PD gastroenterology

Spleen percussion Location: ___ ( ) percuss triangle picture

left lower anterior chest wall (Traube's space) left lower anterior chest from cardiac dullness (6th rib) to left anterior axillary line and down costal margin (traubes space)

Liver palpation feel for patients normally it is __,__ and __ with __

livers edge to hit finger soft, sharp, and regular with smooth surface

anorexia

loss of appetite

Sphincter of oddi

muscular valve that controls the flow of digestive juices through the ampulla of vater.

normoactive bowel sounds

normal range is 5-35 a minute

Auscultation of bruits Auscultate with locations: - - - -

Bell abdominal aorta: midline between xiphoid and umbilicus renal artery: 1-2 inches lateral of midline in upper quadrants iliac artery: midpoint on line drawn from umbilicus to ASIS femoral artery: midpoint in groin crease

Associated upper GI symptoms Regurgitation obstipation

not actually vomiting but raising of esophageal content without nausea or retching severe constipation with inability to pass stool and gas

dysuria

pain when peeing

Kidney percussion (CVA tenderness) Place

palm along the CVA (costovertebral area) and strike with fist

Kidneys protected by kidney pain at

11th and 12th rib costovertebral angle (CVA tenderness)

Health promotion and counseling: Colonoscopy screening Start screening for one or more first-degree relative with colon cancer

40 years

Exam tips 1. 2. 3. 4. 5. Examine tender areas 6. 7. very important to 8.

5. LAST 7. watch the patients face

Screening protocol for alcohol - - - - Another screening

CAGE C: do you need to cut down A: Has anyone else felt annoyed G: Guilty E: Eye opener (drink first thing in the morning) AUDIT

Associated lower GI symptoms Constipation ≥

Less than three bowel movements per week ≥25% or more defecations with straining or sensation of incomplete evacuation

Right upper quadrant organs __,__,___,__,__,__

Liver, gallbladder, pylorus, duodenum, hepatic flexure of colon, head of pancreas

absent bowel sound

No sounds in any area for 2 minutes or longer of listening

Associated upper GI symptoms Heartburn: Indigestion

Rising retrosternal burning pain or discomfort occurring > weekly distress associated with eating

Health promotion and counseling: Colonoscopy screening Start screening for average risk? Stop screening

Start screening at 45 >75 (if life expectancy is less than 10 years) if they are healthy still screen

Colonoscopy screening Types of tests 1. - - - 2. - ___ gold standard - -

Stool based test -highly sensitive fecal immunochemical FIT every year -highly sensitive guaiac based fecal test -multi targeted stool DNA test every 3 years Visual exam of colon and rectum -colonoscopy: gold standard -CT colonography -flexible signoidoscopy every 5 years

Inspection Skin - - - - __:

Temperature Color Scars Striae: old silver striae or stretch marks are normal

Hematemesis: - - - Anorexia early satiety What to ask with dysphagia

Vomitus that contains blood -coffee grounds -bloody -quantify loss or lack of appetite -food fear -self image abd fullness after light or moderate meals solid, liquid or both?

Inspection of pulsations - - Look for __: should be if ascites, pregnancy or hernias they can have You can see

abdominal aorta pulsations Contour: should be flat bulging flanks peristalsis ascites in the picture (protuberant)

Health promotion and counseling __ Moderate: women men unsafe drinking women men Binge drinking women Men

alcohol screening </= 1 drink/day </= 2 drink/day >3 drinks/day and > 7 wks/week >4 drinks/day and >14 drinks/week >4 drink on one occasion >5 drinks on one occasion

Percussion Percuss in Helps discern __ vs __ vs __

all 4 quadrants solid vs fluid vs air filled areas

Health promotion and counseling: Hepatitis A vaccine for which populations: - - - -

all children at age 1 unstable housing increased risk for infection people who want immunity

Aorta palpation Detect by Signifies AAA what increases as AAA enlarges

applying firm pressure on epigastrium >/= 3 cm (should be 2 cm) sensitivity

Percussion for ascites: central tympany A protuberant abdomen with bulging flanks is suspicious for most complication of What will you find

ascites cirrhosis shifting dullness

melena hematochezia is it on __ stool or __ stool

black tarry stool bright red in stool is it on the stool or mixed in the stool

Associated lower GI symptoms Changes in ___ - ___ ( )

bowel function Jaundice (skin itch)

Right lower quadrant __,__,__,___,__

cecum, appendix, ascending colon, terminal ileum, and right ovary

Associated lower GI symptoms Tenesmus: __,__,__

constant urge to defecate with pain, cramping, or involuntary straining

Friction rubs __,__ - hear where? __ or __

course, scratching sound -liver or spleen

Somatic or parietal pain __ ( ) More __ and __ Patient needs to

inflammation of parietal peritoneum (peritonitis) precise over structure and severe lie still

Auscultation of bowel sounds Auscultate with -Where

diaphragm -All 4 quadrants at least 2 sites in each qudarant

Medical interview of patient with abdominal pain: what is most common inciting event?

eating: how did the pain start

Spleen percussion When enlarged it will __,__ and __ becomes palpable %

expands anteriorly, downward, and medially into traubes space palpable below costal margin 60-80% accurate in measuring splenomegaly

Record findings Abdominal inspection - - - - Bowel sounds - - -

falt protuberant striae present.. scar located.. •Normoactive bowel sounds •Hypoactive bowel sounds •Hyperactive bowel sounds

Associated upper GI symptoms Nausea- Retching-

feeling sick to my stomach involuntary spasms of stomach, diaphragm and esophagus that precedes vomitting

Referred pain sometimes ex:

felt in distant sites that are innervated at same spinal levels non-tender in area of pain Gallbladder pain goes to right shoulder

early satiety

get full quicker

Health promotion and counseling: Hepatitis B recommended for __ and __ Example: - - - -

high-risk groups and settings sexual activity health care workers IV drug users diabetics

Visceral pain Specific or non-specific? Easy or difficult to localize?

hollow abdominal organs contract or stretch forcefully non-specific difficult

Percussion Air-filled (gas, gastric bubble): __,__ solid (stool): __,__ Fluid (urine): __,__

hollow, tympanic sound dull, resonant dull in lower area, hollow in upper area

Initial screening for alcohol

how many times in the past year hav you had 4 or more drinks in a day (women) or 5 (men)

Cholecystitis: Murphy sign 1. 2. Ask patient to 3. positive sign is when patient implies

palpate liver for tenderness ask patient to take a deep breath and breath out, as they breath out push in "splints" or cannot take a deep breath because of pain gallbladder disease

Abdominal profiles 1. 2. 3. 4. protuberant usually for

pregnant women

Appendicitis: Rovsing's sign Perform on Positive (suggestive of __)

press deeply into left lower quadrant and quickly withdraw fingers (rebound tenderness) on opposite side rebound pain referred to the RLQ when you examine the LLQ. (appendicites)

Hernias: if you suspect but do not see umbilical or incisional hernia, ask patient to positive

put chin to chest or perform valsalva to increase intraabdominal pressure it will pop out

Assessing signs for possible peritonitis - - - - -

rebound tenderness positive cough guarding percussion tenderness rigidity

Dyspepsia = - __ or __ AND __ or __

recurrent pain centered in upper abdomen epigastric pain or burning AND postprandial fullness or early satiety

Appendicites: psoas and obtruator signs Psoas sign __ or __ Obtruator sign __ and __

resisted hip flexion or passive side lying hip extensive will be painful Passive hip and knee flexion with internal rotation at hip will be painful

Kidneys location palpable? normally, the urinary bladder

retroperitoneal not palpable unless enlarged is not palpable unless distended above pubis symphysis

Hyperactive bowel sounds __,__,__ with __ or __

rushes, borborygmi, gurgles with hunger or disease

Left lower quadrant __,__,__

sigmoid colon, descending colon, left ovary

Bowel sounds Hypoactive associated with

slow, sluggish acute abdomen

Left upper quadrant organs __,__,__ and __/__

spleen, splenic flexure of colon, stomach and body/tail of pancreas

Spleen picture palpation ask patient to

take deep breath like with liver

Liver percussion From umbilicus From nipple line normal span - -

tympany to dullness resonance to dullness 6-12 cm in right midclavicular line 4-8 cm in midsternal line

Appendicitis Pain pattern: starts at __ and __ Localized tenderness: assess for __ and __ - location of appendix Perform __ and __ exams

umbilicus and shifts to right lower quadrant muscle rigidity and a +McBurneys point (3x more likely if positive) -2/3 b/w umbilicus and ASIS Rectal and pelvic exams

Ampulla of vater = distinguises

union of the pancreatic and common bile duct, distinguishes transition of foregut to midgut.

Health promotion and counseling: Hepatitis C These tests are Regimens that can achieve high rates of sustained virologic response? USPTF recommends screening in adults aged

very sensitive antiviral treatment 18-79 at least 1 time

hematemesis

vomit with blood

shifting dullness: when patient turns to side more sensitive than

when patient turns to side the bubble will move and change area of dullness fluid wave test

Splenic percussion sign

when spleen size is normal the percussion noise remains tympanic despite downward displacement by diaphragm

Abdominal palpation Deep palpation - - - - use

•Delineates organ edges •Abdominal masses •Pain •Rebound tenderness (after you push and lift your hand pain occurs) two hands 2-3 inches deep

Describing enlarged organs

•Hepatomegaly •Splenomegaly •Hepatosplenomegaly

Order of examination for GI 1. 2. ___: do not 3. 4.

•Inspection •Auscultation: Do not disturb bowel contents •Percussion •Palpation

Associated lower GI symptoms Diarrhea = Occurs ___ -acute: -persistent: -chronic:

•Painless loose or watery stools during >75% of defecations >3 or more times a day <14 days 14-30 days >30 days

•Describing abdominal palpation - - - - -

•Soft •Nontender •Rigid, boardlike •Guarding •Rebound tenderness

Abdominal palpation Light palpation for - - - - use

•Superficial organs •Masses •Hernias •Tenderness of increased resistance one hand worm movement

Associated lower gastrointestinal: Urinary symptoms - - __ and __ - - - __ and __

•Suprapubic Pain •Polyuria and Nocturia (pee at night) •Urinary Incontinence •Hematuria •Flank Pain and Ureteral Colic