reduce* * *Hernia* * *cosmetic, surgically*

**Auscultate Bowel Sounds** * *Use ____ of stethescope bc bowel sounds are relatively ___ pitched* * *Begin in _____ bc bowel sounds are always ____ here normally (@ _____ valve)- this is usually sufficient.* * *Hyperactive bowel sounds heard in \_\_\_\_\_\_* * *Hypoactive bowel sounds heard in (3)* * *Must listen for \_\_-\_\_ min before saying there are no bowel sounds*

* *diaphragm, high* * *RLQ, present, ileocecal* * *Gastroenteritis* * *Intestinal obstruction, paralytic ileus, peritonitis* * *2-5*

**Auscultate Vascular Sounds** Where and What are we assessing?

Vascular Sounds * *Presence of any vascular sounds? (\_\_\_\_)? \_\_\_\_, ____ sound* * *Always listen in people with \_\_\_\*\** * *Arterial bruits with both systolic and diastolic components suggest:* * *Epigastric bruit in only systole may be \_\_\_\_\_, Partial occlusion of the ____ artery may cause and explain HTN*

* *bruits, whooshing, blowing* * *HTN\** * *partial occlusion of the aorta or large arteries* * *normal, renal*

Other Abdominal Sounds * *If you suspect a liver tumor, gonococcal infection, or splenic infart: listen over the ____ and ____ for friction ___ or venous \_\_\_\_. Both are \_\_\_* * *Venous hum = soft hum with ___ and ____ component - indicates increased collateral _____ between ____ and ____ venous systems as in hepatic \_\_\_\_\_* * *Friction rubs are ____ sounds with respiratory _____ - indicates _____ of the peritoneal surface of an organ from a liver tumor, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infart*

* *liver, spleen, rubs, hum, rare* * *systolic, diastolic - circulation, portal, systemic, cirrhosis* * *grating, variation, inflammation*

**Percuss for Tympany/Dullness** * *\_\_\_\_\_\_: should predominate bc ___ in intestines ___ when person is supine* * *Note any large areas of \_\_\_\_\_\_: underlying ___ or ____ organ, _____ uterus, ovarian \_\_\_\_, ____ bladder, ____ liver or spleen* * *Dullness in both flanks prompts eval for?* * *In a protuberant abdomen - note where abdominal _____ changes from ____ to ____ of solid posterior structures* * *Obesity = scattered \_\_\_\_\_* * *Ascites = ____ on both sides of the \_\_\_\_\_\_*

* *Tympany, air, rises* * *dullness, mass, enlarged organ, pregnant, tumor, distended, enlarged* * *Ascites* * *tympany, resonant to dullness* * *dullness* * *dullness, flanks*

**Shifting Dullness with Ascites** * *If you suspect ascites dt a protuberant belly - you should assess for ____ dullness* * *In ascites, fluid characteristically ____ with gravity, whereas a gas filled bowel rises. Percussion gives a dull note in dependant abdomen* * *To test for shifting dullness - after ____ the borders of tmpany and dullness, ask the patient to ___ to one side. Percuss and mark the borders again.* * *In a person without ascites, the borders between tympany and dullness usually?* * *In ascites, dullness ____ to the more ____ side, while tympany shifts to the \_\_\_\_.*

* *shifting* * *sinks* * *mapping, turn* * *stay constant* * *shifts, dependent, top*

**Fluid Wave Test** * Fluid wave - have patient or assistant put hands down ____ of abdomen (this helps ___ transmission of wave through \_\_\_\_) * ___ one flank with fingertips, feel ____ flank for an \_\_\_\_\_. * Impulse suggests ______ - must be large

* midline, stops, fat * Tap, opposite, impulse * Ascites

**Percussion of Liver Span** * *Liver span - At the ___ \_\_\_\_\_ line start in area of lung _____ and percuss ____ to change to ___ quality* * *\_\_\_ spot* * *Find abdominal tympany and percuss \_\_. Mark change from tympany to ___ (or keep going down from previous mark) \*s/b \_\_-\_\_cm midclavicular line and \_\_-\_\_cm midsternal line* * *If span of liver dullness is increased when liver is ____ such as in (2)\** * *Span of liver dullness is decreased when liver is _____ such as when there is free ___ below the diaphragm.* * *Liver dullness may be displaced downward by a low diaphragm associated with \_\_\_\_\_*

* *Right midclavicular, resonance, down, dull* * *Mark* * *up, 6-12, 4-8* * *enlarged, hepatitis, CHF\** * *small, air* * *COPD*

**Percussion of the Spleen** * *Splenic dullness or enlargement* * *Often spleen is obscured by _____ contents but you may locate it by a ___ note close to the ___ base just behind the ____ mid-axillary line* * *Now percuss in the lowest _____ in the in the left anterior _____ line* * *You should hear tympany (over the stomach). Ask the person to take deep ____ which will make the spleen \_\_\_\_, if the spleen is normal ____ remains* * *If you change from tympany to a dull sound on \_\_\_\_\_\_, this is a ___ splenic percussion sign and indicates \_\_\_\_\_\_\_\_* * *You can detect mild-moderate splenomegaly before the spleen becomes \_\_\_\_\_\_, as in (3)*

* *stomach, dull, rib, left* * *interspace, anxilary* * *breath, rise, tympany* * *inspiration, + , splenomegaly* * *palpable, \*\*mono, malaria, cirrhosis\*\**

**Palpate Abdomen** * Light palpation: * Light palpation you are looking for: * Deep palpation: * Deep palpation you are looking for: * Ask the pt to \_\_\_\_ * Ask them to ____ breath with jaw \_\_\_

* One hand, light gentle motion * tenderness, muscular resistance, guarding * 2 hands, deeper penetrating * identify masses, tenderness, pulsations and any mobility with respiration or pressure from examining hand * relax * mouth, jaw open

**Palpate Abdomen** Notes * *Side note: a very ticklish person, keep person's hand ____ your own, fingers ____ over his or her fingers. People aren't ticklish to themselves* * *Distract: ____ abdominal ___ while palpating; use ____ voice, avoid ___ movements* * *Correlate palpable findings with _________ notes* * *Making sense of what you're feeling is more difficult than it looks. _____ the anatomy and _____ what is under each quadrant as you palpate. Also, remember some structures are _____ palpable* * *Note: mild tenderness over what is normal? Any other tenderness should be investigated* * *Next, after deep palpation for any masses, palpate for specific organs (4)*

* *under, curled* * *ask, hx, soothing, quick* * *percussion,* * *memorize, visualize, normally* * *sigmoid colon (LLQ)* * *Liver, spleen, kidneys, aorta*

**Palpate Kidney for Tenderness** * *Pressure from ____ or a ____ of ____ may produce tenderness due to (2)* * *Use force sufficient to cause ______ but ____ jar in a normal person* * *Usually performed at ___ of thoracic eval prior to have the patient supine*

* *fingertips, thrust of fist, kidney infection, musculoskeletal reason* * *perceptible, painless* * *end*

**Normally Palpable Structures** * *When palpating, a tip to remember is to keep your hand ___ as the patient takes deep _____ to see if you can feel the edge of either the ____ or ____ on your examining hand.*

* *still, inspiration, liver, spleen*

**Palpate Liver** * *Liver - Place your ___ hand under the person's ____ under lower rib cafe and ___ up to support the abdominal contents.* * *Place ____ hand on RUQ with fingers _____ to midline, lateral to muscle* * *Push gently in and up. Then have the person take a deep \_\_\_\_*

* *left, back, lift* * *Right, parallalel* * *breath*

**Palpate Liver** * *You should feel the liver ____ bump your ____ as the diaphragm pushes it ____ during \_\_\_\_\_\_\_* * *It feels like a s\_\_\_\_, sh\_\_\_\_\_, regular surface, may be slightly \_\_\_\_.* * *A liver edge palpated more than \_\_-\_\_cm below the right costal margin indicates \_\_\_\_\_\_\_* * *With inspriration the liver edge is palpable about ___ cm below the right costal margin in the mid clavicular line* * *Note __ below, _____ (hard, nodules), and \_\_\_\_\_\_* * *Firmness or ____ of the liver, bluntness or _____ of its edge and _____ of its contour suggests abnormalities*

* *edge, fingertips, down, inhalation* * *soft, sharp, tender* * *1-2cm, hepatomegaly* * *3cm* * *cm, consistency, tenderness* * *hardness, rounding, irregularity*

**Palpate Liver** * *****Smooth, large nontender =* * *Smooth, large tender =* * *Large irregular liver =*

* *Cirrhosis (may produce firm nontedner edge in enlarged liver)* * *Inflammation such as in hepatitis or venous congestion from R-CHF* * *Malignancy - enlarged liver that is firm or hard and irregular edge, may be one ore more nodules, may or may not be tender*

**Palpate Liver - Hook Method** * *Hooking technique - an _____ method of palpating the liver is to stand at the person's _____ (facing their \_\_\_) and ___ your fingers under the costal margin from above* * *Ask the person to take a deep _____ and assess liver edge that way*

* *alternative, shoulder, feet, hooking* * *breath*

**Smooth, Large Liver** * **\_\_\_\_\_\_** may produce an ____ liver with a \_\_\_, _____ edge * The liver is ___ \_\_\_\_ enlarged in this condition, however, and many other diseases may produce similar findings * An enlarged liver with a smooth, _____ edge suggests _____ as in (3)

* **Cirrhosis**, enlarged, firm, nontender * not always * tender, inflammation * Hepatitis, Venous Congestion, R-sided HF

**Irregular, Large Liver** * An enlarged that is firm or hard AND has an _____ edge or surface suggests \_\_\_\_\_. There may be one or more \_\_\_\_\_. The liver may or may not be \_\_\_\_.

* irregular, malignancy, nodules, may or may not be tender

**Palpate Spleen** * *Is the spleen normally palpable?* * *Must be __ times normal size to be felt* * *\_\_\_ if you can palpate it* * *How do you search for it? Whats the maneuver?* * *Reach your left hand over the _____ and ____ the L side at the lower L rib cage. Lift up for support, place your R. hand obliquely on the ___ with fingers pointed toward \_\_\_\_\_and under the rib margin. Push hand deep under L costal margin and ask pt to take a deep breath. You should feel nothing firm.*

* *NO* * *3x* * *Bad* * *Abdomen, behind, LUQ, axilla*

**Palpate Spleen** * *When palpating the spleen there may be tenderness but not the spleen - felt in patient who have \_\_\_\_* * *Careful not to start too ___ on abdomen..I usually start down closer to the ____ \_\_\_\_ and palpate up towards the left rib cage, as I move I will ask about tenderness or fullness, there have been enlarged spleens that are ____ bc practictioner started too high*

* *mono* * *high, iliac crest, missed*

**Palpate Spleen** * Lie on ___ side * Knee and hip \_\_\_\_ * Take a deep \_\_\_\_ * Palpate for splenic \_\_\_\_ * *If you suspicious for an _______ spleen and do not feel it while the patient is supine, have them lie on the right side, with knee and hips slightly flexed* * *In this position, gravity may bring the spleen ___ and to the \_\_\_\_\_* * *As we discussed last week about evaluating aorta and palpating for size this would be performed now while the pt is supine.* * *(2) organs are also not oftenly felt unless distended or enlarged*

* right * flexed * inspiration * edge * *enlarged* * *forward, right* * *kidneys, bladder*

**Documentation** * Normal: * Abnorma:

* *ROS; Pt denies changes in appetite, food intolerance, loss of weight, n/v/d/c, reports daily soft brown stool without use of laxative or softener, denies abdominal pain, heartburn/indigestion, regurgitation of food* * *PE: Abdomen flat, symmetric, soft, without lesions, scars or striae, abd non-tender, non-distended, bowel sounds present in four quadrants, no hepatosplenomegaly, no CVA tenderness, liver span 8cm right MCL, no inguinal lymphadenopathy*

**Abdominal Pain** **(5)**

**Acute Abdomen/Peritonitis** **Acute Appendicitis** **Cholecystitis** **Acute Pancreatitis** **Acute Diverticulitis**

**Acute Abdomen/Peritonitis** * Cought test * Have pt ____ and identify ___ the pain is * Guarding * ____ of the abdominal wall muscles to guard ____ organs within the abdomen from the pain of \_\_\_\_\_ * Rigidity * Involuntary reflex ______ of the abdominal wall that persists over the entire exam * Rebound * Ask he pt which hurts more when I ____ \_\_ or ___ \_\_ * A positive finding is when?

* Cought test * cough, where * Guarding * Tensing, inflamed, pressure * Rigidity * contraction * Rebound * press in or let go * + if withdrawal produces pain

**Acute Abdomen/Peritonitis** Notes * *An a\_\_\_\_ localized or generalized inflammation of the _____ layer of the abdominal cavity, (\_\_\_\_\_\_) results from _____ contamination after _____ of an abdominal organ, such as the large bowel or the appendix, or the _____ of irritating \_\_\_\_, such as _____ enzymes.* * *Peritonitis requires ____ intervention, including _____ administration and probable \_\_\_\_\_*

* *acute, peritoneal, (peritonitis), bacterial, perforation, release, chemicals, pancreatic enzymes* * *rapid, antibiotic, surgery*

**Acute Abdomen/Peritonitis** * *Clinical findings associated with peritonitis vary, depending on severity of infection but may include* * ***Acute, _____ abdominal pain with _____ tenderness, involuntary \_\_\_\_, and muscle \_\_\_\_\_* * *Pain that eventually _____ to the source of _____ (ex \_\_\_\_\_\_)* * *\_\_\_\_\_ pain to either \_\_\_\_\_\_, at times accompanied by \_\_\_\_\_* * *F\_\_\_\_\_, often as high as ____ F, accompanied by chills, N/V* * *Abdominal \_\_\_\_\_* * *\_\_\_\_\_\_ or ______ bowel sounds* * *Elevated ____ with high \_\_\_\_\_\_\_*

* *Clinical findings* * ***diffuse, rebound, guarding, rigidity* * *localizes, infection (appendicitis)* * *Referred, shoulder, hiccups* * *Fever, 103* * *distension* * *Diminished, absent* * *WBC, neutrophils*

**Presentation of Acute Abdomen: URGENT** * Patient is lying very \_\_\_\_, ___ moving * Pain can be _____ to either \_\_\_\_\_ * F\_\_\_\_ * N\_\_\_\_\_, V\_\_\_\_\_\_ * Abdominal \_\_\_\_\_\_ * Generalized ________ of the _______ layer of the abdominal cavity * Caused by (3)\*

* still, not * referred, shoulder * Fever * Nausea, Vomiting * Distension * inflammation, peritoneal * **Appendicitis, Cholecystitis, Perforated bowel**

**Acute Appendicitis** * ______ of appendix with d\_\_\_\_\_\_ or o\_\_\_\_\_\_ * Peri _____ pain migrating to ____ pain * M\_\_\_\_ c\_\_\_\_\_ to S\_\_\_\_\_ * \_\_/\_\_/\_\_\_\_\_\_ maybe present * Lasts \_\_-\_\_ hours can ___ and go * Evaluate for inflammation by testing (3) signs * Concern for r\_\_\_\_\_ and _____ \_\_\_\_\_\_

* Inflammation, distention, obstruction * umbilical, RLQ * mild cramping - severe * N/V/Anorexia * 4-6, come and go * Psoas, Obturator, Rosving * Rupture, Acute abdomen

**Acute Appendicitis** * *\_\_\_\_\_\_ Point is 2" form the anterior superior iliac crest in a straight line drawn from the umbilicus - where ____ of appendix is attached to the ____ (most _____ location of pain)* * *Psoas: ___ tenderness* * *Rosving sign: pain felt in the ____ when the ____ is \_\_\_\_\_\_* * *Obturator sign: pain in the pt lying ____ when internally and externally _____ the ____ hip* * *\_\_\_ scan*

* *McBurney's, base, cecum, common* * *muscle* * *RLQ, LLQ, palpated* * *supine, rotating, flexed* * *CT*

**Psoas** * *Place hand on \_\_\_\_, raise leg against _______ - pain suggests _____ of psoas muscle by inflamed appendix*

* *thigh, resistance, irritation*

**Obturator** * *\_\_\_\_ patients right thigh at hip, rotate leg ______ at hip - stretches obturator muscle* * *\_\_\_\_ sided pain = ____ obsturator sign, suggesting irritation from inflamed appendix*

* *flex, internally* * *Right, positive*

**Rovsing's Sign** * *Press _____ and evenly in \_\_\_* * *Quickly _____ your hand* * *Pain the _____ considered positive sign*

* *deeply, LLQ* * *withdrawal* * *RLQ*

**Cholecystitis** * **Inflammation of the _______ usually from _____ of the ____ \_\_\_ of the gallbladder** * ****May have history of biliary ____ pain * S\_\_\_\_ a\_\_\_\_ pain in the ____ radiating to ____ or right \_\_\_\_\_ * Jarring ____ breathing ____ pain * Associated with a\_\_\_\_\_, v\_\_\_\_\_, f\_\_\_\_\_

* **gallbladder, obstructing, cystic duct** * ****colic * Steady aching, RUQ, back, scapula * deep, increases * anorexia, vomiting, fever

**Cholecystitis** Notes * *Biliary colic is a term used to describe ______ pain resulting in ____ obstruction of biliary _____ system, usually occurs after \_\_\_\_, especially meals high in ____ as they require increased _____ for the gallbladder to digest* * *\_\_\_\_\_\_\_ are gallstones*

* *intermittent, partial, drainage, meals, fat, enzymes* * *Cholelithiasis*

**Murphy Sign** * Tenderness in \_\_\_\_\_ * Evaluate Murphy's sign * ____ your fingers of your ____ hand under the ____ margin * Ask patient to take a deep \_\_\_\_\_ * Positive sign = * *Murphy's Sign - test for \_\_\_\_\_\_\_\_* * *-hook your left _____ or fingers of ____ hand under costal margin near rectus muscle. Ask pt to deep breathe- a sharp increase in ______ with a sudden ____ in inspiratory effort constitutes a positive Murphy's sign of _____ disease, could be biliary ___ or \_\_\_\_\_\_* * *As you apply pressure to the liver if the gallbladder is inflamed you will see the patient catch his breath or even call out in pain*

* RUQ * Murphy's sign * Hook, right, costal * breath * Tenderness with a sudden stop in inspiratory effort * *cholecystitis* * *thumb, right, tenderness, stop, gallbladder, colic, cholecystiti*

**Acute Pancreatitis** * _______ tenderness, ______ tenderness, abdomen \_\_\_\_ * Pain radiates to the \_\_\_\_\_ * Severe d\_\_\_\_, c\_\_\_\_\_ pain * Worse when _____ better with ____ or ___ position * Associated with \_/\_ * Associated with _____ intake, _____ attack, ____ meal * Abdominal \_\_\_\_\_, _ \_ _ and ____ tenderness * ____ murphy's sign * Can be associated with f\_\_\_\_\_, j\_\_\_\_\_\_\_

* Epigastric, rebound, soft * back * dull, constant * supine, sitting, fetal * n/v * alcohol, previous, heavy * distention, LUQ, epigastric * Negative * fever, jaundice ## Footnote * In many but not all cases, the abdomen is soft - pts are usually in SEVERE dull/constant pain* * The pain of pancreatitis is classivly relieved by sitting up and leaning forward*

**Acute Diverticulitis** * Usually involves s\_\_\_\_ c\_\_\_\_ * Resembles a left sided \_\_\_\_\_\_ * Pain is: * Chang in ____ habits * Abdominal \_\_\_\_\_\_, B\_\_\_\_\_ * F\_\_\_, \_/\_ * Hx of D\_\_\_\_\_\_\_\_ * *Acute diverticulitis* * *Less commonly, abdominal pain that may be mild at first and become worse over several days, possibly fluctuating in intesnity* * *History of diverticulosis =* * *Differential includes _____ adenitis along with _____ cyst for women*

* sigmoid colon * appendicitis * sudden, severe and often located in lower left side * bowel * distention, bloating * Fever, n/v * Diverticulosis * *outpouching of large colon* * *mesenteric adenitis, ovarian cyst*

**Gastroesophageal Reflux** * Impaired esophageal \_\_\_\_\_ * Incompetent esophageal \_\_\_\_\_ * H. \_\_\_\_\_/ H\_\_\_\_\_ * ____ or ____ pain * B\_\_\_\_, gn\_\_\_\_\_, _____ of food * Aggravated by ____ over, ____ \_\_\_ after eating * Risk factors (3) * Risk for ______ esophagus = esophageal \_\_

* motility * sphincter * H. Pylori/Hernia * Epigastric, Chest * Burning, gnawing, regurgitation * bending, lying down * Smoking, Alcohol, Fatty foods * Barrett's = CA

**Peptic Ulcer Disease** * ______ or \_\_\_\_\_\_ * _ \_\_\_\_\_ often present * Prolonged ____ or ____ use * ____ pain radiating to \_\_\_\_ * G\_\_\_\_\_, b\_\_\_\_\_ aching, pressing or ____ like pain * Approximate associations with food * Gastric = worse ___ eating * Duodenal = worse ____ eating, pain wakes at \_\_\_\_, i\_\_\_\_\_\_

* Gastric, Duodenum * H. Pylori * NSAID, Aspirin * Epigastric, back * Gnawing, burning, hunger * Pain associations w food * with * after, night, intermittent

GERD and PUD Notes * *GERD: Also maybe associated with d\_\_\_\_\_, chronic ____ due to epigastric context ____ up and irritating \_\_\_\_, sore \_\_\_\_\_* * *PUD: N/V, belching, bloating, heartburn more so with \_\_\_\_\_. Weight loss in \_\_\_\_\_\_* * *Gastric usually over \_\_\_\_* * *Duodenal usually \_\_-\_\_\_*

* *dysphagia, chronic cough, reflexing, trachea, sore throat* * *duodenal, duodenal* * *50* * *30-60*

**Cystitis/Pyelonephritis** * Bacterial infection * Most commonly: * Urinary symptoms such as * D\_\_\_\_\_ * U\_\_\_\_\_ * F\_\_\_\_\_\_ * ______ void * ______ pain * Can ascend up the ureter and cause * _____ pain * F\_\_\_\_\_ * \_/\_ * M\_\_\_\_\_\_ * At risk for \_\_\_\_\_\_

* Bacterial * E.coli * Urinary sx * Dysuria * Urgency * Frequency * Incomplete void * Suprapubic * Ascend * Flank * Fever * N/V * Malaise * sepsis

**Irritable Bowel Syndrome** * What is it? * Sx present _\>_ __ months * Abdominal pain _\>_ __ months * \_/3 features * _____ with defecation * Onset with change in stool \_\_\_\_\_ * Onset with change in stool \_\_\_\_\_

* Functional change in frequency or form of bowel movements * 6m * 3m * 2 * Improves * frequency * form

**Irritable Bowel Syndrome** * Pain usually \_\_\_\_, ____ abdominal * D\_\_\_\_\_, f\_\_\_\_\_\_, n\_\_\_\_\_ * Etiology \_\_\_\_\_ * Most common in what population? * *IBS can be predominantly \_\_\_\_\_\_, _____ or \_\_\_\_\_*

* crampy, lower * Distention, flatulence, nausea * unknown * young and middle aged adults, especially women * *diarrhea, constipation, mixed*

**Inflammatory Bowel Disease** **(2)**

**Ulcerative Colitis** **Crohn's Disease**

**Ulcerative Colitis** * Inflammation of the ____ and submucosa of the _____ and _____ with \_\_\_\_\_\_\_ * Usually extends _____ from the rectum * Stools are? * Typically r\_\_\_\_\_ and p\_\_\_\_\_\_ diarrhea may ____ at night * Mild \_\_\_\_, _____ generalized abdominal pain * A\_\_\_\_\_, w\_\_\_\_\_ * _____ people * Increased risk of?

* mucosa, rectum, colon, ulceration * proximally * soft watery with blood * recurrent persistent, awaken * cramping, lower * anorexia, weakness * young * colon cancer

Crohn's Disease * Chronic ______ inflammation of the bowel \_\_\_\_ * ___ to \_\_\_, ___ pattern * Stools are? * _____ or recurrent episodes, may ___ at night * Crampy ______ or ____ or d\_\_\_\_ pain * A\_\_\_\_, ___ fever, weight \_\_\_\_ * What population of people? * Increased risk of?

* transmural, wall * mouth to anus, skip * small, soft loose to watery stool usually FREE OF BLOOD * Chronic, wake * periumbilical, RLQ, diffuse * Anorexia, low, loss * Late teens * Colon CA

**Inflammatory Bowel Disease** Notes * *UC from:* * *CD from:* * *Presents similary: Which one has more blood?* * *Young ppl usually teenage years are at increased risk for Colon CA -\> need to to be followed by a \_\_\_\_\_\_, screening with \_\_\_\_\_*

* *rectum up* * *mouth to anus* * *Ulcerative colitis* * *gastroenterologist, colonscopy*

Abdomen Flashcards

(93 cards)