Clinical Skills - exam 4 (abdomen)

visceral abdominal pain

a hollow organ is distended or ischemic

common descriptions of visceral pain

gnawing

cramping

aching

non-specific and hard to localize

causes of visceral abdominal pain

gas pains

hepatitis

early appendicitis

mesenteric ischemia

somatic or parietal abdominal pain

pain from inflammation of peritoneum

peritonitis

description of parietal abdominal pain

steady, aching, more severe than visceral

more localized, pts don't want to move

example of somatic/parietal abdominal pain

late appendicitis

how you know a patient has referred pain

no tenderness noted in referred pain area

ex of referred pain

pancreas noted in back

biliary noted in R scapular region

alleviation when leaning forward

stomach ulcers

usually generalized then localized

problems swallowing solids only

more likely esophageal stricture or narrowing

scar tissue = shatzi's rings

problems swallowing solids and liquids

more likely mobility disorder like achalasia

odynophagia

pain on swallowing

causes of odynophagia

esophageal ulcers

caustic ingestion

radiation

infections like candida, CMV, herpes, HIV

indigestion

general term for distress associated with eating

heartburn

rising, retrosternal pain

chronic discomfort in upper abdomen often with postpranidal fullness or early satiety

regurgitation

reflux of food or stomach contents

heartburn + regurgitation =

GERD

ercutations

belching

obstipation

passing no stool or gas

decreased gas passing

ask about acute nausea, vomiting, bloating/pain

no gas or obstipation = bowel obstruction

increased gas passing

sign of food intolerance, excess fiber, biome imbalance

coffee ground hematemesis

partially digested blood

bright red hematemesis

mallory weiss tears (small amt)

esophageal varices (large amt)

PUD

acute diarrhea

<14 days

persistent diarrhea

14-30 days

chronic diarrhea

>30 days

chronic diarrhea concerns

IBS

Chron's

Ulcerative colitis

Food intolerance

tenesmus

urge to defecate

rome IV criteria for constipation

last 3 months w/ onset of 6 mo ago, 2 or more:

-<3 bowel movements/wk

-25% or more defectations w/ straining or sensation of incomplete evacuation

-lumpy or hard stools

-require manual facilitation

chronic medical conditions related to constipation

hypothyroidism

diabetes

MS

Parkinson's

Hematochezia

fresh blood passed in stool

cause of hematochezia

lower GI

-cancer

-ulcerative colitis

-diverticulitis

-hemorrhoids

-large volume upper GI bleeds

melena and causes

black, tarry stools

upper GI tract

hemorrhoids

swollen, possibly inflamed veins in rectum

large internal hemorrhoids

palpable w/ rectal fullness or tenesmus sensations

painless jaundice can indicate

cancer

acute upper abdominal pain ddx

duodenal/gastric ulcer disease w/ worsening or perforation

acute heartburn

MI

acute pancreatitis

gastroenteritis

acute cholelithiasis

chronic upper abd discomfort

dyspepsia

GERD

PUD

malignancies

chronic pancreatitis

chronic cholecystitis

IBS

acute lower abdominal pain

appendicitis

diverticulitis

bowel obstruction

kidney stone (refers to labia or testicle)

gyn sources of lower abd pain

PID

ectopic pregnancy

ruptured ovarian follicle

chronic lower abd pain

IBS

food intolerances

colon cancer

acute red flag sx

severe, diffuse abdominal pain, worse w/ movement

chronic red flag abd sx

GI bleeds

weight loss

anemia

palpable abd masses

FHx of GI cancer

dull, pressure suprapubic pain

bladder infection

agonizing suprapubic pain

acutely overdistended bladder

5 categories of urinary incontinence

stress

urge

overflow

functional

combined stress and urge

stress incontinence

pushing on bladder (sneezing)

common

urge incontinence

muscle contraction before you're ready

common

overflow incontinence

too much urine

functional incontinence

valve issue

pelvic floor weakness/problem

why do you auscultate before palpate in the abdomen?

palpation can alter bowel sounds

increased aortic pulsations

AAA

normoactive bowel sounds

5-34 sounds/min

hypoactive bowel sounds

<5/min

hyperactive bowel sounds

>34/min

protuberant abdomen w/ tympany throughout

small bowel obstruction

normal liver percussion size

6-12 cm

dullness at mid or anterior axillary line for spleen

splenomegaly

normal splenic percussion

tympanic

abnormal splenic percussion

dullness

positive splenic percussion sign

splenomegaly

positive CVA tenderness

pyelonephritis or kidney stones

normal bladder percussion

tympanic

dull bladder percussion

abnormal

-bladder distension

-BPH, urethral stricture, medication

how full does bladder need to be before dullness occurs

400-600 mL

tenderness of bladder

UTI

causes of acute inflammation of peritoneum

ischemic intraabdominal process

perforation

acute appendicitis

cholecystitis

diverticulitis

normal hook technique for liver palpation

soft, distinct, smooth liver edge

may be non-palpable in some pt

abnormal hook technique for liver palpation

firm, hard, blunt liver edge

masses/abnormalities

causes of distended bladder

mass

strictured urethra

meds

BPH

scarring from self-cath

causes of bladder tenderness

infection

inflammation

masses

normal aorta width

<3cm

aorta width >3cm

concerning for AAA

McBurney point

classic positive for appendicitis

Rovsing sign

positive = appendicitis likely

psoas sign

classic positive for appendicitis

retrocecal appendix

obturator sign

low sensitivity

pain on RLQ w/ rotation

Murphy sign

assessment of pt for cholecystitis

-sharp pain + inspiratory halt

if bulge or mass appears on strain then reduces:

hernia

remains palpable w/ strain:

abdominal wall mass

strain obscures mass:

intra-abdominal mass

GERD pathophys

stomach acid flows into esophagus

presentation of GERD

heartburn and regurg

bad epigastric palpation pain

PUD pathophys

H. pylori infection

Excess acid

NSAID overuse

typical presentation of PUD

duodenal = better w/ food

gastric = worse w/ food

-vomiting blood, heartburn, tender

typical presentation gastric cancer

weight loss

abdominal pain

grainy blood in stool

distension

possible mass

acute appendicitis pathophys

lumen obstruction = inflammation and overgrowth of bacteria

acute appendicitis typical presentation

RLQ pain

+ McBurney, Psoas, Rosving, obturator signs

fever and diarrhea

acute cholecystitis pathophys

blockage of cystic duct = infection and inflammation

typical presentation of acute cholecystitis

RUQ pain and tenderness that refers to shoulder

+ Murphy sign

Sharp pain that halts w/ inspiration

biliary colic pathophys

gallbladder bile duct impacted by gallstone

typical presentation of biliary colic

sudden onset, persistent sharp pain in RUQ under rib cage

-waves of pain

acute pancreatitis pathophys

inflamed pancreatic tissue due to premature enzyme release

typical presentation of acute pancreatitis

LUQ

pain radiates to upper back

cullens sign(umbilical bruising)

gray-turner sign(lateral flank bruised)

vomiting

pathophys of chronic pancreatitis

similar to acute, prolonged, fibrosis, endo/exocrine loss

pancreatic cancer pathophys

mutation in driver gene

pancreatic cancer typical presentation

weight/appetite loss

dark urine

jaundice

pathophys of acute diverticulitis

small pouches in colon wall are inflamed

typical presentation diverticulitis

LLQ pain

fever

chills

changes in bowel habits

bowel obstruction pathophys

build-up of fluid and gas = obstruction, distention, vomiting, inability to pass gas, constipation, loss of bowel sounds

mesenteric ischemia pathophys

less blood flow to mesenteries causes tissue hypoxia