advanced physical assessment - The abdomen

•Stomach emptying time is ______ hours

6

1. A new mother asks the nurse how much weight loss is expected of the baby after birth. The most accurate reply is a. 10-15% b. 5-8% c. 4% d. None

Ans: (B) A weight loss of 5-8% of a newborn's weight within 3-4 days of life is normal. This is due to passage of urine and feces, and also of metabolic and physiologic adjustments to extrauterine feeding.

15. A daycare worker presents to your office with jaundice. She denies IV drug use, blood transfusion, and travel and has not been sexually active for the past 10 months. Which type of hepatitis is most likely? A) Hepatitis A B) Hepatitis B C) Hepatitis C D) Hepatitis D

Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: The lack of contact with blood and body fluids makes hepatitis B, C, and D unlikely. She regularly changes the diapers of her clients and is at risk for hepatitis A. Vaccine against hepatitis A is recommended for daycare workers.

Pink-purple striae on the abdomen are a hallmark of

Cushing syndrome

Name the type of Incontinence: Incontinence on the way to the toilet or only in the early morning.

Functional Incontinence

Name the type of Incontinence: Problems in mobility resulting from weakness, arthritis, poor vision, or other conditions.

Functional Incontinence

Name the type of Incontinence: The patient is functionally unable to reach the toilet in time because of impaired health or environmental conditions.

Functional Incontinence

you heart a bruit in the abdomen. what is the next step of assessment?

If bruits are heard, DO NOT PALPATE the abdomen

Name the type of Incontinence: Drugs may contribute to any type of incontinence listed.

Incontinence Secondary to Medications

what and were is Castell's point?

Look for a splenic enlargement by percussing in Castell's point (the most inferior interspace on the left anterior axillary line) as the patient takes a deep inspiration. Percussion that changes from tympanitic to dull as the patient takes a deep breath suggests splenomegaly

name the diagnosis: •chronic inflammatory disorder of colon & rectum: with bloody, frequent watery diarrhea, weight loss, fatigue, debilitation; predisposes to rectal carcinoma

Ulcerative Colitis

Tympany in the abdomen represents what?

air/gas

Involuntary voiding or lack of awareness suggests

cognitive or neurosensory deficits.

patient has gnawing epigastric pain that is received by eating. what does this suggest?

peptic ulcer

name the order of abdominal assessment (inspection, percussing, auscultate, palpating)

•Always auscultate before palpating or percussing the abdomen

which kidney is rarely palpable?

A normal left kidney is rarely palpable.

A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an

AAA

1. Which of the following assessment findings in a newborn baby is considered normal? a. Passage of green sticky stools within the first 24 hours b. Respirations of 75 per minute while at rest c. Yellowish skin and sclera after 6 hours of birth d. Frank bleeding at the umbilicus

Ans: (A) Meconium is the greenish and sticky stool of the newly born baby. It is normally passed within 24 hours of birth.

1. A woman complaining of right lower abdominal pain was admitted to the unit for a possible ectopic pregnancy. Which of the following data on the client's history can be responsible for this condition? a. Age under 20 b. Asthma c. Previous long-standing chlamydial infection d. Previous spontaneous abortion

Ans: (C) Sexually transmitted disease that progressed to pelvic inflammatory disease can cause ectopic pregnancies secondary to strictures of the fallopian tube.

17. Mrs. LaFarge is a 60-year-old who presents with urinary incontinence. She is unable to get to the bathroom quickly enough when she senses the need to urinate. She has normal mobility. Which of the following is most likely? A) Stress incontinence B) Urge incontinence C) Overflow incontinence D) Functional incontinence

Ans: B Chapter: 11 Page and Header: 418, The Health History Feedback: Stress incontinence occurs with increased intra-abdominal pressure such as with coughing, sneezing, or laughing. This history is most consistent with urge incontinence secondary to detrusor overactivity. Overflow incontinence occurs with anatomic obstruction such as prostatic hypertrophy (obviously not in this case, as the patient is a woman), urethral stricture, or neurogenic bladder. Functional incontinence results from lack of mobility severe enough to impair getting to the bathroom quickly enough.

16. Linda is a 29-year-old who had excruciating pain which started under her lower ribs on the right side. The pain eventually moved to her lateral abdomen and then into her right lower quadrant. Which is most likely, given this presentation? A) Appendicitis B) Dysmenorrhea C) Ureteral stone D) Ovarian cyst

Ans: C Chapter: 11 Page and Header: 418, The Health History Feedback: The presentation of right flank pain spiraling down to the groin is typical of a ureteral stone. There would most likely be microscopic hematuria as well. The migration pattern of this condition makes the others less likely.

12. Bill, a 55-year-old man, presents with pain in his epigastrium which lasts for 30 minutes or more at a time and has started recently. Which of the following should be considered? A) Peptic ulcer B) Pancreatitis C) Myocardial ischemia D) All of the above

Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Epigastric pain can have many causes. History and physical will help discern which causes are most likely, but it is important to realize that any of the above, including myocardial ischemia, is always a possibility. Pneumonia and gallbladder pain can also cause pain in this location.

when may the liver size estimate be falsely increased?

Dullness from a right pleural effusion or consolidated lung, if adjacent to liver dullness, may falsely increase estimated liver size.

what is an abnormal finding when palpating the liver?

Firmness or hardness of the liver, bluntness or rounding of its edge, and surface irregularity are suspicious for liver disease.

what bowel sounds would you hear in an early intestinal obstruction

Increased

Name the type of pain (Visceral, Parietal, Referred): This type of pain is more severe and is usually easily localized

Parietal

Name the type of pain (Visceral, Parietal, Referred): : This pain occurs when there is inflammation from the hollow or solid organs that affect the parietal peritoneum.

Parietal

Where is the cecum located?

RLQ

Where is the gallbladder located?

RUQ, inferior to liver

what time pf incontinence arises from decreased intraurethral pressure?

Stress incontinence

other than percussing, what 2 tests should be conducted to confirm ascites?

Test for shifting dullness. Test for a fluid wave.

Rigidity is:

an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations.

•patient presents with pain: -have patient ________ to localize the pain

cough

what technique when palpating can be helpful when a patient is obese?

hooking technique.

A patient with jaundice and Dark urine indicates

impaired excretion of bilirubin into the GI tract.

Odynophagia definition

painful swallowing

what are the mechanisms of jaundice?

● Increased production of bilirubin ● Decreased uptake of bilirubin by the hepatocytes ● Decreased ability of the liver to conjugate bilirubin ● Decreased excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood

where is the "McBurney point"?

"McBurney point" lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus Just below the middle of a line joining the umbilicus and the anterior superior iliac spine (McBurney point)

•Iliopsoas Muscle Test can help rule out:

(r/o appendicitis)

•Obturator test can help rule out

(r/o appendix rupture or pelvic abscess)

How deep is light palpation?

1-2 cm

A palpable liver does not necessarily indicate hepatomegaly. Percussion may show some enlargement, too. what are reasons for these findings in normal livers?

1. Downward Displacement of the Liver by a Low Diaphragm 2. Normal Variations in Liver Shape

what are causes of Nocturia With High Volumes?

1. Most types of polyuria 2. Decreased concentrating ability of the kidney with loss of the normal drop in nocturnal urine output (Chronic renal insufficiency due to a number of diseases) 3. Excessive fluid intake before bedtime 4. Fluid-retaining, edematous states. Daytime accumulation of dependent edema that is excreted at night when the patient is supine (Heart failure, nephrotic syndrome, hepatic cirrhosis with ascites, chronic venous insufficiency). Edema and other symptoms of the underlying disorder; urinary output during the day may be reduced as fluid accumulates in the body tissues

How would you to detect splenomegaly

1. Percuss the left lower anterior chest wall. percuss roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space. 2. Check for a splenic percussion sign. Percuss the lowest interspace in the left anterior axillary line (Fig. 11-22). This area is usually tympanitic. Then ask the patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains tympanitic.

you are percussing the liver. whats the normal size on the midsternal line?

4 - 8 cm

diarrhea goes from acute to chronic at what time?

4 weeks or more

how deep is deep palpation?

4-6 cm

you are measuring the liver size with percussion. what are the normal measurements?

4-8 cm in midsternal line 6-12 cm in right midclavicular line

you are percussing the liver. whats the normal size on the midclavicular line?

6 - 12 cm

If a patient has hypertension and you hear a bruit in the abdomen that has systolic and diastolic components, what would this suggest?

A bruit in one the epigastrium, either upper quadrant, or CVA that has both systolic and diastolic components strongly suggests renal artery stenosis as the cause of hypertension

describe an abdominal Tumor and assessment findings (percussion).

A large solid tumor, usually rising out of the pelvis, is dull to percussion. Air-filled bowel is displaced to the periphery. Causes include ovarian tumors and uterine fibroids. Occasionally, a markedly distended bladder is mistaken for such a tumor.

describe an Umbilical Hernia

A protrusion through a defective umbilical ring is most common in infants but also occurs in adults. In infants, it usually closes spontaneously within 1-2 yrs.

what does a positive murphy sign look like?

A sharp increase in tenderness with inspiratory effort is a positive Murphy sign.

describe an Epigastric Hernia

A small midline protrusion through a defect in the linea alba occurs between the xiphoid process and the umbilicus. With the patient coughing or performing a Valsalva maneuver, palpate by running your fingerpad down the linea alba.

what is a venous hum?

A venous hum is a rare soft humming noise with both systolic and diastolic components. It points to increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis.

Intrahepatic jaundice can be , from damage to the hepatocytes, or cholestatic, from impaired excretion as a result of damaged hepatocytes or intrahepatic bile ducts. Extrahepatic jaundice arises from obstruction of the extrahepatic bile ducts, most commonly the common bile ducts.

A: hepatocellular

Intrahepatic jaundice can be _____A_______, from damage to the hepatocytes, or ______B_________, from impaired excretion as a result of damaged hepatocytes or intrahepatic bile ducts.

A: hepatocellular B: cholestatic

what kind of bowel sounds would you hear in paralytic ileus?

Absent bowel sounds

Tenderness in the RLQ may indicate what?

Acute Appendicitis The typical area of tenderness, McBurney point, is illustrated. Examine other areas of the right lower quadrant as well as the right flank.

Tenderness and rigidity during palpation of the RUQ could indicate what?

Acute Cholecystitis

Local causes of peritoneal inflammation include:

Acute Cholecystitis, Acute Pancreatitis, Acute Diverticulitis, Acute Appendicitis

tenderness over the LLQ may indicate what?

Acute Diverticulitis Acute diverticulitis is a confined inflammatory process, usually in the left lower quadrant, that involves the sigmoid colon. If the sigmoid colon is redundant there may be suprapubic or right-sided pain. Look for localized peritoneal signs and a tender underlying mass. Microperforation, abscess, and obstruction may ensue.

Tenderness, rebound tenderness during palpation of the epigastric area could indicate what?

Acute Pancreatitis

what are aggravating and relieving factors in Chronic Pancreatitis?

Aggravating Factors: Alcohol, heavy or fatty meals Relieving Factors: possibly leaning forward with trunk flexed; often intractable

what are aggravating and relieving factors in Biliary Colic?

Aggravating Factors: Fatty meals but also fasting; often precedes cholecystitis, cholangitis, pancreatitis Relieving Factors: none

what are aggravating and relieving factors in Acute Bowel Obstruction?

Aggravating Factors: Ingestion of food or liquids Relieving Factors: none

what are aggravating and relieving factors in Acute Cholecystitis?

Aggravating Factors: Jarring, deep breathing Relieving Factors: none

what are aggravating and relieving factors in Acute Pancreatitis?

Aggravating Factors: Lying supine; dyspnea if pleural effusions from capillary leak syndrome; selected medications, high triglycerides may exacerbate Relieving Factors: Leaning forward with trunk flexed

what are aggravating and relieving factors in Acute Appendicitis?

Aggravating Factors: Movement or cough Relieving Factors: If it subsides temporarily, suspect perforation of the appendix.

what are aggravating and relieving factors in Pancreatic Cancer?

Aggravating Factors: Smoking, chronic pancreatitis Relieving Factors: Possibly leaning forward with trunk flexed; often intractable

what are aggravating and relieving factors in Gastric Cancer?

Aggravating Factors: food Relieving Factors: Not relieved by food or antacids

what are aggravating and relieving factors in Acute Diverticulitis?

Aggravating Factors: none Relieving Factors: Analgesia, bowel rest, antibiotics

A patient is being screened for liver disease and is an alcoholic. what are they at high risk for?

Alcoholic hepatitis or alcoholic cirrhosis

describe an Irregular Large Liver and when you would see it

An enlarged liver that is firm or hard with an irregular edge or surface suggests hepatocellular carcinoma. There may be one or more nodules. The liver may or may not be tender.

1. The nurse is reviewing literature on a client's symptoms known as biliary colic. Which of the following is not consistent with biliary colic? a. Poorly localized periumbilical pain, followed usually by right lower quadrant pain b. Steady, aching; not colicky pain c. Sudden obstruction of the cystic duct or common bile duct by a gallstone Epigastric or right upper quadrant, may radiate to the right scapula and shoulder

Ans: (A) Biliary colic is caused by sudden obstruction of the cystic duct or common bile duct by a gallstone. The pain in biliary colic is steady and aching but not colicky and is felt in the epigastric or right upper quadrant that may radiate to the right scapula and shoulder.

1. The nurse is taking the history of a client with suspected colorectal cancer. Which of the following is NOT an indication of high risk for colorectal cancer? a. History of appendicitis in the recent 3 years b. History of inflammatory bowel disease c. Single small adenoma (<1 cm): 3 to 6 years after initial polypectomy d. Single large adenoma (>1 cm), multiple adenomas, adenoma with highgrade dysplasia or villous change: within 3 years of initial polypectomy

Ans: (A) Colonoscopy is indicated for the following increased risk factors: single small adenoma <1 cm): 3 to 6 years after initial polypectomy, single large adenoma (>1 cm), multiple adenomas, adenoma with highgrade dysplasia or villous change: within 3 years of initial polypectomy, history of resection of colorectal cancer: within 1 year after resection, any first-degree relative younger than 60 years, two or more first degree, relatives with either colorectal cancer or adenomatous polyps: at age 40 or 10 years before youngest case in immediate family, whichever is earlier, familial adenomatous polyposis or nonpolyposis colon cancer, and history of inflammatory bowel disease, chronic ulcerative colitis, or Crohn disease.

1. A nurse in a hospice care facility is caring for a 70-year old coherent bedridden client who reports abdominal fullness and discomfort. Upon digital rectal examination, the nurse notes fecal mass that is large, firm and immovable. Which of the following questions asked by the nurse should take priority? a. "When was the last time you had a bowel movement?" b. "When was your last meal?" c. "What did you eat in the last 24 hours?" d. "When was the last time you took your medication for hypertension?

Ans: (A) Fecal impaction is characterized by the presence of a large, firm and immovable fecal mass in rectum. It is characterized by rectal fullness, abdominal pain, and diarrhea around the impaction. It is common in debilitated, bedridden, and elderly patients. It would be pertinent to ask about last bowel movement in this case.

1. The nurse is doing the history of a patient with pain that ifs felt in the epigastric area. Which of the following cluster of client manifestations are considered "alarm symptoms" for gastric cancer? a. Dysphagia, odynophagia, coffee ground emesis b. Weight loss, diarrhea, dehydration c. Recurrent vomiting, 2cm x 2cm lump on the upper right quadrant, fever d. Hematochezia, hematemesis, epistaxis

Ans: (A) Red flags or alarm symptoms for gastric cancer include: difficulty swallowing (dysphagia), pain with swallowing (odynophagia), recurrent vomiting, and evidence of gastrointestinal bleeding (coffee ground emesis), weight loss and anemia.

1. A client with chest pain tells the nurse that he also feels the pain on the jaw and the shoulder. The nurse understands that this type of pain is called a. Referred pain b. Parietal pain c. Muscular pain d. Visceral pain

Ans: (A) Referred pain is felt in more distant sites that share the same innervations as the source of pain. 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.

1. A woman with a history of 3 normal deliveries and one caesarian section that are all uneventful is being seen by the nurse on the examining table. When assessing her abdomen, the nurse asks the client to raise her head while lying down. She notes a vertical ridge in the abdomen of the client that seems to separate the abdomen into left and right portions. Auscultation, percussion and palpation did not reveal any abnormality. The client denies any pain or discomfort. What is the best nursing action? a. Document the findings b. Inform the physician immediately c. Put the client on NPO d. Administer an enema

Ans: (A) Separation of the two rectus abdominis muscles, through which abdominal contents form a midline ridge when the patient raises head and shoulder, is called diastasis recti. It is often observed in repeated pregnancies, obesity, and chronic lung disease and it has no clinical significance.

1. The nurse is examining a patient who reported dull pain in the upper right quadrant of the abdomen. The nurse also notes that the client has an enlarged abdomen and does percussion if the enlargement is due to ascites or to bloating. Which of the following assessment findings are true? a. If the client sits upright, percussion reveals tympany over the entire upper abdomen and dullness on the lower abdomen b. If the client turns to the left while lying on the examining table, dullness shifts to the more dependent side, and tympany shifts to the top. c. If the patient lies prone on the table, the tympany is noted on the client's right side only d. If the patient lies prone, the dullness is felt over the entire back

Ans: (B) Ascitic fluid characteristically sinks with gravity, whereas gas-filled loops of bowel float to the top. Percussion gives a dull note in dependent areas of the abdomen. In a person without ascites, the borders between tympany and dullness usually stay relatively constant.

1. A patient has been found to have pancreatic insufficiency and is showing signs of malabsorption. The client reports passing stools that are "fatty, frothy, foul-smelling and floating." The nurse is sure to document this subjective finding as a. Melena b. Steatorrhea c. Acholic stools d. Hematochezia

Ans: (B) In pancreatic insufficiency, there is defective absorption of fat, including fat-soluble vitamins, with steatorrhea (excessive excretion of fat). The stools are typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul smelling and usually floats in the toilet.

1. A mother takes her 2 year old child to the emergency department after the child suddenly lets out a loud cry and saying that her tummy hurt. The nurse notes "currant jelly" looking stools on the child's diaper. Diagnostic tests reveal telescoping of the bowel into itself. The nurse suspects which condition? a. Biliary colic b. Intussusception c. Protrusion of an hernia d. Fecal impaction

Ans: (B) Intussusception is the telescoping of the bowel into itself. The client reports colicky abdominal pain, abdominal distention, and often "currant jelly" looking stools (red blood and mucus).

1. A nurse is preparing a 3-day old newborn for discharge. As she evaluates the baby, she observes a yellowish tinge on the client's forehead after briefly pressing the skin. The nurse understands that this indicates a. An infectious liver disorder b. A normal biologic response c. An Rh incompatibility problem d. Related to breastfeeding

Ans: (B) Jaundice that appears after 24 hours of birth is called physiologic jaundice. It is caused by accelerated destruction of fetal RBC's, immature conjugation of bilirubin, and increased reabsorption of bilirubin from the intestines. These conditions are not pathologic.

1. During the assessment of a 2-day old newborn, the nurse notes bruising and cephalhematoma. The baby also appears jaundiced. The nurse observes the mother breastfeeding her newborn. What is the most probable interpretation of the jaundice? a. Pathologic jaundice that necessitates blood transfusion b. Hyperbilirubenemia due to the bruising and cephalhematoma c. Breast milk jaundice d. Hyperbilirubinemia caused by Rh incompatibility

Ans: (B) The increased bilirubin levels are caused by the bruising and cephalhematoma secondary to free circulating bilirubin from the reabsorbed blood that had been displaced. Pathologic jaundice is evident in the first 24 hours of life while breast milk jaundice is seen after a week.

1. A nurse is reviewing the client's records from an earlier shift and notes that the result of the barium enema revealed "apple core" lesions on the sigmoid colon. The client is passing pencil-like stools. Which disorder is the nurse most likely considering? a. Gastric cancer b. Colon cancer c. Diverticulitis d. Chron disease

Ans: (B) Thin, pencil-like stool occurs in an obstructing "apple core" lesion of the sigmoid colon. The nurse considers colon cancer if the above are accompanied by the following: melena, hematochezia, diarrhea, constipation, feeling of incomplete bowel emptying, bloating, cramps weight loss and fatigue.

1. The nurse admits a client with intermittent colicky pain at the left lower quadrant of the abdomen. Which type of pain is the client referring to? a. Muscular pain b. Visceral pain c. Referred pain d. Parietal pain

Ans: (B) 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. Visceral pain may be difficult to localize. It is typically palpable near the midline at levels that vary according to the structure involved. Visceral pain 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.

1. A client presenting with upper right quadrant steady pain is getting frantic about his stools that has turned grey. Which of the following nursing response will correctly address the client's concern? a. "Your body cannot digest food properly because it lacks the enzymes that turn stools brownish or greenish" b. "Bile, the substance in your gallbladder that gives color to the stool, has been totally blocked from flowing to your intestines" c. "The bacteria that are causing your infection have spread to affect your bowels as well." d. "You are deficient in an important mineral that is affected by your disorder."

Ans: (B) When excretion of bile into the intestine is completely obstructed, the stools become gray or light colored, or acholic, without bile.

1. A 21-year old woman is being seen at the emergency department due to right lower abdominal pain. She has missed her period for two consecutive months. She feels weak and dizzy. The nurse knows to prioritize which of the following nursing actions? a. Continue assessing by palpating the abdomen b. Perform a pregnancy test c. Apply hot compress to the affected area. d. Inspect the abdomen for ascites

Ans: (B) With the given findings of lower abdominal pain and missed periods, the nurse suspects ectopic pregnancy especially if accompanied by other symptoms like rigidity of abdominal muscles, weakness and dizziness. Palpating the abdomen is contraindicated as the risk of rupturing the fallopian tube is high.

1. The nurse is reviewing the expected physiologic changes in aging. Which of the following findings does the nurse consider as pathologic in an 80-year old client? a. Increased residual volume b. Decreased sphincter control of the bladder c. Significant increase in diastolic pressure d. Decreased response to touch, heat and pain

Ans: (C) A modest increase in systolic blood pressure and not the diastolic pressure is expected in the elderly due to increased vascular resistance and decreased vessel elasticity. The significant change in diastolic pressure needs to be evaluated.

1. A 23-year old pregnant for the first time is annoyed for being nauseous most of the time. She asks the nurse what causes her symptom. Which of the following responses is most accurate to tell the client? a. "Progesterone causes relaxation of the esophageal sphincter causing spillage of stomach content out into the mouth." b. "HPL causes abdominal muscles to contract that causes the vomiting." c. "HCG is linked to nausea and vomiting in the first trimester." d. "Estrogen casing insulin resistance causes you to feel like throwing up."

Ans: (C) Although not clearly understood, human chorionic gonadotropin (HCG) which is abundant in the first trimester is linked to nausea and vomiting in this phase of pregnancy. As HCG levels diminish with the growing placenta, nausea diminishes, too.

1. The nurse is asking this series of questions to assess a client: "Do you have trouble starting your stream? Do you have to stand closer to the toilet to void? Is there a change in the force or size of your stream, or straining to void? Do you hesitate or stop in the middle of voiding?" The nurse is eliciting information about which disorder? a. Pyelonephritis b. Colon cancer c. Benign prostatic hypertrophy d. Urethritis

Ans: (C) Benign prostatic hypertrophy is the enlargement of the prostrate that surrounds the urethra that results to hesitancy in urination, decrease in size and force of urine, and dribbling urine.

1. A client is being seen by the nurse in the out-patient department. The client states that he has long been suffering from acid reflux and recently has started regurgitating partly digested solid food. The client does not report any chest or abdominal pain and denies any weight loss. The nurse suspects which of the following disorders? a. Peptic ulcer b. Cholecystitis c. Esophageal stricture d. Esophageal cancer

Ans: (C) Esophageal stricture is a kind of mechanical narrowing of the esophagus that is largely caused by repeated irritation by acid reflux. The narrowing of the passageway causes swallowed solid food to be regurgitated. If the symptoms are associated with chest pain or back pain with accompanying weight loss, the nurse suspects esophageal cancer.

1. A pregnant woman on her 26th week of gestation confided to the nurse that she seemed to have urinated without her feeling an urge. When further questioned, she stated that she noticed that after sexual activity. What is the most appropriate nursing action? a. Document this as normal b. Inform the physician immediately c. Let the client lie on her side and assess fetal heart tones d. Advise her to use a cotton pad and encourage hygiene measures

Ans: (C) Fluid that gushes from the vagina other than urine is a danger sign during pregnancy. It can mean ruptured amniotic membrane. The initial action of the nurse is to have the mother lie on her side and assess fetal tones. The physician should be informed immediately after.

1. The nurse is doing a health teaching on a client with colon cancer. She is explaining the different types of bleeding manifestations. Of particular interest to her is the type of bleeding associated with colon cancer and that is passing of fresh blood or maroon-colored stool. The client understands the teaching if he replies with which answer? a. Hematemesis b. Steatorrhea c. Hematochezia d. Melena

Ans: (C) Hematochezia is passing of blood-streaked stools, stools that are bright or dark red in color. This is caused by lower gastrointestinal bleeding. Hematemesis is vomiting of fresh blood or of occult blood of 'coffee-grounds' consistency. Steatorrhea is passing of fatty malodorous stools. Melena is presence of occult blood in the stool.

1. A patient comes to the emergency department in a wheelchair because of pain in the abdomen. He is bent down with arms hugging his abdomen. The nurse suspects appendicitis. Which of the following is an accurate manifestation of appendicitis? a. (+) Rovsing sign - increased abdominal pain when the patient is asked to raise his thigh against the nurse's hand positioned above the knee b. (+) psoas sign - Pain in the right lower quadrant during left-sided pressure c. (+) obturator sign - pain in the right hypogastric area when the client is asked to flex thigh at the hip and the knee bent and rotated internally d. (-) cutaneous hyperesthesia - localized pain as the nurse pinches the abdomen

Ans: (C) In appendicitis, pain in the right lower quadrant during left-sided pressure suggests appendicitis (a positive Rovsing sign). There is also - increased abdominal pain when the patient is asked to raise his thigh against the nurse's hand positioned above the knee (psoas sign). If the client is asked to flex thigh at the hip and bend the knee and rotate it internally, and pain is felt in the hypogastric are, the client is positive for obturator sign. The client should also be able to localize pain over the lower left quadrant if the nurse pinches skin in different areas of the abdomen (cutaneous hyperesthesia).

1. A 56-year old client comes to the clinic complaining of abdominal pain. Upon assessment by the nurse, the client reports that the pain is gnawing in quality especially right after meals. Sometimes the pain is also felt at the back. Palpation and percussion of the abdomen reveals no abnormalities. The assessment findings are consistent with which disorder? a. Chron disease b. Irritable bowel syndrome c. Peptic ulcer d. Diverticulitis

Ans: (C) Peptic ulcer refers to a mucosal ulceration, usually in the duodenum or stomach. Dyspepsia causes similar symptoms but no ulceration. Infection by Helicobacter pylori is often present. The pain experienced by the client is described as gnawing, burning, boring, aching, pressing, or hunger-like, and may radiate to the back.

1. A 60-year old elderly admits to being sexually active and confides to the nurse that she experiences dyspareunia during intercourse and that she has vaginal dryness. Which of the following should be included in the nurse's care plan? a. Provide health teachings on the importance of increasing fluid intake to prevent vaginal dryness b. Review all medications that the client is taking and identify those that can cause the dryness c. Advise the client to use water based lubricant to ease discomfort during intercourse d. Refer the client to the physician for a diagnostic work-up

Ans: (C) Vaginal dryness or decreased secretions is caused by a decrease in estrogen. The decline in estrogen is caused by the atrophy of the ovaries. To preserve ego integrity in this client, the nurse advises the client to use a water-based lubricant to help ease discomfort during sexual intercourse.

1. A client with hepatitis is asking the nurse why his skin turned yellow. Which response is the most accurate to explain why jaundice happens? a. Decreased production of bilirubin b. Increased uptake of bilirubin by the hepatocytes c. Increased ability of the liver to conjugate bilirubin d. Decreased excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood

Ans: (D) Jaundice or the yellowing of the skin is caused by several factors: increased production of bilirubin, decreased uptake of bilirubin by the hepatocytes, decreased ability of the liver to conjugate bilirubin, decreased excretion of bilirubin into the bile, resulting in absorption of conjugated bilirubin back into the blood

1. A patient with acute cholecystitis has just been admitted to the unit. The nurse wants to assess the client for murphy sign. Which of the following maneuver is correct in eliciting murphy sign? a. the patient is asked to raise his thigh against the nurse's hand positioned above the knee b. the nurse exerts downward pressure on the lower left quadrant of the abdomen c. the client is asked to flex thigh at the hip and the knee bent and rotated internally d. hooking the fingers of the right hand on the client's right costal margin and asking him to breathe deeply

Ans: (D) The nurse hooks her left thumb or the fingers of her right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Or if the liver is enlarged, the nurse hooks thumb or fingers under the liver edge at a comparable point below then asks the patient to take a deep breath. A sharp increase in tenderness with a sudden stop in inspiratory effort constitutes a positive Murphy sign of acute cholecystitis.

A 26-year-old sports store manager comes to your clinic, complaining of severe right-sided abdominal pain for 12 hours. He began having a stomachache yesterday, with a decreased appetite, but today the pain seems to be just on the lower right side. He has had some nausea and vomiting but no constipation or diarrhea. His last bowel movement was last night and was normal. He has had no fever or chills. He denies any recent illnesses or injuries. His past medical history is unremarkable. He is engaged. He denies any tobacco or drug use and drinks four to six beers per week. His mother has breast cancer and his father has coronary artery disease. On examination he appears ill and is lying on his right side. His temperature is 100.4 and his heart rate is 110. His bowel sounds are decreased and he has rebound and involuntary guarding, one third of the way between the anterior superior iliac spine and the umbilicus in the right lower quadrant. His rectal, inguinal, prostate, penile, and testicular examinations are normal. What is the most likely cause of his pain? A) Acute appendicitis B) Acute mechanical intestinal obstruction C) Acute cholecystitis D) Mesenteric ischemia

Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: Appendicitis is common in the young and usually presents with periumbilical pain that localizes to the right lower quadrant in an area known as McBurney's Point, described above as one third of the way between the anterior superior iliac spine and the umbilicus on the right. Rebound and guarding are common. Remote rebound or Rovsing's sign is also seen commonly when the course of appendicitis is advanced. Bowel movements are usually unaffected.

A 76-year-old retired farmer comes to your office complaining of abdominal pain, constipation, and a low-grade fever for about 3 days. He denies any nausea, vomiting, or diarrhea. The only unusual thing he remembers eating is two bags of popcorn at the movies with his grandson, 3 days before his symptoms began. He denies any other recent illnesses. His past medical history is significant for coronary artery disease and high blood pressure. He has been married for over 50 years. He denies any tobacco, alcohol, or drug use. His mother died of colon cancer and his father had a stroke. On examination he appears his stated age and is in no acute distress. His temperature is 100.9 degrees and his other vital signs are unremarkable. His head, cardiac, and pulmonary examinations are normal. He has normal bowel sounds and is tender over the left lower quadrant. He has no rebound or guarding. His rectal examination is unremarkable and his fecal occult blood test is negative. His prostate is slightly enlarged but his testicular, penile, and inguinal examinations are all normal. Blood work is pending. What diagnosis for abdominal pain best describes his symptoms and signs? A) Acute diverticulitis B) Acute cholecystitis C) Acute appendicitis D) Mesenteric ischemia

Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: Diverticulitis is caused by localized infections within the colonic diverticula. Constipation, fever, and abdominal pain are common. Mesenteric ischemia classically presents in older people with a history of vascular disease elsewhere. The typical pain is unusual in that it is not made worse by examination despite being severe. Some mistake this feature to indicate malingering, with bad results.

1. A 52-year-old secretary comes to your office, complaining about accidentally leaking urine when she coughs or sneezes. She says this has been going on for about a year now. She relates that she has not had a period for 2 years. She denies any recent illness or injuries. Her past medical history is significant for four spontaneous vaginal deliveries. She is married and has four children. She denies alcohol, tobacco, or drug use. During her pelvic examination you note some atrophic vaginal tissue, but the remainder of her pelvic, abdominal, and rectal examinations are unremarkable. Which type of urinary incontinence does she have? A) Stress incontinence B) Urge incontinence C) Overflow incontinence

Ans: A Chapter: 11 Page and Header: 418, The Health History Feedback: Stress incontinence usually occurs when the intra-abdominal pressure goes up during coughing, sneezing, or laughing. This is usually due to a weakness of the pelvic floor, with inadequate muscle support of the bladder. Vaginal deliveries and pelvic surgery are often associated with these symptoms. Usually female patients are postmenopausal when stress incontinence begins. Kegel exercises are usually recommended to strengthen the pelvic floor muscles.

26. Mr. Martin is a 72-year-old smoker who comes to you for his hypertension visit. You note that with deep palpation you feel a pulsatile mass which is about 4 centimeters in diameter. What should you do next? A) Obtain abdominal ultrasound B) Reassess by examination in 6 months C) Reassess by examination in 3 months D) Refer to a vascular surgeon

Ans: A Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A pulsatile mass in this man should be followed up with ultrasound as soon as possible. His risk of aortic rupture is at least 15 times greater if his aorta measures more than 4 centimeters. It would be inappropriate to recheck him at a later time without taking action. Likewise, referral to a vascular surgeon before ultrasound may be premature.

Cody is a teenager with a history of leukemia and an enlarged spleen. Today he presents with fairly significant left upper quadrant pain. On examination of this area a rough grating noise is heard. What is this sound? A) It is a splenic rub. B) It is a variant of bowel noise. C) It represents borborygmi. D) It is a vascular noise.

Ans: A Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A rough, grating noise over this area represents a splenic rub, which can accompany splenic infarction. Rubs also occur over the liver and pleura and pericardium.

A 27-year-old policewoman comes to your clinic, complaining of severe left-sided back pain radiating down into her groin. It began in the middle of the night and woke her up suddenly. It hurts in her bladder to urinate but she has no burning on the outside. She has had no frequency or urgency with urination but she has seen blood in her urine. She has had nausea with the pain but no vomiting or fever. She denies any other recent illness or injuries. Her past medical history is unremarkable. She denies tobacco or drug use and drinks alcohol rarely. Her mother has high blood pressure and her father is healthy. On examination she looks her stated age and is in obvious pain. She is lying on her left side trying to remain very still. Her cardiac, pulmonary, and abdominal examinations are unremarkable. She has tenderness just inferior to the left costovertebral angle. Her urine pregnancy test is negative and her urine analysis shows red blood cells. What type of urinary tract pain is she most likely to have? A) Kidney pain (from pyelonephritis) B) Ureteral pain (from a kidney stone) C) Musculoskeletal pain D) Ischemic bowel pain

Ans: B Chapter: 11 Page and Header: 418, The Health History Feedback: The pain from a kidney stone causes dramatic, severe, colicky pain at the costovertebral angle that radiates across the flank and down into the groin.

14. Jim is a 60-year-old man who presents with vomiting. He denies seeing any blood with emesis, which has been occurring for 2 days. He does note a dark, granular substance resembling the coffee left in the filter after brewing. What do you suspect? A) Bleeding from a diverticulum B) Bleeding from a peptic ulcer C) Bleeding from a colon cancer D) Bleeding from cholecystitis

Ans: B Chapter: 11 Page and Header: 418, The Health History Feedback: When blood is exposed to the environment of the stomach, it often resembles "coffee grounds." This is not always recognized by patients as blood, so it is important to inquire about this. This symptom is not common in cholecystitis, and the other possibilities occur lower in the intestine. It should be noted that conversely, rapid bleeding from the stomach or other upper gastrointestinal source can produce bright red blood in the stool. Do not rule out proximal bleeding on the basis of the absence of "coffee grounds." Likewise, bright red blood seen with emesis may originate from the stomach. Black, sticky stools also can accompany upper GI bleeding.

28. Which of the following is consistent with obturator sign? A) Pain distant from the site used to check rebound tenderness B) Right hypogastric pain with the right hip and knee flexed and the hip internally rotated C) Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion D) Pain that stops inhalation in the right upper quadrant

Ans: B Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: Obturator sign is seen in appendicitis. It is pain with the stretching of the internal obturator muscle because of inflammation. Pain distant from the site used to check rebound tenderness is Rovsing's sign and is a reliable sign of peritonitis. Answer "C" describes psoas sign, which is also seen in appendicitis. Palpation in the right upper quadrant that causes pain severe enough to stop inhalation is consistent with inflammation of the gallbladder and is called Murphy's sign.

23. Josh is a 14-year-old boy who presents with a sore throat. On examination, you notice dullness in the last intercostal space in the anterior axillary line on his left side with a deep breath. What does this indicate? A) His spleen is definitely enlarged and further workup is warranted. B) His spleen is possibly enlarged and close attention should be paid to further examination. C) His spleen is possibly enlarged and further workup is warranted. D) His spleen is definitely normal.

Ans: B Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: This scenario is not uncommon in infectious mononucleosis. The presence of dullness with inspiration should definitely increase your attention to further examination of the spleen, although dullness can occur in normal patients too.

22. You are palpating the abdomen and feel a small mass. Which of the following would you do next? A) Ultrasound B) Examination with the abdominal muscles tensed C) Surgery referral D) Determine size by percussion

Ans: B Chapter: 11 Page and Header: 451, Recording Your Findings Feedback: It is easy to determine whether the mass is actually in the abdominal wall versus in the abdomen by palpating with the abdominal wall tensed. This can be accomplished by having the patient lift her head off the bed while supine. Usually, abdominal wall masses can be observed, whereas intra-abdominal masses are more concerning.

A 15-year-old high school freshman is brought to the clinic by his mother because of chronic diarrhea. The mother states that for the past couple of years her son has had diarrhea after many meals. The patient states that the diarrhea seems the absolute worst after his school lunches. He describes his symptoms as cramping abdominal pain and gas followed by diarrhea. His stools are watery with no specific smell. He denies any nausea, vomiting, constipation, weight loss, or fatigue. He has had no recent illness, injuries, or foreign travel. His past medical history is unremarkable. He denies tobacco, alcohol, or drug use. His parents are both healthy. On examination you see a relaxed young man breathing comfortably. His vital signs are normal and his head, eyes, ears, throat, neck, cardiac, and pulmonary examinations are normal. His abdomen is soft and nondistended. His bowel sounds are active and he has no tenderness, no enlarged organs, and no rebound or guarding. His rectal examination is nontender with no blood on the glove. You collect a stool sample for further study. What is the most likely explanation for this patient's chronic diarrhea? A) Malabsorption syndrome B) Osmotic diarrhea C) Secretory diarrhea

Ans: B Chapter: 11 Page and Header: 458, Table 11-4 Feedback: Usually related to lactose intolerance, watery diarrhea often follows meal ingestion. Crampy abdominal pain, distension, and gas often accompany symptoms. Diarrhea is often provoked by pizza, milkshakes, yogurt, and other lactose-containing foods. This condition is more common in African-Americans, Latinos, Native Americans, and Asians.

A 77-year-old retired bus driver comes to your clinic for a physical examination at his wife's request. He has recently been losing weight and has felt very fatigued. He has had no chest pain, shortness of breath, nausea, vomiting, or fever. His past medical history includes colon cancer, for which he had surgery, and arthritis. He has been married for over 40 years. He denies any tobacco or drug use and has not drunk alcohol in over 40 years. His parents both died of cancer in their 60s. On examination his vital signs are normal. His head, cardiac, and pulmonary examinations are unremarkable. On abdominal examination you hear normal bowel sounds, but when you palpate his liver it is abnormal. His rectal examination is positive for occult blood. What further abnormality of the liver was likely found on examination? A) Smooth, large, nontender liver B) Irregular, large liver C) Smooth, large, tender liver

Ans: B Chapter: 11 Page and Header: 469, Table 11-12 Feedback: With his past history of colon cancer and with recent weight loss and fatigue, a relapse of his colon cancer would be expected. Colon cancer usually metastasizes to the liver, creating hard, irregular nodules, which can sometimes be palpated on examination. A smooth, large liver which is tender is often seen in hepatitis.

A 22-year-old clerk, primigravida, comes to your office for a prenatal visit. She is in her second trimester and has had prenatal care since she was 8 weeks pregnant. Her only complaint is that she has a new brownish line straight down her abdomen. On examination her vital signs are unremarkable. Her urine has no protein, glucose, or leukocytes. With a Doptone the fetal heart rate is 140, and her uterus is palpated to the umbilicus. Today you are sending her for congenital abnormality screening and setting up an ultrasound. What physical finding is responsible for her new "brown line"? A) Corpus luteum B) Linea nigra C) Linea alba D) Diastasis recti

Ans: B Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: The linea nigra is a linear hyperpigmented area of skin along the midline of the abdomen. It is caused by the hormonal changes of pregnancy. It is considered normal.

3. A 21-year-old receptionist comes to your clinic, complaining of frequent diarrhea. She states that the stools are very loose and there is some cramping beforehand. She states this has occurred on and off since she was in high school. She denies any nausea, vomiting, or blood in her stool. Occasionally she has periods of constipation, but that is rare. She thinks the diarrhea is much worse when she is nervous. Her past medical history is not significant. She is single and a junior in college majoring in accounting. She smokes when she drinks alcohol but denies using any illegal drugs. Both of her parents are healthy. Her entire physical examination is unremarkable. What is most likely the etiology of her diarrhea? A) Secretory infections B) Inflammatory infections C) Irritable bowel syndrome D) Malabsorption syndrome

Ans: C Chapter: 11 Page and Header: 418, The Health History Feedback: Irritable bowel syndrome will cause loose bowel movements with cramps but no systemic symptoms of fever, weight loss, or malaise. This syndrome is more likely in young women with alternating symptoms of loose stools and constipation. Stress usually makes the symptoms worse, as do certain foods.

A young patient presents with a left-sided mass in her abdomen. You confirm that it is present in the left upper quadrant. Which of the following would support that this represents an enlarged kidney rather than her spleen? A) A palpable "notch" along its edge B) The inability to push your fingers between the mass and the costal margin C) The presence of normal tympany over this area D) The ability to push your fingers medial and deep to the mass

Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A left upper quadrant mass is more likely to be a kidney if there is no palpable "notch," you can push your fingers between the mass and the costal margin, there is normal tympany over this area, and you cannot push your fingers medial and deep to the mass. These findings are very difficult to appreciate in an obese patient.

Mr. Patel is a 64-year-old man who was told by another care provider that his liver is enlarged. Although he is a life-long smoker, he has never used drugs or alcohol and has no knowledge of liver disease. Indeed, on examination, a liver edge is palpable 4 centimeters below the costal arch. Which of the following would you do next? A) Check an ultrasound of the liver B) Obtain a hepatitis panel C) Determine liver span by percussion D) Adopt a "watchful waiting" approach

Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A liver edge palpable this far below the costal arch should not be ignored. Ultrasound and laboratory investigation are reasonable if the liver is actually enlarged. Mr. Patel has developed emphysema with flattening of the diaphragms. This pushes a normal-sized liver below the costal arch so that it appears to be enlarged. A liver span should be determined by percussing down the chest wall until dullness is heard. A measurement is then made between this point and the lower border of the liver to determine its span; 6-12 centimeters in the mid-clavicular line is normal. Percussion is the only way to assess liver size on examination, and in this case it saved the patient much inconvenience and expense.

8. Which is the proper sequence of examination for the abdomen? A) Auscultation, inspection, palpation, percussion B) Inspection, percussion, palpation, auscultation C) Inspection, auscultation, percussion, palpation D) Auscultation, percussion, inspection, palpation

Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: The abdominal examination is conducted in a sequence different from other systems, for which the usual order is inspection, percussion, palpation, and auscultation. Because palpation may actually cause some bowel noise when the bowels are not moving, auscultation is performed before percussion and palpation in an abdominal examination.

A 46-year-old former salesman presents to the ER, complaining of black stools for the past few weeks. His past medical history is significant for cirrhosis. He has gained weight recently, especially around his abdomen. He has smoked two packs of cigarettes a day for 30 years and has drunk approximately 10 alcoholic beverages a day for 25 years. He has used IV heroin and smoked crack in the past. He denies any recent use. He is currently unemployed and has never been married. On examination you find a man appearing older than his stated age. His skin has a yellowish tint and he is thin, with a prominent abdomen. You note multiple "spider angiomas" at the base of his neck. Otherwise, his heart and lung examinations are normal. On inspection he has dilated veins around his umbilicus. Increased bowel sounds are heard during auscultation. Palpation reveals diffuse tenderness that is more severe in the epigastric area. His liver is small and hard to palpation and he has a positive fluid wave. He is positive for occult blood on his rectal examination. What cause of black stools most likely describes his symptoms and signs? A) Infectious diarrhea B) Mallory-Weiss tear C) Esophageal varices

Ans: C Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: Varices are often found in alcoholic patients, but only when they have a diagnosis of significant cirrhosis. This patient has symptoms of cirrhosis, including jaundice, ascites, spider hemangiomas, and dilated veins on his abdomen (caput medusa).

29. An elderly woman with a history of coronary bypass comes in with severe, diffuse, abdominal pain. Strangely, during your examination, the pain is not made worse by pressing on the abdomen. What do you suspect? A) Malingering B) Neuropathy C) Ischemia D) Physical abuse

Ans: C Chapter: 11 Page and Header: 454, Table 11-1 Feedback: Ischemic pain can be severe but is not made worse with palpation. The history of bypass could be a clue that there is vascular narrowing elsewhere. Malingering is less likely, and neuropathic pain, as seen in herpes zoster, would worsen with touch. You are to be commended if you considered elder abuse, because this is frequently missed. Ordinarily, this pain would be worse with examination because of the preceding trauma.

A 29-year-old homemaker who is G4P3 comes to your clinic for her first prenatal check. Her last period was 2 months ago. She has had three previous pregnancies and deliveries with no complications. She has no medical problems and has had no surgeries. Her only current complaint is of severe reflux that occurs in the mornings and evenings. On examination she is in no acute distress. Her vitals are 110/70 with a pulse of 88. Her respirations are 16. Her head, eyes, ears, nose, throat, thyroid, cardiac, pulmonary, and abdominal examinations are unremarkable. On bimanual examination her cervix is soft and her uterus is 10 weeks in size. Pap smear, cultures, and blood work are pending. What is the most likely cause of her first-trimester reflux? A) Increasing prolactin levels B) Increasing ADH (antidiuretic hormone) levels C) Increasing progesterone D) Enlarged gravid uterus

Ans: C Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: Progesterone lowers the esophageal sphincter tone, leading to reflux and heartburn. It also relaxes tone and contraction of the ureters and bladder, increasing risk of UTI and subsequent bacteremia.

A 79-year-old retired banker comes to your office for evaluation of difficulty with urination; he gets up five to six times per night to urinate and has to go at least that often in the daytime. He does not feel as if his bladder empties completely; the strength of the urinary stream is diminished. He denies dysuria or hematuria. This problem has been present for several years but has worsened over the last 8 months. You palpate his prostate. What is your expected physical examination finding, based on this description? A) Normal size, smooth B) Normal size, boggy C) Enlarged size, smooth D) Enlarged size, boggy

Ans: C Chapter: 20 Page and Header: 899, Anatomy and Physiology Feedback: This is the expected physical examination finding in benign prostatic hyperplasia (BPH).

An 88-year-old retired piano teacher comes for evaluation of fatigue. You notice that her clothes are hanging loosely off her frame and that she has lost 15 pounds. She is unaware of this. Her husband of 63 years died a few months ago. You ask the patient to complete a Rapid Screen for Dietary Intake. Which of the following statements is considered to be part of this rapid screen? A) I eat more than two meals per day. B) I drink one glass of alcohol every day. C) Without wanting to, I have lost or gained 10 pounds in the last 6 months. D) I eat with at least one other person most of the time.

Ans: C Chapter: 20 Page and Header: 906, The Health History Feedback: This is part of the Rapid Screen for Dietary Intake.

5. A 22-year-old law student comes to your office, complaining of severe abdominal pain radiating to his back. He states it began last night after hours of heavy drinking. He has had abdominal pain and vomiting in the past after drinking but never as bad as this. He cannot keep any food or water down, and these symptoms have been going on for almost 12 hours. He has had no recent illnesses or injuries. His past medical history is unremarkable. He denies smoking or using illegal drugs but admits to drinking 6 to 10 beers per weekend night. He admits that last night he drank something like 14 drinks. On examination you find a young male appearing his stated age in some distress. He is leaning over on the examination table and holding his abdomen with his arms. His blood pressure is 90/60 and his pulse is 120. He is afebrile. His abdominal examination reveals normal bowel sounds, but he is very tender in the left upper quadrant and epigastric area. He has no Murphy's sign or tenderness in the right lower quadrant. The remainder of his abdominal examination is normal. His rectal, prostate, penile, and testicular examinations are normal. He has no inguinal hernias or tenderness with that examination. Blood work is pending. What etiology of abdominal pain is most likely causing his symptoms? A) Peptic ulcer disease B) Biliary colic C) Acute cholecystitis D) Acute pancreatitis

Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Acute pancreatitis causes epigastric and left upper quadrant pain and often radiates into the back. There is often a history of long-standing gallbladder disease or recent alcohol ingestion. Severe abdominal pain and vomiting are often seen. Medications such as proton pump inhibitors can also cause pancreatitis in people without these other risk factors. Treatment includes hydration, pain management, and bowel rest.

Monique is a 33-year-old administrative assistant who has had intermittent lower abdominal pain approximately one week a month for the past year. It is not related to her menses. She notes relief with defecation, and a change in form and frequency of her bowel movements with these episodes. Which of the following is most likely? A) Colon cancer B) Cholecystitis C) Inflammatory bowel disease D) Irritable bowel syndrome

Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Although colon cancer should be a consideration, these symptoms are intermittent and no note is made of progression. Cholecystitis usually presents with right upper quadrant pain. Inflammatory bowel disease is often associated with fever and hematochezia. Because there is relief with defecation and there are no mentioned structural or biochemical abnormalities, irritable bowel syndrome seems most likely. This is a very common condition which can be triggered by certain foods and stress.

4. A 42-year-old florist comes to your office, complaining of chronic constipation for the last 6 months. She has had no nausea, vomiting, or diarrhea and no abdominal pain or cramping. She denies any recent illnesses or injuries. She denies any changes to her diet or exercise program. She is on no new medications. During the review of systems you note that she has felt fatigued, had some weight gain, has irregular periods, and has cold intolerance. Her past medical history is significant for one vaginal delivery and two cesarean sections. She is married, has three children, and owns a flower shop. She denies tobacco, alcohol, or drug use. Her mother has type 2 diabetes and her father has coronary artery disease. There is no family history of cancers. On examination she appears her stated age. Her vital signs are normal. Her head, eyes, ears, nose, throat, and neck examinations are normal. Her cardiac, lung, and abdominal examinations are also unremarkable. Her rectal occult blood test is negative. Her deep tendon reflexes are delayed in response to a blow with the hammer, especially the Achilles tendons. What is the best choice for the cause of her constipation? A) Large bowel obstruction B) Irritable bowel syndrome C) Rectal cancer D) Hypothyroidism

Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: Many metabolic conditions can interfere with bowel motility. In this case the patient has many symptoms of hypothyroidism, including cold intolerance, weight gain, fatigue, constipation, and irregular menstrual cycles. On examination, thyromegaly and delayed reflexes can help to make the diagnosis. Medication will usually correct these symptoms.

Chris is a 20-year-old college student who has had abdominal pain for 3 days. It started at his umbilicus and was associated with nausea and vomiting. He was unable to find a comfortable position. Yesterday, the pain became more severe and constant. Now, he hesitates to walk, because any motion makes the pain much worse. It is localized just medial and inferior to his iliac crest on the right. Which of the following is most likely? A) Peptic ulcer B) Cholecystitis C) Pancreatitis D) Appendicitis

Ans: D Chapter: 11 Page and Header: 418, The Health History Feedback: This is a classic history for appendicitis. Notice that the pain has changed from visceral to parietal. It is well localized to the right lower quadrant, making appendicitis a strong consideration.

27. Mr. Maxwell has noticed that he is gaining weight and has increasing girth. Which of the following would argue for the presence of ascites? A) Bilateral flank tympany B) Dullness which remains despite change in position C) Dullness centrally when the patient is supine D) Tympany which changes location with patient position

Ans: D Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: A diagnosis of ascites is supported by findings that are consistent with movement of fluid and gas with changes in position. Gas-filled loops of bowel tend to float so that dullness when supine would argue against this. Likewise, because fluid gathers in dependent areas, the flanks should ordinarily be dull with ascites. Tympany which changes location with patient position ("shifting dullness") would support the presence of ascites. A fluid wave and edema would support this diagnosis as well.

19. A 62-year-old woman has been followed by you for 3 years and has had recent onset of hypertension. She is still not at goal despite three antihypertensive medicines, and you strongly doubt nonadherence. Her father died of a heart attack at age 58. Today her pressure is 168/94 and pressure on the other arm is similar. What would you do next? A) Add a fourth medicine B) Refer to nephrology C) Get a CT scan D) Listen closely to her abdomen

Ans: D Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: At this point, it is important to consider secondary causes for this woman's hypertension because of its severity, rapidity of progression, and lack of response to therapy. While you will most likely add a fourth medicine, it is important to carefully examine the abdomen for the presence of renal artery bruits. These are usually heard best in the upper quadrants. It may be necessary to have the patient hold her breath, to have a very quiet room, and to listen with the diaphragm for a very soft, high-pitched sound with systole. It may also help to simultaneously feel the patient's pulse (a bruit with both a systolic and diastolic component is very specific for a significant blockage, while a lone systolic bruit may not be abnormal). Obtaining a CT scan is not likely to be useful, and you may save the delay, expense, and inconvenience of a nephrology referral if you can hear a bruit.

25. Mr. Kruger is an 84-year-old who presents with a smooth lower abdominal mass in the midline which is minimally tender. There is dullness to percussion up to 6 centimeters above the symphysis pubis. What does this most likely represent? A) Sigmoid mass B) Tumor in the abdominal wall C) Hernia D) Enlarged bladder

Ans: D Chapter: 11 Page and Header: 434, Techniques of Examination Feedback: It is possible that this represents a sigmoid colon mass, but this is less likely than an enlarged bladder. Prostatic hypertrophy is very common in this age group and can frequently cause partial urinary obstruction with bladder enlargement. If the mass resolves with catheterization, this is a likely cause. Other forms of urinary obstruction such as neurogenic bladder, urethral stricture, and side effects of drugs can also be contributing to the problem. A hernia would most likely not be dull to percussion. Midline abdominal wall tumors of this size would be unusual but could be discerned by having the patient tense his abdominal muscles.

A pregnant woman is concerned by the recent onset of a midline swelling. It is soft and nontender. What does this represent? A) Linea nigra B) Chadwick's sign C) Round ligament pain D) Diastasis recti

Ans: D Chapter: 19 Page and Header: 871, Anatomy and Physiology Feedback: In advanced pregnancy, muscle tone diminishes, which may aid in the separation of the rectus abdominis muscles. This is a benign finding and does not usually cause other symptoms. You may palpate the fetus well through this opening. Linea nigra is a hyperpigmentation along the midline. Chadwick's sign is the bluish tinge to the cervix and vaginal walls seen early in pregnancy, and round ligament pain occurs as the uterus enlarges. This discomfort is usually found in the right more often than the left.

Which of the following is commonly seen in aging men? A) Erectile dysfunction in 20% of all men B) Testicles ride higher within the scrotum C) Strong response to visual erotic cues D) Persistent sexual interest

Ans: D Chapter: 20 Page and Header: 899, Anatomy and Physiology Feedback: Erectile dysfunction affects about half of elderly men but sexual interest generally remains intact. A decrease in sexual interest may indicate other problems such as depression. Visual cues become less important and tactile stimulation more important. The testicles are positioned lower in the scrotum.

An 89-year-old retired school principal comes for an annual check-up. She would like to know whether or not she should undergo a screening colonoscopy. She has never done this before. Which of the following factors should not be considered when discussing whether she should go for this screening test? A) Life expectancy B) Time interval until benefit from screening accrues C) Patient preference D) Current age of patient

Ans: D Chapter: 20 Page and Header: 909, Health Promotion and Counseling Feedback: The current age of the patient is not as important as her actual life expectancy and current health status.

describe ascitic fluid, and percussion notes.

Ascitic fluid seeks the lowest point in the abdomen, producing bulging flanks that are dull to percussion. The umbilicus may protrude. Turn the patient onto one side to detect the shift in position of the fluid level (shifting dullness).

how do you test for a fluid wave

Ask the patient or an assistant to press the edges of both hands firmly down the midline of the abdomen. This pressure helps to stop the transmission wave through fat. While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid

where is the location of pain, quality, and timing in GERD?

Chest or epigastric Heartburn, regurgitation After meals, especially spicy foods

describe a Smooth Large Liver and when you would see it

Cirrhosis may produce an enlarged liver with a firm, nontender edge. The cirrhotic liver may also be scarred and contracted. Many other diseases may produce similar findings such as hemochromatosis, amyloidosis, and lymphoma. An enlarged liver with a smooth, tender edge suggests inflammation, as in hepatitis, or venous congestion, seen in right-sided heart failure.

Intussusception

Colicky abdominal pain, abdominal distention, and in intussusception, often "currant jelly" stools (red blood and mucus) Intussusception is a condition in which one segment of intestine "telescopes" inside of another, causing an intestinal obstruction (blockage). Although intussusception can occur anywhere in the gastrointestinal tract, it usually occurs at the junction of the small and large intestines

describe abdominal lipomas

Common, benign, fatty tumors usually in the subcutaneous tissues almost anywhere in the body, including the abdominal wall. Small or large, they are usually soft and often lobulated. Press your finger down on the edge of a lipoma. The tumor typically slips out from under your finger and is well demarcated, nonreducible, and usually nontender.

name the diagnosis: chronic inflammatory disorder occurring anywhere along the GI tract: with chronic diarrhea, mild bleeding, malabsorption, fistula or fissure formation & characteristic cobblestone changes of mucosa

Crohn Disease

when would you see Pink-purple striae

Cushing's syndrome

what bowel sounds would you hear in adynamic ileus?

Decreased

what bowel sounds would you hear in peritonitis?

Decreased

what type of bulge is Often present in patients with repeated pregnancies, obesity, and chronic lung disease?

Diastasis Recti

what type of dysphagia can cause Chest pain that mimics angina pectoris or myocardial infarction and lasts min to hrs?

Diffuse esophageal spasm

name the diagnosis: •LLQ pain, anorexia, nausea, vomiting, altered bowel habits

Diverticulitis

____________________ ulcers tend to cause more consistent pain. Pain is absent when the patient awakens but appears in mid-morning and is relieved by food but recurs 2 to 3 hours after a meal.

Duodenal

where is the location of pain and quality and timing in Biliary Colic?

Epigastric or right upper quadrant; may radiate to the right scapula and shoulder Steady, aching; not colicky Usually last longer than 3 hrs Rapid onset over a few min, lasts one to several hrs and subsides gradually; often recurrent

Causes of visceral pain in the Epigastric area?

Epigastric pain from the stomach, duodenum, or pancreas

where is the location of pain and quality and timing in Peptic Ulcer and Dyspepsia?

Epigastric, may radiate straight to the back pigastric gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike Intermittent; duodenal ulcer is more likely than gastric ulcer or dyspepsia to cause pain that (1) wakes the patient at night, and (2) occurs intermittently over a few wks, disappears for months, then recurs

where is the location of pain and quality in Acute Pancreatitis and timing ?

Epigastric, may radiate straight to the back or other areas of the abdomen; 20% with severe sequelae of organ failure Usually steady Acute onset, persistent pain

where is the location of pain and quality and timing in Chronic Pancreatitis?

Epigastric, radiating to the back Severe, persistent, deep Chronic or recurrent course

________________ arises from obstruction of the extrahepatic bile ducts, most commonly the common bile ducts.

Extrahepatic jaundice

Obturator sign:

Flex the patient's right thigh at the hip with the knee flexed and rotate internally. Increased pain at the right lower quadrant suggests inflammation of the internal obturator muscle from overlying appendicitis or abscess.

what does stool look like in Ulcerative colitis?

Frequent, watery, often containing blood Onset typically abrupt; often re- current, persisting, and may awaken at night

_____________ incontinence arises from impaired cognition, musculoskeletal problems, or immobility.

Functional

Name the type of Incontinence: Environmental factors such as an unfamiliar setting, distant bathroom facilities, bed rails, or physical restraints.

Functional Incontinence

__________________ ulcer symptoms often do not follow a consistent pattern (eg, eating sometimes exacerbates rather than relieves pain).

Gastric

what are other associated symptoms of Achalasia?

Heartburn Regurgitation, often at night when lying down, with nocturnal cough; possibly chest pain precipitated by eating

A patient is asked about Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs. What liver disease are you inquiring about?

Hep A

A patient is asked about illicit injection drug use or blood transfusion What liver disease are you inquiring about?

Hep c

Describe how to do the Murphy sign

Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Watch the patient's breathing and note the degree of tenderness.

Causes of visceral pain in the Hypogastric area?

Hypogastric pain from the colon, bladder, or uterus. Colon pain may be more diffuse than illustrated.

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), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity suggest:

IBS

where is the location of pain and quality and timing in Pancreatic Cancer?

If cancer in body or tail, epigastric, in either upper quadrant, often radiates to the back Steady, deep Persistent pain; relentlessly progressive illness

how do you assess for a hernia?

If you suspect but do not see an umbilical or incisional hernia, ask the patient to raise both head and shoulders off the table.

Pyloric Stenosis

In pyloric stenosis, deep palpation in the right upper quadrant or midline can reveal an "olive," or a 2-cm firm pyloric mass. While feeding, some infants with this condition will have visible peristal- tic waves pass across their abdomen, followed by projectile vomiting. Infants present at about 4 to 6 weeks of age. the lower portion of the stomach that connects to the small intestine is known as the pylorus. problem that affects babies between birth and 6 months of age and causes forceful vomiting that can lead to dehydration

Describe Normal Variations in Liver Shape

In some individuals the right lobe of the liver may be elongated and easily palpable as it projects downward toward the iliac crest. Such an elongation, sometimes called Riedel lobe, represents a variation in shape, not an increase in liver volume or size.

where is the location of pain and quality and timing in Gastric Cancer?

Increasingly in "cardia" and GE junction; also in distal stomach pain Variable Pain is persistent, slowly progressive; duration of pain is typically shorter than in peptic ulcer

name the diagnosis: •several etiologies: common features (fever, anorexia, weight loss, abdominal discomfort, diarrhea, rectal urgency & rectal bleeding)

Inflammatory Bowel Disease

a patient has jaundice and itching. what does this suggest?

Itching occurs in cholestatic or obstructive jaundice.

kidney pain is what type of pain?

Kidney pain is a visceral pain usually produced by distention of the renal capsule and typically dull, aching, and steady.

Where is the spleen located?

LUQ

where is referred pain from renal colic?

LUQ

where is referred pain from spleen?

LUQ, left side/midaxillary

where is the location of pain and quality and timing in Acute Diverticulitis?

Left lower quadrant May be cramping at first, then steady Often gradual onset

the __________________ or ________________ is a clinical sign in which pain in the right lower quadrant of the abdomen is elicited by dropping from standing on the toes to the heels with a jarring landing. It is found in patients with localised peritonitis due to acute appendicitis

Markle sign or jar tenderness

where is the location of pain and quality and timing in Mesenteric Ischemia?

May be periumbilical at first, then diffuse; may be postprandial, classically inducing "food fear" Cramping at first, then steady; pain disproportionate to examination findings Usually abrupt in onset, then persistent

what are special techniques to test for Appendicitis

McBurney point tenderness, Rovsing sign, the psoas sign, obturator sign described on the next page

where could the referred pain be in disorders of the •Aorta, Pancreas

Midback

what is the difference between esophageal dysphasia and dysplasia caused by motor disorders?

Motor disorder = solids and liquids esophageal dysphasia = solids only (except in late stage of esophageal ca)

When RUQ pain and tenderness suggest acute cholecystitis, what special technique/test should you do?

Murphy sign

what organs/structures would be tender upon deep palpation NORMALLY?

Normal cecum, Normal (or spastic) sigmoid colon, Normal aorta

Describe the normal journey of bilirubin

Normally, the hepatocytes conjugate unconjugated bilirubin with other substances, making the bile water soluble, and then excrete the conjugated bilirubin into the bile. The bile passes through the cystic duct into the common bile duct, which also drains the extrahepatic ducts from the liver. More distally, the common bile duct and the pancreatic ducts empty into the duodenum at the ampulla of Vater.

-flex the patient's thigh and rotate the leg internally at the hip; pain indicates a positive sign

Obturator sign

Name the type of Incontinence: Decreased force of the urinary stream.

Overflow Incontinence

Name the type of Incontinence: Detrusor contractions are insufficient to overcome urethral resistance, causing urinary retention. The bladder is typically flaccid and large, even after an effort to void.

Overflow Incontinence

Name the type of Incontinence: Examination often reveals an enlarged, sometimes tender, bladder. Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes.

Overflow Incontinence

Name the type of Incontinence: Impaired bladder sensation that interrupts the reflex arc, as in diabetic neuropathy.

Overflow Incontinence

Name the type of Incontinence: Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor.

Overflow Incontinence

Name the type of Incontinence: Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present.

Overflow Incontinence

Name the type of Incontinence: Weakness of the detrusor muscle associated with peripheral nerve disease at S2-4 level.

Overflow Incontinence

Name the type of Incontinence: When intravesicular pressure overcomes urethral resistance, continuous dripping or dribbling incontinence ensues.

Overflow Incontinence

How do you palpate mcburneys point?

Palpate over McBurney's point which is located two-thirds down an imaginary line from the umbilicus to the anterior superior iliac spine. Tenderness implies possible appendicitis, inflammation of the ileocolic area such as Crohn disease or infectious etiology with bacteria that have a predilection for the ileocecal area

How do you test for Appendicitis at the McBurney point?

Palpate the tender area for guarding, rigidity, and rebound tenderness. Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflam- mation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness.

what would be suspected when there is pain relief when eating Food or taking antacids

Peptic Ulcer and Dyspepsia (less likely in gastric ulcers)

How do you percuss when ascites is suspected?

Percuss for dullness outward in several directions from the central area of tympany. Map the border between tympany and dullness

how do you test for shifting dullness.

Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side. Percuss and mark the borders again (Fig. 11-34). In a person without ascites, the border between tympany and dullness usually stays relatively constant In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top.

Psoas sign:

Place your hand just above the patient's right knee and ask the patient to push up against your hand causing contraction of the psoas muscle which causes pain if the psoas muscle is inflamed, which could be due to appendicitis, or another source of inflammation.

how do you palpate the liver?

Place your palpating hand below the lower rib margin and have the patient exhale and then take in a deep breath. With mild pressure, you should feel the liver margin move under your hand as a gentle wave. Feel for any nodularity or tenderness.

where is the location of pain and quality and timing in Acute Appendicitis?

Poorly localized periumbilical pain, usually migrates to the right lower quadrant Mild but increasing, possibly cramping Steady and more severe Lasts roughly 4-6 hrs, depend- ing on intervention

the patient flexes their thigh against the examiner's hand; pain indicates a positive sign

Psoas sign

Name the type of pain (Visceral, Parietal, Referred): Pain that originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder)

Referred

what may relieve the symptoms of Scleroderma and Achalasia?

Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis)

you hear a bruit in the RLQ or LLQ. where could this be coming from?

Right or Left inguinal artery stenosis or an aneurysm

where could the referred pain be in disorders of the Biliary tract, Aorta, Pancreas?

Right scapular

where is the location of pain and quality and timing in Acute Cholecystitis?

Right upper quadrant or epigastrium; may radiate to right shoulder or interscapular area Steady, aching Gradual onset; course longer than in biliary colic

risk factors for gerd?

Risk factors include reduced salivary flow, which prolongs acid clearance by damping action of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; and hiatal hernia.

palpate LLQ induce pain @ RLQ

Rovsing's sign

______________ can decrease motility anywhere in the gastrointestinal tract. The most common source of decreased motility is the esophagus and the lower esophageal sphincter, leading to dysphagia and chest pain

Scleroderma

what is Diastasis Recti?

Separation of the two rectus abdominis muscles, through which abdominal contents form a midline ridge typically extending from the xiphoid to the umbilicus and seen only when the patient raises the head and shoulders.

where is the location of pain and quality and timing in Acute Bowel Obstruction?

Small bowel: periumbilical or upper abdominal Colon: lower abdominal or generalized Cramping in both small bowel and colon Small bowel: Paroxysmal; may decrease as bowel mobility is impaired Colon: Paroxysmal, though typically milder

what does stool look like in Crohn disease?

Small, soft to loose or watery, with bleeding if colitis, obstructive symptoms, if enteritis More insidious onset; chronic or recurrent

Name the type of Incontinence: Causes include childbirth and surgery. Local conditions affecting the internal urethral sphincter, such as postmenopausal atrophy of the mucosa and urethral infection, may also contribute.

Stress Incontinence

Name the type of Incontinence: In women, pelvic floor weakness and inadequate muscular and ligamentous support of the bladder neck and proximal urethra change the angle between the bladder and the urethra

Stress Incontinence

Name the type of Incontinence: Momentary leakage of small amounts of urine with coughing, laughing, and sneezing while the person is in an upright position. Urine loss is unrelated to a conscious urge to urinate.

Stress Incontinence

Name the type of Incontinence: The urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance.

Stress Incontinence

in Appendicitis, where does the pain usually start, and were does it eventually migrate?

The pain of appendicitis classically begins near the umbilicus, then migrates to the RLQ. older adults are less likely to report this pattern

when would the span of liver dullness be decreased?

The span of liver dullness is decreased when the liver is small, or when there is free air below the diaphragm, as from a perforated bowel or hollow viscus.

when the span of the liver dullness is increased, what would this mean?

The span of liver dullness is increased when the liver is enlarged.

describe the Downward Displacement of the Liver by a Low Diaphragm

This finding is common when the diaphragm is flattened and low, as in COPD. The liver edge may be palpable well below the costal margin. Percussion, however, reveals a low upper edge, and the vertical span of the liver is normal.

describe an Incisional Hernia

This is a protrusion through an operative scar. Palpate to detect the length and width of the defect in the abdominal wall. A small defect, through which a large hernia has passed, has a greater risk for complications than a large defect.

what does stool look like in Malabsorption syndrome

Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in toilet (steatorrhea)

what kind of kidney pain is a dramatically different severe colicky pain radiating around the trunk into the lower abdomen and groin, or possibly into the upper thigh, testicle, or labium?

Ureteral pain/Ureteral colic

Name the type of Incontinence: Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level.

Urge Incontinence

Name the type of Incontinence: Detrusor contractions are stronger than normal and overcome the normal urethral resistance. The bladder is typically small.

Urge Incontinence

Name the type of Incontinence: Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction.

Urge Incontinence

Name the type of Incontinence: Involuntary urine loss preceded by an urge to void. The volume tends to be moderate.

Urge Incontinence

Name the type of Incontinence: Urgency, frequency, and nocturia with small to moderate volumes.If acute inflammation is present, pain on urination.

Urge Incontinence

Name the type of Incontinence: Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volumes.

Urge Incontinence

Name the type of Incontinence: Possibly "pseudo-stress incontinence"—voiding 10-20 sec after stresses such as a change of position, going up- or downstairs, and possibly coughing, laughing, or sneezing.

Urge Incontinence

how do you estimate the size of the aorta?

Use a two-handed technique for estimating aorta size. Place one hand longitudinally on the left along the long axis of the aorta at the lateral border of pulsation. Place the other hand longitudinally on the right side of the abdomen and move it toward the first hand until you fell the border of pulsation.

Name the type of pain (Visceral, Parietal, Referred): This type of pain is usually gnawing, cramping or aching. It is often difficult to localize.

Visceral

Name the type of pain (Visceral, Parietal, Referred): When hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also have this type of pain when they swell against their capsules.

Visceral

defile acholic

When excretion of bile into the intestine is completely obstructed, the stools become gray or light colored, or acholic, without bile.

How many drinks is considered binge drinking?

Women: >3 drinks/d and >7 drinks/wk Men: >4 drinks/d and >14 drinks/wk

how many drinks is considered moderate drinking?

Women: ≤1 drink/d Men: ≤2 drinks/d

how many drinks is considered unsafe drinking levels?

Women: ≥4 drinks on one occasion Men: ≥5 drinks on one occasion

Hirschsprung's disease

a condition that affects the large intestine (colon) and causes problems with passing stool. The condition is present at birth (congenital) as a result of missing nerve cells in the muscles of the baby's colon

dysphagia with solids and liquids suggest what?

a motility disorder like achalasia

Cullen's sign -

a periumbilical ecchymotic discoloration from retroperitoneal hemorrhage or from intra-abdominal hemorrhage such as ectopic pregnancy

Signs of peritonitis include

a positive cough test, guarding, rigidity, rebound tenderness, and percussion tenderness. During palpation, check for signs of guarding, rigidity, and rebound tenderness. Even before palpation, ask the patient to cough and identify where the cough produces pain.

RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, is suspicious for: ________A______ But it could also be ________b________ in women:

a: appendicitis. b: consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy.

A ___A______ ulcer is an erosion in a segment of the gastrointestinal mucosa, typically in the stomach (______b_______ ulcer) or the first few centimeters of the duodenum (_______c______ ulcer), that penetrates through the muscularis mucosae.

a: peptic b: gastric c: duodenal

Tenderness may originate in the abdominal wall. When the patient raises the head and shoulders, this tenderness _______A________, whereas tenderness from a deeper lesion (protected by the tightened muscles) ______b________.

a: persists b: decreases

Abdominal pain and tenderness may result from _________________. When unilateral, it can mimic acute cholecystitis or appendicitis. Rebound tenderness and rigidity are less common; chest signs are usually present.

acute pleural inflammation

Flank pain, fever, and chills signal

acute pyelonephritis

Frequently bilateral, the tenderness of _______________ is usually maximal just above the inguinal ligaments. Rebound tenderness and rigidity may be present. On pelvic examination, motion of the cervix and uterus causes pain.

acute salpingitis (inflammation of the fallopian tubes)

When a spleen enlarges, where does it expand?

anteriorly, downward, and medially, often replacing the tympany of stomach and colon with the dullness of a solid organ. It then becomes palpable below the costal margin.

what are some causes of peritonitis?

appendicitis, cholecystitis, and a perforation of the bowel wall.

A protuberant abdomen with bulging flanks is suspicious for

ascites

Dullness in both flanks prompts further assessment for

ascites

bulging flanks is seen in

ascites

•A protuberant abdomen with bulging flanks is suspicious for

ascites

?what is the Rovsing sign

assesses for appendicitis. Palpate for Rovsing sign and referred rebound tenderness. Press deeply and evenly in the LLQ. Then quickly withdraw your fingers Pain in the RLQ during left-sided pressure is a positive Rovsing sign.

how do you assess the Assess the psoas sign?

assesses for appendicitis. Place your hand just above the patient's right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient's right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it. Increased abdominal pain on either maneuver is a positive psoas sign, sug- gesting irritation of the psoas muscle by an inflamed appendix.

what is the obturator sign?

assesses for appendicitis. Flex the patient's right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Internal rotation of the hip is described on p. 681. Right hypogastric pain is a positive obtu- rator sign, from irritation of the obtura- tor muscle by an inflamed appendix. This sign has very low sensitivity.

where in the abdomen would you listen for bruits?

auscultate the epigastrium and in each upper quadrant for bruits. Later in the examination, when the patient sits up, listen also in the CVAs.

Hoe do you identify an Organ or a Mass in an Ascitic Abdomen.

ballotte the organ or mass Straighten and stiffen the fingers of one hand together, place them on the abdominal surface, and make a brief jabbing movement directly toward the anticipated structure. This quick movement often displaces the fluid so that your fingertips can briefly touch the surface of the structure through the abdominal wall

You are palpating the abdomen and note rigidity. What are ways to help the patient relax?

begin palpation with the patient's hand under yours. After a few moments, slip your hand underneath to palpate directly. distract the patient with conversation or questions. Palpate after asking the patient to exhale, which usually relaxes the abdominal muscles. Ask the patient to mouth-breathe with the jaws wide open.

•Lack of __________ leads to decreased digestion & absorption of fats, leading to diarrhea

bile

•Lack of __________, produces clay colored or acholic stools

bile & its metabolite

What is cystitis?

bladder infection

what kind of bowel sounds would you hear in IBS?

borborygmi

what kind of bowel sounds would you hear in small bowel obstruction

borborygmi

Acholic stools may occur when?

briefly in viral hepatitis; they are common in obstructive jaundice.

When would liver dullness may be displaced downward?

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

A hepatic bruit suggests:

carcinoma of the liver or cirrhosis.

when percussing the spleen, what would be a positive splenic percussion sign?

change in percussion note from tympany to dullness on inspiration is a positive splenic percussion sign, but this sign is only moderately useful for detecting splenomegaly

when palpating the liver, firmness or hardness may indicate:

cirrhosis

painful jaundice points to:

commonly infectious in origin, as in hepatitis A and cholangitis.

LLQ pain, especially with a palpable mass, signals

diverticulitis

what sound would you hear when percussing large stool or a mass

dullness

Pain that awakens a patient at night is common and is highly suggestive of _____________________ ulcer.

duodenal

a patient has Periumbilical pain. what could be the cause?

early acute appendicitis (It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum)

Grey Turner sign -

ecchymosis of flank and groins from hemorrhagic pancreatitis.

when percussing the spleen, If tympany is prominent, what would this mean?

especially laterally, splenomegaly is unlikely. The dullness of a normal spleen is usually masked by the dullness of other posterior tissues.

describe the reasons for Protuberant Abdomens

fat, gas, tumor, pregnancy, Ascitic Fluid

what is food fear

fear of abdominal discomfort

what words are used to describe the abdomen contour?

flat, rounded, protuberant, or scaphoid (markedly concave or hollowed)

What is the costovertebral angle?

formed by the lower border of the 12th rib and the trans- verse processes of the upper lumbar vertebrae, defines where to examine for kidney tenderness, called costoverte- bral angle tenderness (CVAT).

what 3 diagnosis would you see Caput medusa (Vein dilation)

from hepatic cirrhosis, Inferior Vena Cava obstruction, or thrombosis.

what organ produces bile?

gallbladder

a patient is having abdominal pain that Radiates to the left shoulder. what would you suspect?

gallstone 2/2: Acute Cholecystitis (gallstone): Right upper quadrant or epigastrium; may radiate to right shoulder or interscapular area or Biliary Colic (gallstone): Epigastric or right upper quadrant; may radiate to the right scapula and shoulder

patient has epigastric pain that is worse after eating. what does this suggest?

gastritis

how do you palpate the gallbladder?

gently place the palpating hand below the right lower rib margin at the midclavicular line and ask the patient to exhale as much as possible. As the patient exhales, slowly push your hand deeper. Then ask the patient to inhale deeply. A positive Murphy sign is the sudden cessation of inspiration with pain.

A patient is asked about parenteral or mucous membrane expo- sure 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 What liver disease are you inquiring about?

hep b

Friction rubs over RUQ are present in

hepatoma, gonococcal infection around the liver, splenic infarction, and pancreatic carcinoma

how do you assess abdominal wall masses?

if mass 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.

voluntary guarding

in which the patient voluntarily tightens the abdominal muscles to protect a deeper inflamed structure

abdominal friction rubs are rare grating sounds with respiratory variation. They indicate:

inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct. When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.

High-pitched tinkling sounds suggest:

intestinal fluid and air under tension in a dilated bowel.

A protuberant abdomen that is tympanitic throughout suggests

intestinal obstruction or paralytic ileus.

Rushes of high-pitched sounds coinciding with an abdominal cramp signal:

intestinal obstruction.

Ecchymosis of the abdominal wall is seen in

intraperitoneal or retroperitoneal hemorrhage.

Jaundice or icterus definition

is a striking yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin.

define Guarding

is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted.

where is referred pain from pancreatitis?

left shoulder, RUQ

where is referred pain from liver, gallbladder, or duodenum?

left shoulder, left neck, left upper back

borborygmi

long gurgles

Painless jaundice points to

malignant obstruction of the bile ducts, seen in duodenal or pancreatic carcinoma;

What is regurgitation?

may not actually vomit but raise esophageal or gastric contents without nausea or retching

"Food fear" with abdominal pain and a slightly distended soft nontender abdomen are hallmarks of

mesenteric ischemia.

Diarrhea is common with what medications?

of penicillins and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines.

how many days would be an CHRONIC case of diarrhea?

over 30 days

In __________ incontinence, neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes over distended

overflow

where is referred pain from cholecystitis?

pain in the right side of back, mid-scapula or shoulder

what is Referred pain?

pain is felt in more distant sites which are innervated at approximately the same spinal levels as the disordered structures. often develops as the initial pain becomes more intense and seems to radiate or travel from the initial site. It may be palpated superficially or deeply but is usually localized.

what is Visceral pain?

pain occurs when hollow abdominal organs Visceral pain may be difficult to localize. Ischemia also stimulates visceral pain fibers.

what is Parietal pain?

pain originates from inflammation of the parietal peritoneum, called peritonitis. It is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing. Patients with parietal pain usually prefer to lie still.

Arterial bruits with both systolic and diastolic components suggest

partial occlusion of the aorta or large arteries.

pain with absent bowel sounds, rigidity, percussion tenderness, and guarding points to

peritonitis

Bilateral kidney enlargement suggests what?

polycystic kidney disease.

Where is the pancreas located?

posterior to the stomach, epigastric area, LUQ

Borborygmi definition

prolonged gurgles of hyperperistalsis from "stomach growling,"

There is referred pain to the sacrum. where could the pain be originating from?

rectum

what is rebound tenderness and how do you assess for it?

refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand. To assess rebound tenderness, ask the patient "Which hurts more, when I press or let go?" Press down with your fingers firmly and slowly, then withdraw your hand quickly. The maneuver is positive if withdrawal produces pain. Percuss gently to check for percussion tenderness.

bruits in the epigastrium are suspicious for

renal artery stenosis or renovascular hypertension.

Doubling over with cramping colicky pain signals:

renal stone.

you hear a bruit in the RUQ. where could this be coming from?

right renal artery stenosis or an aneurysm

Dullness in the abdomen represents what?

scattered areas of dullness from fluid and feces

in appendicitis, what would a rectal exam show?

sensitive in the right or anterior rectum.

Define obstipation

severe constipation, impaction

you are percussing a liver. the liver is 2 cm MSL. what could this indicate?

small hard cirrhotic liver

Diffuse abdominal pain with abdominal distention, hyperactive high-pitched bowel sounds, and tenderness on palpation may be:

small or large bowel obstruction

What is a normal finding when palpating the liver?

soft, sharp, and regu- lar with a smooth surface

what may relieve the symptoms of Diffuse esophageal spasm?

sometimes nitroglycerin Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis)

you hear a bruit in the LUQ. where could this be coming from?

splenic artery, left renal artery stenosis, or an aneurysm

Oily residue, sometimes frothy or floating, occurs with __________ (fatty diarrheal stools)? Causes?

steatorrhea from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.

In _____________ incontinence, increased abdominal pressure causes bladder pressure to exceed urethral resistance—there is poor urethral sphincter tone or poor support of bladder neck

stress

Combined _____ and _______ incontinence is mixed incontinence.

stress and urge

Causes of visceral pain in the periumbilical area?

suggests early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum. could be from the small intestine, appendix, or proximal colon For pain disproportionate to physical findings, suspect intestinal mesenteric ischemia.

Causes of visceral pain in the RUQ?

suggests liver distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis. Right upper quadrant or epigastric pain from the biliary tree and liver

you are percussing a liver. the liver is 14 cm MCL. what could this indicate?

swollen enlarged liver

Because ascitic fluid characteristically sinks with gravity, whereas gas-filled loops of bowel rise, dullness appears in:

the dependent areas of the abdomen.

Pain from pleurisy or inferior wall myocardial infarction may be referred to:

the epigastric area.

Most persons with chronic Hep B infection are asymptomatic until

the onset of advanced liver disease.

The peritoneum is:

the serous membrane forming the lining of the abdominal cavity. It covers most of the intra-abdominal (or coelomic) organs, and is composed of a layer of mesothelium supported by a thin layer of connective tissue.

Pain of duodenal or pancreatic origin may be referred to:

to the back, pain from the biliary tree, to the right scapular region or the right posterior thorax.

what is Esophageal Dysphagia?

transfer of food through esophagus to stomach, complaints of "food sticking" after swallowing

you hear a bruit in the Epigastrium. where could this be coming from?

transmitted heart murmur or aortic stenosis or an aneurysm

what sound would you hear when percussing hollow sounds of the abd?

tympany

what are The more common ventral hernias?

umbilical, incisional, and epigastric.

how many days would be an ACUTE case of diarrhea?

under 14 days

In ___________ incontinence, urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance.

urge

associated symptoms of Gastritis, GERD, peptic ulcer (gastric or duodenal)

usually epigastric discomfort from heartburn, dysmotility; if peptic ulcer, pain after meals (delay of 2-3 hrs if duodenal ulcer; may be asymptomatic

Impaired excretion of conjugated bilirubin is seen in

viral hepatitis, cirrhosis, primary biliary cirrhosis, and drug-induced cholestasis from drugs such as oral contraceptives, methyl testosterone, and chlorpromazine.

when do Hernias and diastasis recti usually become more evident?

when the patient is supine and raises the head and shoulders.

involuntary guarding

where the intra-abdominal pathology has progressed to cause rigidity of the abdominal muscles that the patient can not relax

Rovsing's sign:

while standing on the patient's right side, gradually do slow deep palpation of the left lower quadrant. Increased pain on the right suggests right sided peritoneal irritation.

Epigastric pain occurs with:

with gastroesophageal reflex disease (GERD), pancreatitis, and perforated ulcers.

There is referred pain to the Shoulder. where could the pain be originating from?

•Diaphragm, Subphrenic abscess

name the type of incontinence: frequently or constantly dribble urine: BPH

•Overflow incontinence

when does pain get worse in acute inflammation of the duodenum, gall bladder or pancreas?

•Pain worsens at this site during digestion •Pain worsens 2-3 hours after eating

what kind of stools in Cystic Fibrosis and Celiac Disease

•Stools are: -Pale -Bulky (fatty) -Have foul odor Pancreas Insufficiency

name the type of incontinence: sudden, intense urge to urinate, followed by an involuntary loss of urine: UTI, MS, Parkinsons, Alzheimer's, stroke, injury, overactive bladder

•Urge incontinence