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Clinical Assesment
Abdomen Chapter 11
111
Anatomy
Graduate
11/23/2009

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Cards

Term
Gastrointestinal Disorders
Definition

  • Abdominal pain, acute and chronic

  • Indigestion, nausea, vomiting including blood, loss of appetite, early satiety

  • Dysphagia and/or odynophagia

  • Change in bowel function

  • Diarrhea, constipation

  • Jaundice

Term
Urinary and Renal Disorders
Definition
  • Suprapubic pain

  • Dysuria, urgency, or frequency

  • Hesitancy, decreased stream in males

  • Polyuria or nocturia

  • Urinary incontinence

  • Hematuria

  • Kidney or flank pain

  • Ureteral colic

Term
3 broad categories of abdominal pain:
Definition

Visceral pain

Parietal pain

Referred pain

Term
Visceral pain
Definition

 -difficult to localize.

-typically palpable near the midline at levels that vary according to the structure involved.

-varies in quality and may be gnawing, burning, cramping, or aching. When it becomes severe, it may be associated with sweating, pallor, nausea, vomiting, and restlessness

 

Visceral pain occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. Solid organs such as the liver can also become painful when their capsules are stretched.

Term
Visceral pain in the right upper quadrant may result from
Definition
liver distention against its capsule in alcoholic hepatitis.
Term
Visceral periumbilical pain may signify early acute?
Definition
appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the right lower quadrant from inflammation of the adjacent parietal peritoneum
Term
Parietal pain
Definition

-It is a steady, aching pain

-usually more severe than visceral pain 

 -more precisely localized over the involved structure.

-It is typically aggravated by movement or coughing. -Patients with this type of pain usually prefer to lie still

 

originates from inflammation in the parietal peritoneum.

Term
Referred pain
Definition

Referred pain is felt in more distant sites, which are innervated at approximately the same spinal levels as the disordered structures.

 

Referred pain often develops as the initial pain becomes more intense and thus seems to radiate or travel from the initial site. It may be felt superficially or deeply but is usually well localized

Term
1-Pain of duodenal or pancreatic origin may be referred to?
 2-Pain from the biliary tree may be referred to?
Definition

1-Pain of duodenal or pancreatic origin may be referred to the back

 

2-pain from the biliary tree, to the right shoulder or the right posterior chest.

Term

Pain may also be referred to the abdomen from

3

Definition
the chest, spine, or pelvis, thus complicating the assessment of abdominal pain
Term
Pain from pleurisy or acute myocardial infarction may be referred to what area
Definition
Pain from pleurisy or acute myocardial infarction may be referred to the epigastric area
Term
Studies suggest that neuropeptides like 5-hydroxytryptophan and substance P mediate
Definition
interconnected symptoms of pain, bowel dysfunction, and stress
Term

1-Doubling over with cramping colicky pain indicates 

 

2-Sudden knifelike epigastric pain occurs in

Definition

1-renal stone.

 

2-gallstone, pancreatitis

Term

1-Epigastric pain occurs with (2)

 

 2-Right upper quadrant and upper abdominal pain signify

Definition

1-gastritis or GERD.

 

2-cholecystitis

Term
angina from inferior wall coronary artery disease may present as ____1_____ but is precipitated by exertion and relieved by rest
Definition
1-“indigestion,”
Term
Bloating may occur with (3)
Definition
inflammatory bowel disease, belching from aerophagia, or swallowing air
Term
• Many patients with upper abdominal discomfort or pain will have functional, or nonulcer, dyspepsia, defined as
Definition
a 3-month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease.
Term

Chronic Upper Abdominal Discomfort or Pain

 

Multifactorial causes include

Definition
delayed gastric emptying, gastritis from H. pylori, peptic ulcer disease, and psychosocial factors.
Term
Many patients with chronic upper abdominal discomfort or pain complain primarily of heartburn, acid reflux, or regurgitation. If patients report these symptoms more than once a week, they are likely to have
Definition
gastroesophageal reflux disease (GERD) until proven otherwise.
Term
Symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include
Definition

-reduced salivary flow, which prolongs acid clearance by damping action of the bicarbonate buffer;

-delayed gastric emptying;

-selected medications;

-hiatal hernia.

Term
Heartburn is a rising retrosternal burning pain or discomfort occurring weekly or more often. It is typically aggravated by
Definition
food such as alcohol, chocolate, citrus fruits, coffee, onions, and peppermint; or positions like bending over, exercising, lifting, or lying supine.
Term
angina from inferior wall coronary ischemia along the diaphragm may present as
Definition
heartburn
Term

1-GERD  atypical respiratory symptoms

2-Some patients may have “alarm symptoms,” such as
Definition

1-cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness and chronic sore throat

 

2-difficulty swallowing (dysphagia), pain with swallowing (odyophagia), recurrent vomiting, evidence of gastrointestinal bleeding, weight loss, anemia, or risk factors for gastric cancer

Term
Patients with uncomplicated GERD who do not respond to empiric therapy, patients older than 55 years, and those with “alarm symptoms” warrant
Definition
endoscopy to detect esophagitis, peptic strictures, or Barrett's esophagus (in this condition the squamocolumnar junction is displaced proximally and replaced by intestinal metaplasia, increasing the risk of esophageal cancer 30-fold).
Term
1-Right lower quadrant acute pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, is most likely to predict
2-in woman?
Definition

appendicitis.

 

In women other causes include pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy.

Cramping pain radiating to the right or left lower quadrant may be a renal stone.
Term

1-Left lower quadrant acute pain with a palpable mass may be 

 2-Diffuse abdominal pain with absent bowel sounds and firmness, guarding, or rebound on palpation indicates

Definition

1-diverticulitis.

 

2-small or large bowel obstruction

 

Term

1-Change in bowel habits with mass lesion indicates

2-Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), without structural or biochemical abnormalities are symptoms of

Definition

1-colon cancer

 

2-irritable bowel syndrome

Term
Anorexia, nausea, and vomiting accompany many gastrointestinal disorders; these are all seen in
Definition

pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, adverse drug reactions, and other conditions.

 

Induced vomiting without nausea is more indicative of anorexia/bulimia.

Term
Retching describes
Definition
involuntary spasm of the stomach, diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth
Term
 regurgitation
Definition
Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching
Term
Regurgitation occurs in 3
Definition
GERD, esophageal stricture, and esophageal cancer
Term

1-Vomiting and pain indicate  1

 

2-Fecal odor occurs with 2

Definition

1-small bowel obstruction.

 

2-small bowel obstruction or gastrocolic fistula

Term
Brownish or blackish vomitus with a “coffee grounds” appearance suggests
Definition
blood altered by gastric acid. Coffee-grounds emesis or red blood is termed hematemesis
Term
Hematemesis may accompany
Definition
esophageal or gastric varices, gastritis, or peptic ulcer disease.
Term
Symptoms of blood loss such as lightheadedness or syncope depend on the rate and volume of bleeding and are rare until blood loss exceeds 500 ml
Definition
Term
Anorexia is?
Definition

loss or lack of appetite.

 

Find out if it arises from intolerance to certain foods or reluctance to eat because of anticipated discomfort. Check for associated symptoms of nausea and vomiting

Term
Patients may complain of unpleasant abdominal fullness after light or moderate meals, or early satiety- (the inability to eat a full meal) Consider?
Definition
 diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, gastric cancer; early satiety in hepatitis.
Term
Indicators of oropharyngeal dysphagia include
Definition
drooling, nasopharyngeal regurgitation, and cough from aspiration in muscular or neurologic disorders affecting motility; gurgling or regurgitation of undigested food occur in structural conditions like Zenker's diverticulum
Term
Ask the patient to point to where the dysphagia occurs.
Definition
esophageal dysphagia.
Term
Dysphagia w/ solid foods, consider
Definition

structural esophageal conditions like esophageal stricture, web or Schatzki's ring, neoplasm;

 

if solids and liquids, a motility disorder is more likely.

Term
Is there odynophagia, or pain on swallowing Consider
Definition
esophageal ulceration from radiation, caustic ingestion, or infection from Candida, cytomegalovirus, herpes simplex, or HIV.
Can be pill-induced (aspirin, nonsteroidal anti-inflammatory agents).
Term
complain of passing excessive gas Consider
Definition
 aerophagia, legumes or other gas-producing foods, intestinal lactase deficiency, irritable bowel syndrome
Term
Increased water content of the stool results in diarrhea, or stool volume greater than 200 grams in 24 hours. Patients, however, usually focus on the change to loose watery stools or increased frequency.
Definition
Term
1-Acute diarrhea is usually caused by
2-chronic diarrhea is typically
Definition

1-infection;

 

2-noninfectious in origin, as in Crohn's disease and ulcerative colitis.

Term

1-High-volume, frequent watery stools usually are from the

 

2-small-volume stools with tenesmus, or diarrhea with mucus, pus, or blood occur in

Definition

1-small intestine;

 

2-rectal inflammatory conditions

Term
Nocturnal diarrhea usually has pathologic significance.
Definition
Term
Oily residue, sometimes frothy or floating, occurs with steatorrhea, or fatty diarrheal stools, from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.
Definition
Term
Diarrhea is common with use of what meds?.
Definition
penicillins and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines
Term
Thin, pencil-like stool occurs in an?
Definition
obstructing “apple-core” lesion of the sigmoid colon
Term
1-w/ constipation consider medications such as 
2-Constipation occurs with what diseases? (6)
Definition

1-anticholinergic agents, calciumchannel blockers, iron supplements, and opiates.

 

2-diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, Parkinson's disease, and systemic sclerosis.

Term

 obstipation

1- what is it

2-Obstipation signifies what?

Definition

1-when there is no passage of either feces or gas at all

 

2-Obstipation signifies intestinal obstruction

Term
color of stools
1-melena,
2-hematochezia
Definition

1-black tarry stools

2-stools that are red or maroon-colored

Term

1-Melena may appear w/ how much bleeding from where

 

2-hematochezia how much bleeding from where

Definition

1-100 ml of upper gastrointestinal bleeding

 

2-if more than 1000 ml of blood, usually from lower gastrointestinal bleeding

Term
icterus
Definition
In some patients, you will be struck by jaundice or icterus, the yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin. Normally the hepatocytes conjugate, or combine, unconjugated bilirubin with other substances, making the bile water soluble, and then excrete it into the bile. The bile passes through the cystic duct into the common bile duct, which also drains the extrahepatic ducts from the liver.
Term
 jaundice (Predominantly unconjugated bilirubin)  is a result of 
Definition

 -Increased production of bilirubin

-Decreased uptake of bilirubin by the hepatocytes
-Decreased ability of the liver to conjugate bilirubin
-in hemolytic anemia (increased production) and Gilbert's syndrome.
Term
Impaired excretion of conjugated bilirubin occurs with? 5
Definition

viral hepatitis, cirrhosis, primary biliary cirrhosis,

 

-and drug-induced cholestasis, as from oral contraceptives, methyl testosterone, and chlorpromazine

Term
Gallstones or pancreatic carcinoma may obstruct
Definition
the common bile duct
Term
Dark urine from bilirubin indicates
Definition
 impaired excretion of bilirubin into the gastrointestinal tract
Term
 acholic stools
Definition
without bile, the stools become gray or light colored
Term
Acholic stools may occur in 
Definition

-briefly in viral hepatitis

 

-they are common in obstructive jaundice

Term
1-skin Itching indicates 
2-skin pain may signify
Definition

1-cholestatic or obstructive jaundice

 

2-a distended liver capsule, biliary cholic, or pancreatic cancer.

 

 

Term
Risk factors for liver diseases
Definition
  • Hepatitis: Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A); parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis B); intravenous illicit drug use; or blood transfusion (hepatitis C)
  • Alcoholic hepatitis or alcoholic cirrhosis (interview the patient carefully about alcohol use)
  • Toxic liver damage from medications, industrial solvents, or environmental toxins
Term
Pink-purple striae of the abdominal region suggest
Definition
Cushing's syndrome
Term
Dilated veins of abdomine suggest
Definition
hepatic cirrhosis or of inferior vena cava obstruction
Term
The umbilicus. Observe its contour and location and any inflammation or bulges suggesting a
Definition
hernia
Term
1-Bulging flanks suggests?
2-suprapubic bulge suggests?
Definition

1-ascites-fluid wave test

 

2- a distended bladder or pregnant uterus; hernias

Term
an ovarian or a uterine tumor seen as a

Definition
Lower abdominal mass
Term
Increased peristaltic waves in (visible peristalsis)
Definition
intestinal obstruction
Term
Increased pulsation seen in 
Definition
aortic aneurysm or of increased pulse pressure
Term
Bruits suggest
Definition

vascular occlusive disease

 

listen with the bell

Term
Bowel sounds may be altered in
Definition
diarrhea, intestinal obstruction, paralytic ileus, and peritonitis.
Term
Listen for bruits over the aorta, the iliac arteries, and the femoral arteries. Bruits confined to systole are relatively common, however bruits w/ both systolic and diastolic components strongly suggests
Definition
renal artery stenosis as the cause of hypertension
Term
Bruits with both systolic and diastolic components suggest
Definition
the turbulent blood flow of partial arterial occlusion or arterial insufficiency.
Term
Listen over the liver and spleen for friction rubs.
Definition
liver tumor, gonococcal infection around the liver, splenic infarction
Term
A protuberant abdomen that is tympanitic throughout on percussion suggests
Definition
intestinal obstruction
Term

 large dull areas in percussion suggets

 

Definition
Pregnant uterus, ovarian tumor, distended bladder, large liver or spleen
Term
Percussion Dullness in both flanks prompts further assessment for
Definition
ascites
Term
In situs inversus (rare), organs are
Definition
reversed: air bubble on the right, liver dullness on the left.
Term
if Involuntary rigidity (muscular spasm) typically persists during Light Palpation.
even with the relaxing breathing methods
Definition
It indicates peritoneal inflammation.
Term
Abdominal masses may be categorized in several ways:
Definition

physiologic (pregnant uterus)

inflammatory (diverticulitis of the colon)

vascular (an abdominal aortic aneurysm), neoplastic (carcinoma of the colon)

 obstructive (a distended bladder or dilated loop of bowel)

Term
Abdominal pain from coughing or from light percussion suggests
Definition
peritoneal inflammation
Term
Rebound tenderness suggests
Definition

 peritoneal inflammation.

 

If tenderness is felt elsewhere than where you were trying to elicit rebound, that area may be the real source of the problem

Term

1-The span of liver dullness is increased

2-The span of liver dullness is decreased 
 3-Liver dullness may be displaced downward by
Definition

1-when the liver is enlarged

 

2-when the liver is small, or when free air is present below the diaphragm, as from a perforated hollow viscus.

 

3-the low diaphragm of chronic obstructive pulmonary disease. Span, however, remains normal.

Term
Only about half of livers with an edge below the right costal margin are palpable, but when the edge is palpable it suggests
Definition
the likelihood of hepatomegaly roughly doubles
Term
Firmness or hardness of the liver, bluntness or rounding of its edge, and irregularity of its contour suggest an abnormality of the liver.
Definition
Term
An obstructed, distended gallbladder may form an oval mass below the edge of the liver and merge with it. It is dull to percussion.
Definition
Term
Tenderness over the liver suggests
Definition
inflammation, as in hepatitis, or congestion, as in heart failure.
Term
Percuss the left lower anterior chest wall between lung resonance above and the costal margin, an area termed
Definition
Traube's space
Term
Fluid or solids in the stomach or colon may also cause dullness in what area
Definition
Traube's space.
Term
A change in percussion note from tympany to dullness on inspiration over traube's space suggests
Definition
splenic enlargement. This is a positive splenic percussion sign
Term
Splenomegaly is eight times more likely when the spleen is palpable. Causes include
Definition
portal hypertension, hematologic malignancies, HIV infection, and splenic infarct or hematoma
Term
The enlarged spleen is palpable about 2 cm below
Definition
the left costal margin on deep inspiration
Term
A left flank mass may represent marked splenomegaly or an enlarged left kidney. Suspect splenomegaly if
Definition
a notch is palpated on medial border, the edge extends beyond the midline, percussion is dull, and your fingers can probe deep to the medial and lateral borders but not between the mass and the costal margin.
Term
Attributes favoring an enlarged kidney over an enlarged spleen include
Definition
 preservation of normal tympany in the left upper quadrant and the ability to probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders.
Term
Causes of kidney enlargement include
Definition
hydronephrosis, cysts, and tumors. Bilateral enlargement suggests polycystic kidney disease.
Term
Pain with pressure or fist percussion of kidney suggests
Definition
pyelonephritis but may also have a musculoskeletal cause.
Term
The bladder normally cannot be examined unless it is distended above the symphysis pubis.
Definition

urethral stricture, prostatic hyperplasia; also from medications and neurologic disorders such as stroke, multiple sclerosis.

Suprapubic tenderness in bladder infection
Term
Risk factors for abdominal aortic aneurysm (AAA) are
Definition
age 65 years or older, history of smoking, male gender, and a first-degree relative with a history of AAA repair
Term
1-A periumbilical or upper abdominal mass with expansile pulsations that is 3 cm or more wide suggests
Definition

1-an AAA.

 

 Pain may signal rupture.

Term
Ascites from increased hydrostatic pressure in
Definition
cirrhosis, congestive heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction; from decreased osmotic pressure in nephrotic syndrome, malnutrition. Also in ovarian cancer.
Term
with ascites, when percussing, what happens
Definition
dullness shifts to the more dependent side, whereas tympany shifts to the top.
Term
An easily palpable impulse suggests ascites. A positive fluid wave, shifting dullness, and peripheral edema make the diagnosis of ascites highly likely
Definition
Term
The pain of appendicitis classically begins near, then shifts to?
Definition

begins near the umbilicus, then shifts to the right lower quadrant, where coughing increases it.

 

 

Older patients report this pattern less frequently than younger ones

Term
Localized tenderness anywhere in the right lower quadrant, even in the right flank, may indicate
Definition

appendicitis

 

Early voluntary guarding may be replaced by involuntary muscular rigidity

Term
Rebound tenderness suggests
Definition
peritoneal inflammation, if appendicitis
Term
Pain in the right lower quadrant during left-sided pressure suggests
Definition

appendicitis (a positive Rovsing's sign).

 

 

 

So does right lower quadrant pain on quick withdrawal (referred rebound tenderness).

Term
Increased abdominal pain on either maneuver (a positive Rovsing's sign and referred rebound tenderness) constitutes a positive
Definition
psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix.
Term
Right hypogastric pain constitutes a positive
Definition

obturator sign, suggesting irritation of the obturator muscle by an inflamed appendix.

 

 

(Localized pain with this maneuver, in all or part of the right lower quadrant, may accompany appendicitis.)

Term
A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive
Definition
Murphy's sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized
Term

ask the patient to raise both head and shoulders off the table.

Definition

hernia

 

(Ventral hernias are hernias in the abdominal wall exclusive of groin hernias)

Term
Distinguishing an Abdominal Mass From a Mass in the Abdominal Wall.
An occasional mass is in the abdominal wall rather than inside the abdominal cavity. Ask the patient either to raise the head and shoulders or to strain down, thus tightening the abdominal muscles. Feel for the mass again.
Definition

1-remains palpable when the pt flexes

 

2-is obscured by muscular contraction.

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