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- Pitting Edema (of the leg)
o Blood pooling on heel of the foot
o Differential Dx:
Cardiovascular (most common)
• Most likely CHF
Renal failure probably caused death (more common)
Hepatic (no jaundice)
- Clubbing (right hand)
o Findings:
White male
40’s
Swelling at DIP
Enlarged nails (no splinter hemorrhage)
• Psoriasis has pitted nails
o Enlargement of the terminal tuffs (seen on x-ray)
o AKA: Hypertrophic Osteoarthropathy (digital clubbing)
M/c lung disease because of hypoxia
• Generally seen in COPD
o Bronchial generally over dilated – pt can’t exhale
Emphysema (pink),
Asthma,
Chronic Bronchitis,
Bronchiectasis
Can be associated with GI and GU problems
A.M.P.L.E.
- Allergies (wheat, soy, peanut, shellfish, iodine, meds)
o Sx - hives, itching, edema, difficulty breathing
Seasonal allergy – hay fever
Dog allergy – pollen, dandruff, saliva
Shellfish – iodine
Nuts -
- Medications
o Common drugs that affect GI tract
Autonomic drugs – sympathetic & parasympathetic
Antibiotics
o Name
o Dose
o Why
o How long
o Time of day
o Effectiveness
O.P.P.Q.R.S.T.
- Onset (what cause, when, how long it takes)
o When – sudden (rupture or torn) or gradually
The more sudden in abdominals the more serious the condition
o How – insidious (unknown cause) or non-insidious
- Provocative (what makes it worse)
o Foods
Spice in foods (may be bad for reflux)
Spice hot
Lack of food
o Gluten or Lactate
o Position
o BM
o Anxiety
o Trauma
o Pressure
o Medications
o Alcohol
o Smoking
o Caffeine
- Palliative (what makes it better)
o The list is identical to Provocative
- Quality (describe the pain)
o Sharp
o Dull
o Aching
o Cramping
o Colicing
o Stabbing
o Constant – very serious, just like
o Intermittent
- Radiation/Region of pain (where does it hurt)
o Abdominal pain is more referred pain
Gallbladder right shoulder, right jaw
Heart left shoulder, left arm, left face
Pancreas radiating pain to back
Triple A referred pain to back
- Setting (when – time)/Site/Severity
o What were you doing when it happened?
Bend over
BM
- Timing (time it happen & how long does it last)
o Constant = 24/7/365
o Serious
Review: what organs are in what region?
Picture
- Large smooth dome-shaped mass in the LUQ
- Appears pale over lesion
- Have pt do a sit up so that abdominal muscles contract
o Either outside the belly – least common; ie, cystic, lypoma
o In the wall
o Abdominal wall hernia – m/c
- Incisional Hernia (past surgery) – laparoscopy
o Gets larger when she bears down and painful
o Auscultation will hear bowel sounds
o Feels like it is filled with air (like balloon)
o Very mobile
o When blood supply is lost to a hernia is call strangulation
o Tender
o Lateral debicutis
HISTORY
- Hospitalization
- Injuries/Immunizations
- Sugar Diabetes
- Tumors/Trauma
- Operations
- Review of Systems
- Youth Illness
10-Day rule
• Can only take X-ray’s first 10 days of cycle (starting at 1st day of menses)
• Unless chance Mom’s life is in danger or severe morbidity
Physical Examination
Inspection
- Symmetry, size (distension), shape
- Lumps, bumps, scars (pt. w/always have bear down to look for hernia), ecchymoses
(bruising)
Auscultation
- Bowel sounds (5-35/minute)
o AKA: Borborygmi
o Relatively high pitched use diaphragm
o Very high pitched and get faster than 35/minute sign for obstruction
o No bowel sounds Paralytic (Adynamic) Ileus (blunt trauma, post operative)
o Early bowel obstruction Rapid sounds to force fecal bolus
o Late bowel obstruction Shuts down and patient vomits (no bowel sounds)
o Adynamic Illius → no bowel sounds b/c no peristalsis
- Bruits
o Swishing Noise (hi pitch in stenosis, low in aneurysm)
o Caused by turbulent flow (change in speed of blood flow)
o Occurs with aneurysm and stenosis
o M/C in the aorta (infrarenal AAA)
Percussion
- Liver, spleen, diaphragm
o Size
o Diaphragmatic Excursion
o Note pitch
LUQ: Not eaten tympanic (b/c air in the stomach)
Eaten dull
o Spleen: dull
o Liver: dull
o Rest of the abdomen: resonance
o Bowel obstruction: dull
Tympanic: proximal
? : distal
Palpation
- Organomegaly
o Hepatosplenomegaly
Caused by sickle cell, etc..
- Aneurysms
o Start in non-tender quadrant and go to tender quadrant
o Superficial mass: in abdominal wall
o Contraction of abdominal mm
Accentuated: in abdominal wall
If not in abdomen
o If mobile: better than mass that is non mobile
Malignant masses do not move b/c not encapsulated and they invade other
tumors and inflammatory tumor that makes scar tissue and makes more
immobile
Benign tumors grow in the original tissue and do not invade
- Palpation of organs
o Liver
o Spleen
- Aorta
o Lateral pulsation is not good, could represent AAA
o 3.5 cm or less is normal size of aneurysm
o AAA produce non-mechanical back pain
Abdominal Exam Tips
- Comfortable room temperature
- Patient gowned with abdomen exposed
- Groin uncovered with genitalia draped
- Bladder empty
- Start in non-tender quadrant (end up in the tender quadrant)
- Use your hand over patients if ticklish (use little firmer touch)
- Normal kidney is non-palpable (possible in thin patient)
- Normal liver may be palpable (8-12cm in height @ Mid Clavicular line)
o Most common cause is alcoholism
- A palpable spleen is enlarged
- When abdomen is involuntarily flex and is very hard → abdominal rigidity usually caused
by peritonitis
Abdominal Regions
- 4 quadrants
o Right upper
Right kidney
Gallbladder
Right renal artery
Transverse colon
Biliary tree
Biliary aa & vein
Pancreas (Head of)
o Left upper
Left kidney
Splenic Flexure
Stomach (fundus)
Spleen
Tail of the pancreas
Left renal aa
Aorta
o Right lower
Ascending colon
Small intestine
Right ovary
Right kidney
Lower portion of liver
Right common iliac
Cecum
Appendix
o Left lower
Descending colon
Sigmoid colon
Left common iliac vein
Small intestine
Left kidney
Inferior mesenteric artery
Left ovary
Left fallopian tubes
uterus
- 9 regions
o R/L hypochondriac
o Epigastric
o R/L lumbar
o Periumbilical
o R/L pelvic
o Suprapubic (AKA Hypogastric)
- 6 regions
o Epigastric
Duodenum
Pylorus
Liver (left lobe)
Pancreas
Ascending colon
Aorta (Celiac trunk, renal aa. & veins)
o RUQ
o LUQ
o RLQ
o LLQ
o Suprapubic
Diagnostic Imaging
- Barium swallow
o Uses barium sulfate → thick chalky substance
o Shows up very white on radiograph
o Can do upper GI study with a small bowel follow through
- Barium enema
o Barium or barium with air → forces barium against the wall
o Shows endothelial wall in detail
- CT scan with contrast
o Iodine based is injected by IV
Vascular tissues
Barium
- MRI scan with contrast
o IV contrast
o No real good for hollow organs
- Endoscopy
o Use of flexible fiber optic microscope
o From top EGD (Esophagogastroduodenoscopy) very common
o From bottom Anoscopy, Rectoscopy, sigmoscopy, colonoscopy
- KUB (Kidney Ureter Bladder)
o X-ray of abdomen (upright and supine)
o Cheapest and quick
o Not a great tool
o Helps see fluid lines
o Helps see if a mass is moving around
o M/c lesion: calcified lymph node
Follow lumbar or iliac chain
Can also find in mesentery and momentum
Common GI S/SX
Abdominal distension
Abdominal pain
Anorexia
Belching, bloating, flatulence
Bleeding
Constipation/Diarrhea
Nausea/vomiting
Heartburn/indigestion/dyspepsia
Hepatomegaly/splenomegaly
Hernias
Hiccoughs
Jaundice
Rectal Pain/itching
Abdominal Distension
- Mechanical Obstruction (inside or outside lumen a hollow viscous that physically causes
obstruction of fecal matter moving through the viscous)
o Neoplasm (intraluminal or extraluminal) (not found usually until late)
Extraluminal
• Baby
• Hernia
• Abscess from appendicitis
• Ovarian tumor
• Uterine tumor/mass
o Post-operative adhesions
o Abscess
Appendicitis
Chrohn’s
Diveritculitis
o Pregnancy
o Hernias
o Volvulus
Secum
Sigmoid
o Intussception-bowel goes inside self like telescope
Adhesions
Paralyzed persons (bowel doesn’t work as well)
Kid’s maybe hyper mobile bowel (not really sure though)
Trauma
Ischemia
- Non-mechanical Obstruction
o Adynamic illius(immobile bowel)
o Ascites
o Excess gas
o Trauma (set-belt injury)
o Infection
o Peritonitis
Take KUB (kidney, ureters, and bladder) x-ray as a start of diagnosing abdominal problems
5-19-03
Abdominal Pain
- Burning (sometimes described as gnawing)
PUD
GERD
Can be caused by nicotine, alcohol, mint
Can also be cardiac disease
- Cramping usually from organ distension)
Biliary colic (gall bladder disease – esp. gall stones)
IBD
IBS
MESENTERIC ISCHEMIA
- Colicky (crescendo – decrescendo pain pattern)
Renal stones (also called renal colic)
Biliary colic (gall bladder disease – esp. gall stones)
Appendicitis
- Achy
Constipation
Appendicitis (early stages)
AAA (saccular)
- Knife-like (usually very serious)
AAA (dissecting/saccular rupture)
Pancreatitis (stabbing in the mid back)
- Sudden onset
Perforation
Obstruction
Pancreatitis
Rupture ectopic
Focal
- Parietal pain
- Organ distension
- Peritonitis
Epigastric
- PUD (peptic ulcer disease)
- Gallbladder disease
- Hepatic disease
- Cardiac disease
- Pancreatitis
RUQ
- Biliary tree disease
- PUD
- Pancreatitis – tall end
- Renal disease
- Cardiopulmonary disease
LUQ
- PUD
- Pancreatitis
- Splenic disease
- Renal disease
- Cardiopulmonary disease
RLQ
- Late appendicitis
- Crohn’s disease
- Obstruction
- Reproductive disease
- AAA
LLQ
- Diverticulosis/itis
- Obstruction
- UC
- Reproductive disease
- AAA
Periumbilical
- Obstruction
- Early appendicitis
- AAA
- Mesenteric thrombosis
- Pancreatitis
Saccular AAA
- Most common
- Can hear bruits
Dissecting AAA
- Patients are extremely sick
- Usually die within 10 hours
- Bleed to death inside the vessel walls
- Does not widen the aorta very much
- Thoracic AAA are usually caused by trauma
- Lumbar more commonly in elderly (may see calcifications)
Abdominal Aortic Aneurysm
- S/Sx
o Most are asymptomatic (saccular)
o Pulsating sensation in the abdomen
o Abdominal pain (unchanged by position)
o Low Back Pain (unchanged by position)
o Bruit
o Radiating pain into legs
o Cold lower extremities, peripheral pulse loss
o Shock
o Sudden death
- Imaging
o Plain films – can see 75% of AAA
o MRI
o CT
- Treatment
o 3.5-5 cm – careful observation
o 5-7cm – elective surgery (10% rupture/year)
o >7cm – non-elective surgery (25% rupture/6 months)
o If symptomatic → non-elective
- Surgical procedures
o Open laparotomy
o Endoscopic stent placement
- < 50% with rupture survive
o Once ruptures you have minutes to a couple of hours to live
Picture of patient
- Patient has anorexia, cachexia (muscle wasting typically from malignancy), and ascites
- Patient has end stage metastatic cancer
Belching, Bloating, & Flatulence
- Aerophagia swallowing of air (most common reason)
- Insoluble carbohydrate ingestion
o Bacteria acts on and causes different kinds of gases
CO2, methane, etc…
- Malabsorption Syndromes
- Lactose intolerance
o Lack the enzyme lactase used to digest lactose
- Diarrhea
GI Bleeding
- Upper GI
o Ligament of Treats – Suspensory ligament of the duodenum @ the duo-jejunum
junction → junction between the upper and lower GI
o Esophageal varicies (dilated esophageal veins)
Causes by portal hypertension
Classically causes coffee ground emesis
o Esophageal cancer
o Esophagitis
o PUD (Peptic Ulcer Disease)
Usually coffee ground appearance
o Gastric Cancer
o Hiatal hernia
Fundus of stomach loops up toward esophagus
o Swallowed hemoptysis
Coughing up of blood from respiratory tract infection
o Hematemesis
Vomiting of bright red blood
• If bleeding in the mouth esophagus or acutely in the stomach
Acute upper GI bleed above the stomach or massive GI bleed into the
stomach
• Think esophageal disease
o Coffee ground emesis (special type of hematemesis)
Coffee ground appearance
Blood as been around long enough for stomach acids to denature the
proteins
- Lower GI
o Mesenteric Thrombosis
Thrombosis of mesenteric vascular that results in necrosis
More proximal to aorta the more serious
o Meckel’s Diverticulum
No pain but lots of bleeding
o Volvulus/Intussception
Volvulus Portion of valve twists upon itself
Intussception Part telescopes on itself
o Colon Cancer
o Colonic Polyps
o IBD (Crohn’s, UC)
o Diverticulosis/itis
o Hemorrhoids*
Varicose veins in anus
Most common cause of bleeding from the rectum
BRBPR (Bright Red Blood Per Rectum)
o Anal Fissures
o Hematochezia
Bright red blood in the rectum
95% from colon (sigmoid)
Most common cause is hemorrhoids
o Melena
Black tarry stools
Enzymes have worked on the stool to make it look black
Upper or Lower GI bleed that is chronic in nature that the patient has not
vomited up
o Blood streaked stool
Something inside the lumen of the colon that is bleeding as feces passes by
it
Usually means blood is more distal because it is still red
If proximal bleed the blood would get mixed in and the stool would not be
streaked
o Occult blood
Cannot be seen
Polyps or cancer
Detected by occult blood testing Hemoccult or fecal occult blood test or
guiac stool test
• Must have 3 normal tests to rule out bleeding
• 3 positive should be followed up on
Constipation/Diarrhea
- Constipation Decrease in the volume of stool
o Fecal Impaction
Loss of movement of fecal bolus in the colon
Caused by obstruction
Feces becomes very dry and very hard
o Poor Fiber Intake
o Poor Fluid Intake
o Colon Cancer
Pure constipation obstruction
Alternating constipation and diarrhea (floods with water to try to get rid of
constipation so causes diarrhea and then constipation because stops
producing fluid)
o IBD
o Psychiatric Causes
o Meds
o Hemorrhoids
o Most common cause is probably poor bowel hygiene
Not eating enough fiber or drinking enough water
- Diarrhea
o Infection
Viral gastroenteritis (stomach flu)
M/C cause
o IBD
o IBS
Spastic Colon
o Stress
o Colon Cancer
o Psychiatric Causes
o Meds
Parasympathomemetics (stimulate Parasympathetic)
o Increase in volume of loose stools
o Controlled by parasympathetic, increase in activity causes increase peristalsis
Nausea and Vomiting
- Infectious Gastroenteritis → stomach flu
o M/c reason
- Obstruction
o Proximal obstruction (small intestine and up) usually causes
o Picture: Volvulus of sigmoid colon
- Pregnancy
- Severe pain
- Cardiovascular Disorders
- Meds
- PUD
- GI Cancer
- Psychiatric Disorder
Hepatosplenomegaly
Hepatomegaly
Cirrhosis
o Most common cause is alcoholism → alcoholic hepatitis → cirrhosis
o Most common cause of hepatomegaly
o It takes 70 – 80% of damage to liver to start to see symptoms
Hepatitis
Pancreatic CA
Hepatobiliary CA
Cholangitis
o Inflammation of the bile ducts
o Associated with a Charcot’s triad
Late right-sided CHF
Infectious mono
o Epstein Bar virus
Lymphoma
Leukemia
o Affects younger kids and older people
Splenomegaly
Anemias
o Not basic iron-deficiency but the more serious anemia’s
Infectious mono
HIV
Leukemia
Lymphoma
Myeloma
o Cancer of the bone marrow (plasmocyts)
o Multiple myeloma is the most common primary bone tumor
Polycythemia vera
o Severe over production of blood cells
Hernias
Groin
o Inguinal (96%)
Direct
Indirect
o Femoral (4%)
Occur in women in femoral triangle
Umbilical
o Usually in pregnant women
Incisional
Hiatus
Hiccoughs
- Yellow color of the skin and sclera because of the build up bilirubin
- Can cause uncontrolled itching
- Direct Bilirubin
o From Liver
o Extrahepatic obstruction (outside liver)
Calculi, neoplasm, stricture (of collecting duct system from a tumor or
passage of a stone)
Metastatic CA, pancreatic CA (in head of the pancreas)
o Hepatocellular disease
Hepatitis (alcoholic and non-alcoholic form)
Cirrhosis
o Meds (eg. Estrogen)
o Jaundice of pregnancy (hormonal cause)
- Indirect Bilirubin
o Away from liver
o Hemolysis
Congenital anemia’s (sickle cell)
Acquired anemias
o Poor marrow production
o Neonatal Jaundice (treatment by putting under UV light)
o Impaired conjugation of bilirubin from meds
END GI MATERIAL
GU Signs and Symptoms
CVA Pain
- Nephrolithiasis (kidney stones Ca+ based – 80%) – Murphy’s punch test: kidney
infection
- Pyelonephritis → infection of renal pelvis – upper UTI
o Most common from a poorly treated or untreated lower UTI
- Glomerulonephritis (inflammation of glomerulus- aseptic inflammation post strep
infection)
o This is why pt with strep throat must complete their antibiotics
o Mistaken for kidney stone
- Renal Cancer → AKA: hypernephroma old term – one of the fastest growing metastasis
- Renal abscess → people with chronic renal disease, diabetics (most common), IV drug
users, patients with TB
- Spinal disorder
Dysuria
- Painful urination
- Cystitis (Urinary Bladder Infection)
o Infasimatacis Cystitis
Air in the bladder wall
o E. Coli most common bacteria to cause infection
o Diabetics get cystitis a lot
o More common in women
Urethra is shorter in women – shorter pathway for bacteria
Wiping from P to A instead of A to P
Holding the urge to pee
- Urethritis
o Usually infectious
o Causes: Gonorrhea (gonococcal urethritis), Chlamydia (Most Common) (non-
specific or non-gonococcal urethritis)
- Vaginitis
o Inflammation of the vaginal introitus (opening)
Poor hygiene Fungal Infection Candida Albicans (Yeast Infection)
- Prostatitis
o Bacterial Prostatitis (Septic)
o Septic Prostatitis
Both very painful
Can be caused by stones
- Chemical Irritants
o Latex on a condom, Meds, Laundry Detergents, Lubricants, Douche, Deodorant
spray
- Urethral Diverticulum
o Outpouching from a hollow viscus in the ureter (rarely urethra)
Can become infected and cause pain
Can be from high pressure in the system (stone), congenital weakness in the
wall
- Bladder CA
o Usually asymptomatic
o Very aggressive
Polyuria
Urethral Discharge
- Two types
o Gross
o Microscopic
- M/C causes is menstruation
- Painless has worse prognosis (CA, don’t notice, chronic)
- T.I.C.S.
o Trauma
Renal damage
Severe Exercise
o Tumor
Bladder Cancer
Renal cell carcinoma
o Infection
Glomerulonephritis → infectious and noninfectious
• Secondary to strep throat
Pyelonephritis
• Infection of the kidneys
• Cystitis most common in bladder
o Calculi
Kidney stones
• Calcified stones (gallstones made with cholesterol)
• Form b/c of stasis in system that slows the urine down
o Cysts (renal)
Over 50% of population has renal cysts
o Surgery
o Sickle Cell Disease (Ischemia, Infarction, and Infection)
Due to abnormally shaped RBC
Oliguria/anuria
• Reduced/failure to urinate
• < 100 ml = anuria
• < 500 ml to 600 ml = oliguria
• Renal failure = DM
o TX: dialysis, transplant
• Kidney failure = uremia
o Affects BP, acid/base balance, electrolytes
• ↓ fluid intake = usually oliguria
o can only go w/o fluid for 48-72 hrs
• Strenuous exercise
• Sweat the most when sleeping (besides exercise)
• CHF can cause renal failure
• Pre-renal failure = m/c not enough blood going to kidneys
• Intrarenal failure = problem in actual kidney
• Postrenal failure = obstruction past the kidneys
• Can function with 70% loss
Pelvic Pain
- referring anteriorly
- M/c cause = constipation (left side)
- Pelvis is triangle b/w both ASIS and pubic symphysis
• Dysmenorrhea
o Painful menstruation (outside normal)
o Cause: thyroid problem, infection, premenopause, fibroids, endometriosis
• Fibroids
o Benign tumor of uterus (leiomyoma → smooth muscle tumor with fibrous tissue)
o Found on plain films of lumbar spine – very common
o Possible to become malignant
o Can be very large → can make women think they are pregnant
• Adhesions after surgery
• Cystitis → m/c cause = e. coli
• Endometriosis
o Abnormal deposition of endometrial tissue outside of the uterus
• IBD → Chrohn’s, Ulcerative Colitis
Proteinuria