GI/ Urinary / referral pattern tings

Urinary Incontinence- Stress Incontinence

• Involuntary leakage of urine during cough, sneezing or exertion can be seen postpartum, pelvic floor muscle weakness

  • Tx: strengthen pelvic floor muscles

Urinary incontinence- Urge incontinence

• Involuntary contraction of the detrusor muscle with a strong desire to void (urgency). can be seen with infections, parkinson’s disease, UMN lesions

  • Tx: infections, voiding schedule, time urination

Urinary incontinence- Overflow incontinence

• Incontinence caused by an acontractile or underactive detrusor muscle. The bladder is overdistended, can not empty completely, and urine dribbles or leaks out. can be seen with benign prostatic hyperplasia, DM, LMN lesion

  • behavioral modification like sound voiding, medication and catheterization

Urinary Incontinence- Functional incontinence

• Incontinence due to mobility, dexterity, or cognitive deficits. Can be seen with dementia. LE weakness

  • Tx: clear environment, improve accessibility, prompted voiding, voiding schedule

Pain Referral

• Mid back/ scapula → (PEGS)

  • Pancreas, Esophagus, Gallbladder, Stomach

• Shoulder

  • Left shoulder: heart, diaphragm, spleen, tail of pancreas, L kidney

  • Right shoulder: Gallbladder, liver, head of pancreas, R kidney

• Pelvis/ low back/ sacrum → (CAP)

  • Colon, Appendix, Pelvic viscera

• Pancoast Tumor (upper lung tumor): pain referred in C8-T2 nerve distribution, mimics TOS, Pain top of shoulder, ipsilateral shoulder

  • Weight loss, horner’s syndrome, cough, dyspnea, night pain

Typical pain pattern- Quadrants

• RUQ: peptic ulcers, gallbladder pathology (cholecystitis), head of pancreas, right kidney, liver

• LUQ: Tail/ body of pancreas, spleen pathology, diaphragm, left kidney, heart

• RLQ: Appendix, Crohn’s disease

• LLQ: Diverticulitis, Ulcerative colitis, IBS

Gastroesophageal Reflux Disease (GERD)

• Reflux of gastric content of the gastro-duodenal contents into the esophagus

• Symptoms

  • Heartburn- 30 minutes after eating and at night lying down

  • Dysphagia- trouble swallowing

  • Sour Taste- from regurgitation of acids

  • Hoarseness of voice

  • Atypical pain of the head and neck

• Complications

  • Aspiration pneumonia, asthma

  • Esophagitis

GERD- Tx

• Maintain upright positions

• Eat meals at least 3-4 hours before sleep

• Avoid supine- tends to straighten the esophagus

• Sleep on left side, preventing nocturnal reflex

• Exercise must be completed 2-3 hours after eating or before meals

• Avoid spicy, chocolate, fatty food, peppermint

• Drugs

  • Antacids

  • H2 receptor blockers

  • Proton pump inhibitors (PPI)

Hernia and referred pain

• Hiatal hernia causes shoulder pain → stomach entrapped in diaphragm

  • Similar s/s to GERD

• A femoral hernia causes lateral pelvic wall pain and groin pain

• An inguinal hernia causes groin pain

• Umbilical hernia causes pain around the umbilical ring in the mid to lower abdomen

Cholecystitis

• RUQ/ R shoulder

• Blockage or impaction of gallstones in the cystic duct resulting in inflammation of the gallbladder

  • Pain in R upper quadrant, radiating to the right scapula

  • Nausea, vomiting, low-grade fever

  • Pain increases with ingestion of fatty food - around 20 min

• Special test: Murphy’s sign

  • Palpate near R subcostal margin as patient takes a deep breath; if pain and tenderness is elicited during inspiration, the test is positive

Peptic Ulcers

• RUQ

• Gastric (stomach) Ulcers

  • Ulcerative lesions in the stomach caused by chronic use of NSAIDS, stress, anxiety, H. Pylori bacteria

  • Pain increases with the presence of food due to acid secretion, pain after eating

  • Pain relieved with antacids, medically treating H. Pylori infection

• Duodenal Ulcers

  • Ulcerative lesions in the duodenum cause mainly by H. pylori infection

  • Pain increases with absence of food, early mornings, and in between meals

  • Pain relieved by medically treating H. pylori infection

• Pain is burning, cramping in epigastric area, can refer to right shoulder

• Coffee ground emesis (both) and melena (duodenal) (dark) tarry stools are characteristic of peptic ulcer disease

Ulcerative Colitis

• LLQ, lower back/ rectal pain

• Only large intestine and rectum

• Continuous lesions

• s/s: rectal pain, bleeding, bloody diarrhea w/ mucus/ pus, fecal urgency, weight loss, LBP

Chron’s disease

• RLQ, umbilicus and LBP

• Occurs anywhere in GI tract

• Skip lesions

• S/s: pain relieved by passing gas, abdominal pain, weight loss, joint arthritis

Irritable bowel syndrome (IBS)

• LLQ

• Spastic, nervous or irritable colon → bowel is spastic

• Causes: emotional stress, anxiety, high-fat lactose foods

  • Pain is relieved by defecation

  • Sharp cramps in the morning or after eating

  • Nausea, vomiting, bloating, foul breath, diarrhea

  • s/s disappear while sleeping

  • Ribbon-like stools

• Tx: stress reduction, dietary modification, exercise

  • Increase fiber, decrease fatty foods

Appendicitis

• RLQ

• Inflammation of the vermiform appendix, progress can lead to a swollen/gangrenous appendix

• If perforated can lead to peritonitis

• S/s:

  • Pain in RLQ, comes to waves, progressing to steady

  • Anorexia, nausea, vomiting, elevated temperature, leukocytosis, fever

  • Tender at McBurney's point, Rovsing’s sign for pain migration, and Blumberg’s sign for rebound tenderness

• Immediate medical attention required

Appendicitis tests

• McBurney’s point - RLQ over appendix

• Rovsing’s sign- Press on LLQ, pain felt on RLQ

• Obturator sign- PROM- IR of flexed thigh

• Psoas sign- PROM- extension of thigh

• Blumberg’s sign- rebound tenderness

• Single hop test- hopping on right side-pain

• Markels sign- heel drops- pain on right

Liver Disease

• RUQ

• Light clay colored stools, dark colored urine, palmar erythema, easy bruising, Asterixis (flapping tremor of hand)

Aortic Abdominal Aneurysm (AAA)

• Pulsating feeling in the abdomen, abdominal bulge

Acute compartment syndrome

• 6P’s- Pain, palpable tenderness, paresthesia, pallor, paresis, pulselessness

Myocardial ischemia/ cardiac arrest

• Left neck and jaw pain along with chest pain

Cauda Equina

• Saddle anesthesia, loss of bowel bladder function, urine retention, lower extremity weakness

Anaphylaxis (Allergic reaction)

• Sudden hives, itching, SOB, rapid or weak pulse

Diabetic ketoacidosis (DKA)

• Excessive thirst, confusion and difficulty concentrating and fruity odor in breath

Heat stroke

• High body temperature (> 104 F), Altered mental status (confusion, disorientation, loss of consciousness), Hot dry skin, tachycardia, headache

Deep Vein Thrombosis (DVT)

• sudden onset of shortness of breath (dyspnea), rapid and shallow breathing (tachypnea), swelling in LE, anxiety, fever, diaphoresis, cough, blood in sputum (hemoptysis)