PD E2- Study Guide

What should you think of with unexplained weight loss + stool changes + blood in stool + advanced age?

Colon cancer

What should ALWAYS be included if abdominal pain is below umbilicus?

GU exam

When do you examine the sites of discomfort?

Last

What should you think of with early satiety with burning, postprandial fullness, and epigastric pain?

Dyspepsia

How does familial mediterranean fever present?

Before age 20 with severe abd pain, guarding, & rebound and episodic bouts of pleuritis pain, joint pain, & acute peritonitis

At what serum bilirubin level is jaundice apparent?

≥ 2.5 mg/dL

What symptom might hyperbilirubinemia produce?

Generalized pruritus

What is a bluish periumbilical discoloration (usually accompanied by grey turner sign) from peritoneal hemorrhage?

Cullen’s sign

What are causes of Cullen’s sign?

Acute necrotizing pancreatitis, AAA rupture, ruptured ectopic pregnancy, splenic rupture, trauma, liver abscess, mets

What is flank ecchymosis from retroperitoneal hemorrhage?

Grey turner’s sign

What surgery might a scar in the suprapubic area/bikini line indicate (pfannenstiel)?

Abdominal hysterectomy or C section

What surgery would a right subcostal scar indicate?

Cholecystectomy

What surgery would a midline/linea alba scar indicate?

Vascular procedure or bowel/gastric resection

What surgery would a scar in the RLQ indicate?

Appendectomy

What surgery would an inguinal scar (above & parallel to inguinal ligament) indicate?

Inguinal herniorrhaphy

What surgery would a small, periumbilical scar indicate?

Laparoscopy

What are the abdominal retroperitoneal viscera organs?

Suprarenal glands

Aorta/IVC

Duodenum (2-3rd segments, some of 4th)

Pancreas (tail is intraperitoneal) & paraspinal muscle

Ureters

Colon (ascending & descending branches)

Kidneys

Esophagus

Rectum

What condition presents with the following?

• distended venous collaterals lateral to umbilicus, upward flow

• LE edema

• scrotal or vulvar edema

IVC obstruction

What condition presents with the following?

• distended venous collaterals, flow radiates from umbilicus up or down

• caput medusae

• ascites, internal hemorrhoids, small liver, ESLD

Portal HTN

What condition presents with the following?

• Grey turner’s sign

• back pain

• hypotension, anemia, hypo coagulable state, pelvic or hip trauma

Retroperitoneal bleed

What condition presents with the following?

• site of ecchymosis

• no skin atrophy

• indication for heparin

SC Heparin use

What condition presents with the following?

• site of ecchymosis

• skin atrophy

• pt has DM

SC insulin use

What condition presents with the following?

• nodule in umbilicus

• secondary ulceration of nodule

• weight loss, early satiety, painless jaundice, enlarged node of Virchow

• indicates advanced cancer w/in abdomen or pelvis

Sister Mary Josephs nodule

What condition presents with the following?

• tender mass in the sheath of rectus abdominus muscle

• ecchymosis

• Cullen’s sign

• tenderness increases w/ active forward flexion & passive backward extension

• assoc with trauma

Rectus sheath hematoma

Which is done first in the abdominal exam, auscultation or palpation of abdomen?

Auscultation

What are causes of hypoactive bowel sounds?

Ileus, peritonitis

What are causes of hyperactive bowel sounds or borborygmi?

Early intestinal obstruction, diarrhea

What causes epigastric bruits?

AAA, pregnancy, mesenteric angina, HCC

What condition presents with the following?

• epigastric bruit

• bruits over other arteries

• postprandial pain

Mesenteric angina / chronic intestinal ischemia

What condition presents with the following?

• epigastric bruit

• gravid uterus

• fetal heart tones

Third trimester pregnancy

What condition presents with the following?

• flank bruit (RUQ/LUQ)

• HTN

• hypokalemia

Renal artery stenosis

What condition presents with the following?

• RUQ bruit

• hepatomegaly

• nodules

HCC

What condition presents with the following?

• absent bowel sounds

• nonspecific, nonfocal sx

• post surgical

Ileus

What condition presents with the following?

• high pitched tinkling sounds mixed with silence

• distention, vomiting

• tympany

• diffuse tenderness

SBO

What does tympany to percussion indicate?

Air filled (gastric bubble, normal intestines)

What does a dull sound to percussion indicate?

Solid (liver/spleen, impacted colon)

When percussing the abdomen, what is indicated by dullness in the lower area and tympany in the upper/periumbilical area?

Fluid (ascites d/t liver failure, hepatitis, cirrhosis)

Where is the liver?

4-8cm midsternal line & 6-12cm midclavicular line

*determined by tympany below area of dullness & resonance above area of dullness

What should you think of with pain to liver fist percussion (striking R hypochondrium w/ clenched fist)?

Inflammation, acute cholangitis

What is more sensitive than Murphy’s for detecting hepatobiliary infections?

Liver fist percussion

What does dullness to percussion in the RUQ over 12 cm indicate?

Enlarged liver → hepatitis, cirrhosis

What is a positive splenic percussion sign?

Tympany goes to dullness with inspiration → splenomegaly

When percussing in the left lower anterior rib cage & left epigastric region, what does tympany lower in pitch than tympany of the intestine indicate?

Gastric bubble

What is in situs inversus?

Organs are reversed & gastric air bubble is on the right & liver dullness is on the left

What does CVA tenderness / Murphy’s punch indicate?

Renal disease

What is fluid wave?

Press edge of hand firmly down midline of abdomen → tap on one flank sharply w/ finger tips & feel opposite flank for an impulse transmitted through the fluid

*fluid wave (succession splash) suggests ascites

How do you perform shifting dullness?

Percuss abdomen to outline areas of dullness & tympany → have pt roll away from you & percuss again → if dullness has shifted to areas of prior tympany, there is excess peritoneal fluid

What does shifting dullness suggest?

Ascites d/t hepatitis, cirrhosis, liver disease

What does rebound tenderness indicate?

Peritoneal irritation, appendicitis

How does pain with appendicitis present?

Pain starts around periumbilical area, resolves for 6 hrs then returns with intensity in McBurney’s point for 24-36 hrs then disseminates through abdomen

What does involuntary guarding / rigidity of abdominal wall suggest?

Advanced peritonitis → acute or surgical abdomen

What is icterus?

Yellow discoloration of sclera, assoc w/ liver disease

What is bilirubinuria?

Golden/brown discoloration of urine

What can increased systemic estrogen cause?

Gynecomastia, spider angioma (dilated arteriole MC on skin of upper chest), testicular atrophy

*seen in liver disease

What causes varices?

Blood finds alternative pathways back to heart that do not pass through liver due to portal HTN

What are the MC varices seen in portal HTN?

Esophageal varices (via splenic & short gastric veins enroute SVC)

What causes caput medusae?

Blood utilizes recanalized umbilical vein to direct blood through dilated superficial veins in abd wall to get back to the heart, seen in portal HTN

What is a tremor of the hand when the wrist is extended, seen in severe liver disease?

Asterixis

What are signs seen in end stage liver disease (ESLD)?

Spider angiomas, gynecomastia, small testes, small/large liver, icterus, ascites, asterixis

How would a patient who had a splenectomy present?

Tympany to percussion at castell’s point & traube’s space & scar at left subcostal area

What condition presents with the following?

• Dullness to percussion at castell’s point w/ expiration & inspiration

• dullness to percussion at traube’s space

Moderate splenomegaly (or large pleural effusion or cardiomegaly)

What condition presents with the following?

• early satiety, N, postprandial V

• dullness to percussion at castell’s point w/ expiration & inspiration

• dullness at traube’s space

• palpable spleen at LUQ in R lateral decubitus & supine position

• spleen can extend into pelvis

Massive splenomegaly

What kind of hernia is a surgical URGENCY?

Incarcerated (tender/nontender & non reducible)

What kind of hernia is a surgical EMERGENCY?

Strangulated (very tender & non reducible)

What is a palpable or visible mass at the site of a surgical scar, more likely to happen in patients with uncontrolled DM or high dose steroid users?

Incisional hernia

How would an inguinal hernia appear?

Palpable/visible mass in lower medial abdomen (bulge above inguinal ligament)

How would an umbilical hernia appear?

Palpable/visual nodule or mass replacing the umbilicus (points upward in pregnancy, downward w ascites)

What condition presents with the following?

• palpable pulsatile mass in midline, epigastric area w/ bruit

• longstanding HTN

• diminished pulses in extremities

• popliteal aneurysm, femoral & carotid bruits

• PE often unsatisfactory, requires imaging (CT w/ contrast)

AAA

What condition is associated with the following presentation?

• palpable nontender mass RUQ (courvoiser’s sign) near murphy’s point

• palpable gallbladder with jaundice

• associated with: jaundice, clay colored stool, & darkened urine

Periampullary carcinoma

What are common, SC fleshy nodules that remain present with contraction of abdominal muscles, & can be accentuated when completing Carnett’s sign?

Lipoma

What is hepatomegaly?

Liver > 14 cm in right MCL

What is dullness to percussion at castle’s point & traube’s space?

Splenomegaly

How would a distended urinary bladder appear?

Dullness to percussion & fullness in suprapubic area, enlarged prostate on DRE in men (d/t obstruction from BPH)

What should you think of with palpable gallbladder + pain + jaundice?

Periampullary carcinoma

What would a tearing pain in the chest, then abdomen and radiating to the back indicate?

Dissecting aortic aneurysm

What would pain in the umbilicus then RLQ 1-3 hours later indicate?

Appendicitis

If a patient complains of “pain all over my belly,” what might this indicate?

Rupture

Where does pain associated with pancreatitis radiate to?

Back

What can cause scrotal edema?

IVC obstruction

What can cause scrotal pain?

Kidney stone

How is pain described in a perforated gastric ulcer?

Burning

What kind of pain is associated with pyelonephritis?

Dull/aching

What kind of pain?

• hollow abd organs contract forcefully or distended or stretched (biliary tree or intestines)

• capsular distention or stretching of solid organs (liver)

• gnawing, burning, cramping

Visceral pain

What kind of pain?

• inflammation of parietal peritoneum (peritonitis)

• steady aching pain

• pt lies very still

Parietal pain

What kind of pain?

• felt more at distant sites d/t innervation at same spinal levels as disordered stuctures

• usually not as intense as area of initial pain/pathology

Referred pain

What kind of pain may radiate inferior to the scapular angle on the right?

Biliary colic

What kind of pain can radiate to the R shoulder?

Acute cholecystitis, perforated duodenal ulcer, ruptured spleen

What kind of referred pain can radiate to T8-T9 right paravertebral region?

Acute pancreatitis or renal colic

What kind of referred pain can radiate to the lumbar region?

Uterine, prosthetic (pelvic), and rectal pain

What kind of referred pain can radiate to the testicles?

Renal colic w/ ureterolithiasis or appendicitis

Periodic epigastric pain occurring 0.5-1 hour after eating is a classic symptom of _____

Gastric ulcers

Pain 2-3 hours after eating or before the next meal is characteristic of ______

Duodenal ulcer

Pain after eating can also be associated with _____

Vascular disease of the abd viscera

What pre-pain symptoms are seen with obstruction due to SBO or appendicitis?

Anorexia, nausea, then pain in umbilicus (appendix, small bowel), or suprapubic region (large bowel) that then moves to location of organ then becomes diffuse if bursts

What would yellow skin, eyes, or dark urine suggest?

Bile duct obstructed or liver is injured

What does tarry stool (melena) suggest?

Upper GI bleed

What does red blood in the stool (hematochezia) suggest?

Lower GI bleed (colon) or brisk upper GI bleed (peptic ulcer)

What can cause referred pain to the abdomen?

Porphyria

Mediterranean fever

Black widow spider bite

Addisons dz

DKA

Lead poisoning

Uremia

Narrow angle glaucoma

Calcium

Herpes zoster

What are the 3 signs of peritonitis (inflammation of abdominal lining)?

Guarding, rebound tenderness & lying completely still (late sign, exacerbated by heel tap or bumping bed)

What should be done to r/o GI bleed?

Rectal exam and guaiac test for blood