Patient Assessment 2: GI + GU OSCE

xiphoid process

costal margin

rectus abdominis muscle

inguinal ligament

pubic tubercle

symphysis pubis

gnawing, burning, cramping or aching

caused by an organ that is contracted distended or stretched (e.g. hepatitis) OR ischemia

Describe visceral pain. What are some causes?

intense steady, achy pain that worsens with movement or coughing

caused by inflammation of the peritoneum (e.g. peritonitis from appendicitis)

Describe parietal pain. What are some causes?

pain at a distant site which is innervated at approx. the same spinal level as the affected organ/structure

e.g. pancreatic pain can be referred to the back

Describe referred pain. What are some causes?

liver, gallbladder, pylorus, duodenum, hepatic flexure of the colon, head of the pancreas

(e.g. cholecystitis, hepatitis)

What structures are in the RUQ? What are common causes of RUQ pain?

stomach, duodenum, or pancreas

(e.g. PUD, GERD, pancreatitis)

What are common causes of epigastric pain?

small intestine, appendix, or proximal colon

What are common causes of periumbilical pain?

rectum or bladder (e.g. UTI) colon, bladder, or uterus

What are common causes of suprapubic pain?

dysphagia, odynophagia, recurrent vomiting, evidence of GI bleed, early satiety, weight loss, anemia, palpable mass, painless jaundice

What are considered alarm symptoms for GI? (9)

cecum, appendix, ascending colon, terminal ileum, right ovary

Appendicitis, ruptured ovarian cyst

What structures are in the RLQ? What are common causes of RLQ pain?

spleen, splenic flexure of the colon, stomach, body and tail of the pancreas

splenic infarct

What structures are in the LUQ? What are common causes of LUQ pain?

sigmoid colon, descending colon, left ovary

diverticulitis, C. diff colitis

What structures are in the LLQ? What are common causes of LLQ pain?

renal colic

What are common causes of flank pain?

Crohns disease, gastroenteritis, SBO

What are common causes of diffuse abdominal pain?

flank pain that radiates to the groin

Where does ureteral pain present?

flank pain that wraps around to the R or L UQ

Where does kidney pain present?

supine with knees bent

How should the patient be positioned for an abdominal exam?

pale conjunctiva (anemia), Virchow's node, acanthosis nigrans, koilonychia

clubbing of the fingers, palmar erythema, asterixis, gynecomastia

What are some external signs of abdominal disease? (8)

Virchow's node, acanthosis ingrains

What external signs of abdominal disease indicate possible gastric cancer?

pale conjunctiva, koilonychia

What external signs of abdominal disease indicate anemia?

clubbing of the fingers, palmar erythema, gynecomastia

What external signs of abdominal disease indicate cirrhosis?

Asterixis

What external signs of abdominal disease indicate hepatic encephalopathy?

the left supraclavicular lymph node

Where is Virchow's Node located?

Inspection -> Auscultation -> Percussion -> Palpation -> Special Tests

What is the order of the abdominal exam?

Dilated veins around the umbilicus, associated with cirrhosis of the liver.

pink/purple striae from Cushings Disease

Cullen's sign (necrotic pancreatitis)

Grey-Turner's sign (necrotic pancreatitis)

the diaphragm

What part of the stethoscope do you use to auscultate bowel sounds?

the bell

What part of the stethoscope do you use to auscultate bruits?

the bell

What part of the stethoscope do you use to auscultate friction rubs?

areas of gas

What does tympany on percussion indicate?

fluid, feces, organs

What does dullness on percussion indicate?

Guarding/Rebound/Rigidity

have the patient cough and access where it causes pain, palpate the abdomen, and heel tap

What are the peritoneal signs? How do you assess for them?

hooking technique

What technique is used in obese patients to assess the liver?

4-8 cm lower than the midsternal line

6-12 cm lower than the mid clavicular line

Where is the liver edge located?

percussion from border of cardiac dullness at the 6th rib down to anterior

if dullness is past the mid axillary line, indicates an enlarged spleen

How do you access for an enlarged spleen?

False. the right may be palpable, but the left is usually not palpable

T/F: both kidneys are palpable.

CVA Tenderness

What PE finding indicates inflammation of the kidneys?

shifting dulness when the patient shifts from supine to side lying OR fluid wave

What PE finding indicates ascites?

Rosving Sign - press in LLQ causes pain in RLQ (McBurney's point)

Psoas sign

Obturator Sign

also rebound tenderness at McBurney's point

What PE signs indicate appendicitis?

Murphys sign

What PE sign indicates cholecystitis?

have the patient do a crunch, the hernia will protrude

How do you test for a ventral hernia?

Normal active BS, ND/NT, no rebound

What is the abbreviated version of an abdominal exam?

alcohol abuse, viral hepatitis, and colon cancer

What tests are included in a GI screening?

how many times in the past year have you had 4 or more drinks a day (women) or 5 or more drinks a day (men)?

What is the initial screening question for alcohol use in adults?

> or equal to 2 positive answers

What is considered a positive CAGE?

1. Have you ever felt the need to CUT down on your drinking?

2. Have you ever felt ANNOYED by criticism of your drinking?

3. Have you ever felt GUILTY about drinking?

4. Have you ever had to take a morning EYE OPENER?

What are the CAGE questions?

fecal oral

How is Hep A transmitted?

all children at age 1 year

people with:

chronic liver disease

clotting factor disorders

IV drug use

men who have sex with men

working with primates

travel to Hep A prevalent areas

Who should be immunized against Hep A?

Hep A vaccine or single dose of immune globulin within 2 weeks of exposure

what is done for postexposire prophylaxis to HepA?

2 shots

Hep A vaccine is a series of _______ shots

exposure to blood, semen, or other bodily fluid

How is Hep B transmitted?

persons with HIV

IV drug users

men who have sex with men

women in the first trimester of pregnancy

Who should be screened for Hep B?

sexual contacts of patients with + surface antigens

patients with more than one sexual partner in the last 6 months

patient getting tx for STI

men who have sex with men

people with percutaneous exposure to blood

HIV+

chronic liver disease

Who should be immunized against Hep B?

percutaneous exposure to blood

How is HepC transmitted?

people with risk factors for blood Bourne infection

people born between 1945-1965

Who should be screened for Hep C?

1st degree relative with colorectal cancer at < 60 yo

or multiple 1st degree relatives with colorectal cancer

What family history puts a patent at increased risk for colon cancer?

average risk: all adults age 45-75 years

75-85 on an individual basis

high risk: 10 years prior to the youngest case in their family

Who should be screened for colon cancer?

FIT and FOBT

FIT is more sensitive

What are the non-invasive tests for colorectal cancer? Which is more sensitive?

annually

How often are FIT and FOBT screenings performed?

computed tomography colonography (CTC) - 5 years

capsule colonoscopy - 5 years

screening colonoscopy - 10 years (5 years if high risk)

What are the invasive test for colon cancer and how often are they performed?

above the symphysis pubis

Where would a distended bladder be palpable?

liver distention from hepatitis

visceral pain in the RUQ suggests ____________

early acute appendicitis

visceral periumbilical pain can be suggestive of _____________

intestinal mesenteric ischemia

if the patients visceral pain is disproportionate to the physical findings, suspect ___________

steady, aching pain more severe than visceral pain that is localized over the involved structure

Describe somatic/parietal pain

peritonitis = immobile

renal stone = moving

Patients with peritonitis will be (moving/immobile) whereas patients with renal stones will be (moving/immobile).

back, right scapular region or posterior thorax

Where does pain of duodenal or pancreatic origin referred to?

epigastric area

Where does pain from pleurisy or inferior MI refer to?

5-hydroxytrytophan and substance P

Which neuropeptides are involved in symptoms of abdominal pain, bowel dysfunction, and stress?

15-30%

What percentage of patients with non-specific abdominal pain in the ER need surgery?

inferior MI

What cause of epigastric pain is precipitated by exertion and relieved by rest?

heartburn and effortless regurgitation

If patients report _________ and __________ together more than once a week, it is 90% a GERD diagnosis

failing empiric therapy

> 55 years onset

alarm symptoms

What criteria warrants an EGD for a GERD diagnosis?

Dysphagia, odynophagia, recurrent vomiting, evidence of GI bleeding, early satiety, weight loss, anemia, risk factors for gastric cancer, palpable mass, painless jaundice.

What are abdominal alarm symptoms?

50-85%

Of those with suspected GERD _____% haven disease on endoscopy.

10% of patients with heartburn have Barrett's, which is metaplastic changes in the esophageal lining from normal squamous to columnar epithelium

What is Barretts Esophagus? How prevalent is it?

RLQ pain that migrates from the periumbilical region

What referred pain pattern is characteristic of appendicitis?

cramping pain radiating to the flank or groin accompanied by urinary symptoms

What clinical symptoms suggest nephrolithiasis?

Pain in the LLQ accompanied by diarrhea in a patient with a history of constipation

What clinical symptoms suggest diverticulitis?

Nonspecific diffuse abdominal pain with abdominal

distention, nausea, emesis, and lack of flatus and/or bowel movements

What clinical symptoms suggest bowel obstruction?

diffuse abdominal pain and guarding w/ or w/o abdominal distention

What is a characteristic symptom of peritonitis?

late-stage colon cancer

A change in bowel habits with a palpable mass warns of...

1. intermittent pain for

12 weeks of the preceding 12 months with relief from defecation

2. change in frequency of

bowel movements, OR change in form of stool (loose, watery, pellet- like)

What is the diagnostic criteria for IBS?

bulimia

induced vomiting without nausea is indicative of...

severe constipation with the inability to pass both stool and gas, often indicative of a bowel obstruction

Obstipation

insufficient saliva

Xerostomia

esophageal dysphagia

A patient who identifies pain below the sternoclavicular notch suggests...

esophageal stricture (Schatzki ring) webbing or narrowing or neoplasm

What are disorders that cause dysphagia to solid foods only?

achalasia

What disorder cause dysphagia to both solids and liquids?

NSAIDs, ASA, caustic indigestion, radiation, infection with candida, CMV, HSV, or HIV

What are common causes of esophageal ulceration?

excessive repetitive air swallowing

Aerophagia

False. it is typically non-infectious like IBS or a food allergy

T/F: chronic diarrhea is typically infectious.

acute diarrhea that starts in a hospital setting typically after 72 hours

Nosocomial diarrhea