P&D: Abdomen

"Spitting up blood" may mean blood arising from the gastrointestinal (GI) tract but may also mean _____

"Spitting up blood" may mean blood arising from the gastrointestinal (GI) tract but may also mean blood coming from the upper airways.

Symptoms of blood loss such as lightheadedness or syncope depend on the rate and volume of bleeding and are rare until blood loss exceeds ____.

500 mL

Pain may signal rupture. Rupture is 15 times more likely in AAAs ____ than in smaller aneurysms and carries an 85% to 90% mortality rate.3

>4 cm

A ______ bladder may be palpable above the symphysis pubis.

A distended bladder may be palpable above the symphysis pubis.

A hepatic _____ suggests carcinoma of the liver or cirrhosis. Arterial ____ with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Such ____ in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension.

A hepatic bruit suggests carcinoma of the liver or cirrhosis. Arterial bruits with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Such bruits in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension.

A mass in the abdominal wall remains palpable; an intraabdominal mass is obscured by ____

A mass in the abdominal wall remains palpable; an intraabdominal mass is obscured by muscular contraction.

A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an _____. Sensitivity of palpation increases as _____s enlarge: for widths of 3 to 3.9 cm, 29%; 4 to 4.9 cm, 50%; ≥5 cm, 76%, but caution is warranted for palpating a large pulsatile mass. Consider assessment by ultrasound or radiology

A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA. Sensitivity of palpation increases as AAAs enlarge: for widths of 3 to 3.9 cm, 29%; 4 to 4.9 cm, 50%; ≥5 cm, 76%, but caution is warranted for palpating a large pulsatile mass. Consider assessment by ultrasound or radiology

A protuberant abdomen that is tympanitic throughout suggests

A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction or paralytic ileus

A sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination is a positive ____ sign. When positive, ____ sign triples the likelihood of acute cholecystitis.39 Of note, this finding is only useful in a patient who does not have tenderness in the RUQ with regular palpation.

A sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis.39 Of note, this finding is only useful in a patient who does not have tenderness in the RUQ with regular palpation.

A total of 4% to 20% of healthy individuals have

A total of 4% to 20% of healthy individuals have abdominal bruits

Abdominal masses may be categorized in several ways:

Abdominal masses may be categorized in several ways: physiologic (pregnant uterus), inflammatory (diverticulitis), vascular (an AAA), neoplastic (colon cancer), or obstructive (a distended bladder or dilated loop of bowel).

Common or concerning symptoms for GI disorders

Abdominal pain, acute and chronic Associated gastrointestinal symptoms including indigestion, nausea, vomiting including blood (hematemesis), loss of appetite (anorexia), early satiety Difficulty swallowing (dysphagia) and/or painful swallowing (odynophagia) Change in bowel function Diarrhea Constipation Jaundice

Acholic stools may occur briefly in ______; they are common in _____

Acholic stools may occur briefly in viral hepatitis; they are common in obstructive jaundice.

Signs are maximal in the right upper quadrant.

Acute Cholecystitis

Right lower quadrant signs are typical of acute appendicitis but may be absent early in the course. The typical area of tenderness, McBurney point, is illustrated. Examine other areas of the right lower quadrant as well as the right flank

Acute appendicitis

_____ 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.

Acute diverticulitis

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

Acute pleurisy

Frequently bilateral, the tenderness of acute salpingitis (inflammation of the fallopian tubes) 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

Angina from _____ may also present as heartburn.

Angina from inferior wall coronary ischemia along the diaphragm may also present as heartburn.

Anorexia, nausea, and vomiting accompany many disorders ranging from benign to more insidious, including

Anorexia, nausea, and vomiting accompany many disorders ranging from benign to more insidious, including pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, and adverse drug reactions.

____ can cause medication-induced constipation.

Anticholinergic agents, antidepressants, calciumchannel blockers, calcium and iron supplements, and opioids can cause medication-induced constipation.

Appendicitis is twice as likely in the presence of RLQ tenderness, ____ sign (indirect tenderness), and the____ sign; it is three times more likely if there is _____ point tenderness (____ sign)

Appendicitis is twice as likely in the presence of RLQ tenderness, Rovsing sign (indirect tenderness), and the psoas sign; it is three times more likely if there is McBurney point tenderness (McBurney sign)

As you explore factors that aggravate or relieve the pain, pay special attention to body position, association with _____

As you explore factors that aggravate or relieve the pain, pay special attention to body position, association with meals, alcohol, medications (including aspirin, NSAIDs, and any over-the-counter medications), stress, and use of antacids.

Ascites reflects the ______. It may signal decreased ____

Ascites reflects the increased hydrostatic pressure in cirrhosis (the most common cause of ascites), heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. It may signal decreased osmotic pressure in nephrotic syndrome, malnutrition, or ovarian cancer.

_____ 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).

Ascitic Fluid

Abdominal Asymmetry suggests a

Asymmetry suggests a hernia, an enlarged organ, or a mass.

Atypical presentations of abdominal pain can be seen in _____who might not mount an adequate response.

Atypical presentations of abdominal pain can be seen in elderly patients who might not mount an adequate response.

Approximately 10% of patients with chronic longstanding heartburn have ______, a metaplastic change in the esophageal lining from normal squamous to columnar epithelium. In those affected, dysplasia on endoscopy increases the risk of esophageal cancer from 0.1% to 0.5% (no dysplasia) to 6% to 19% per patient year (high-grade dysplasia).

Barrett esophagus

Bloating may occur with a spectrum of disorders ranging from benign to more concerning, such as

Bloating may occur with a spectrum of disorders ranging from benign to more concerning, such as lactose intolerance, irritable bowel syndrome (IBS), inflammatory bowel disease (IBD), and GERD, to early presentation of malignancies.

Blood on the surface or toilet paper may point to the presence of

Blood on the surface or toilet paper may point to the presence of hemorrhoids.

____ may be: Increased, as in diarrhea or early intestinal obstruction Decreased, then absent, as in adynamic ileus and peritonitis. Before deciding that bowel sounds are absent, sit down and listen where shown for 2 min or longer.

Bowel Sounds

; illicit injection drug use or blood transfusion (hepatitis ____).

C

In patients with recent hospitalizations or antibiotic use or those that are immunocompromised, it is important to consider

C. difficile infection

Carotenemia, the presence of the orange pigment carotene in the blood due to

Carotenemia, the presence of the orange pigment carotene in the blood due to ingestion of carrots, presents as a yellow discoloration of the skin, especially palms and soles, but not the sclera or mucous membranes

Causes are generally structural in ___ adults and neurologic/muscular in ___ adults

Causes are generally structural in younger adults and neurologic/muscular in older adults

Contents of RLQ

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

Chronic diarrhea is typically noninfectious in origin, as in

Chronic diarrhea is typically noninfectious in origin, as in IBS (Crohn disease and ulcerative colitis) or food allergy

Nosocomial diarrhea is a subset of acute diarrhea that starts in the hospital, generally after 72 hours, and is less than 2 weeks in duration. The most common is _____

Clostridium difficile infection

Constipation also occurs with

Constipation also occurs with diabetes, hypothyroidism, hypercalcemia, hypomagnesemia, multiple sclerosis, Parkinson disease, and systemic sclerosis.

Cramping pain radiating to the flank or groin accompanied by urinary symptoms may be suggestive of _____

Cramping pain radiating to the flank or groin accompanied by urinary symptoms may be suggestive of nephrolithiasis (renal stone).

Dark urine indicates

Dark urine indicates impaired excretion of bilirubin into the GI tract.

Diagnostic criteria for IBS is a diagnosis of exclusion and requires intermittent pain for 12 weeks of the preceding 12 months with relief from _______, or change in form of stool (loose, watery, pellet-like), linked to _____

Diagnostic criteria for IBS is a diagnosis of exclusion and requires 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

Diarrhea is common with use of

Diarrhea is common with use of penicillin and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines.

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. Often present in patients with repeated pregnancies, obesity, and chronic lung disease. It is clinically benign.

Diastasis Recti

Alarm symptom

Difficulty swallowing (dysphagia) Pain with swallowing (odynophagia) Recurrent vomiting Evidence of GI bleeding Early satiety Weight loss Anemia Risk factors for gastric cancer Palpable mass Painless jaundice

Dilated veins suggest

Dilated veins suggest portal hypertension from cirrhosis (caput medusae) or inferior vena cava obstruction.

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.

Downward Displacement of the Liver by a Low Diaphragm

Dull areas characterize an

Dull areas characterize an intrauterine pregnancy, an ovarian tumor, a distended bladder, large volume ascites, or a large liver or spleen.

Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of ______. There may also be ____

Early voluntary guarding may be replaced by involuntary muscular rigidity and signs of peritoneal inflammation. There may also be RLQ pain on quick withdrawal or deferred rebound tenderness.

Ecchymosis of the abdominal wall is seen in

Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperitoneal hemorrhage.

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.

Epigastric Hernia

Epigastric pain can occur with ______

Epigastric pain can occur with gastroesophageal reflex disease (GERD), pancreatitis, and perforated duodenal ulcers.

Estimates of liver span by percussion have a ____ with actual span.

Estimates of liver span by percussion have a 60% to 70% correlation with actual span.

___ is the most common cause of a protuberant abdomen. Fat thickens the abdominal wall, the mesentery, and omentum. The umbilicus may appear sunken. A pannus, or apron of fatty tissue, may extend below the inguinal ligaments. Lift it to look for inflammation in the skin folds or even for a hidden hernia.

Fat

For example, the term "heartburn" may mean ______

For example, the term "heartburn" may mean pain from reflux but may also mean angina

Frequency <5 per minute is considered to arise from ______ and of >34 per minute from_____

Frequency <5 per minute is considered to arise from hypoactive bowel sounds and of >34 per minute from hyperactive bowel sounds.

Friction rubs are present in

Friction rubs are present in hepatoma, gonococcal infection around the liver, splenic infarction, and pancreatic carcinoma.

A total of 30% to 90% of patients with asthma and 10% with specialty referral for throat conditions have ____like symptoms.

GERD

If patients report heartburn and effortless regurgitation together more than once a week, the accuracy of diagnosing _____ is over 90%

GERD

Gallbladder disease or prior surgery that may result in

Gallbladder disease or prior surgery that may result in extrahepatic biliary obstruction

_____ may obstruct the common bile duct.

Gallstones or pancreatic, cholangio-, or duodenal carcinoma may obstruct the common bile duct.

Gaseous distention may be localized or generalized. It causes a tympanitic percussion note. Selected foods may cause mild distention from increased intestinal gas production. More serious causes are intestinal obstruction and adynamic (paralytic) ileus. Note the location of the distention. Distention is more marked in obstruction in the colon than in the small bowel.

Gas

Heartburn is a rising retrosternal burning pain or discomfort occurring weekly or more often. It is typically aggravated by foods such as ________; or positions like _____.

Heartburn is a rising retrosternal burning pain or discomfort occurring weekly or more often. It is typically aggravated by foods such as alcohol; chocolate; citrus fruits; coffee; onions; and peppermint; or positions like bending over, exercising, lifting, or lying supine.

Hematemesis may accompany

Hematemesis may accompany esophageal or gastric varices, Mallory-Weiss tears, or PUD.

Hereditary disorders such as family history of hemolytic anemia or liver disease, such as

Hereditary disorders such as family history of hemolytic anemia or liver disease, such as hemochromatosis, α-1-antitrypsin deficiency, Wilson disease

Hernias and diastasis recti usually become more evident when the patient is

Hernias and diastasis recti usually become more evident when the patient is supine and raises the head and shoulders.

High-volume frequent watery stools are usually from the ______; small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in _____

High-volume frequent watery stools are usually from the small intestine; small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions.

If fullness or early satiety, consider .

If fullness or early satiety, consider diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, and gastric cancer.

If percussion dullness is present, palpation correctly detects splenomegaly more than_____

If percussion dullness is present, palpation correctly detects splenomegaly more than 80% of the time

If solid foods, consider structural causes like _______, and neoplasm; if solids and liquids, a motility disorder like _____is more likely

If solid foods, consider structural causes like esophageal stricture, webbing or narrowing (Schatzki ring), and neoplasm; if solids and liquids, a motility disorder like achalasia is more likely

Impaired excretion of conjugated bilirubin is seen in

Impaired excretion of conjugated bilirubin is seen in viral hepatitis; cirrhosis; primary biliary cirrhosis; and druginduced cholestasis from drugs such as oral contraceptives, methyl testosterone, and chlorpromazine.

In ascites, dullness shifts to the _____ side, whereas tympany shifts to the ____. Sensitivity of this test is 83% with a specificity of 56%

In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top. Sensitivity of this test is 83% with a specificity of 56%

In chronic liver disease, finding an enlarged palpable liver edge below the ribs is suggestive of an

In chronic liver disease, finding an enlarged palpable liver edge below the ribs is suggestive of an enlarged liver and cirrhosis.

In emergency rooms, 40% to 45% of patients have _____ pain, but 15% to 30% need surgery, usually for ____,____, or _____

In emergency rooms, 40% to 45% of patients have nonspecific pain, but 15% to 30% need surgery, usually for appendicitis, intestinal obstruction, or cholecystitis.

In primary or functional constipation, the cause cannot be identified from the history and physical examination. Types include

In primary or functional constipation, the cause cannot be identified from the history and physical examination. Types include normal transit, slow transit, impaired expulsion (from pelvic floor dysfunction), and combined causes.

In the rare condition of situs inversus,

In the rare condition of situs inversus, organs are reversed—air bubble on the right, liver dullness on the left.

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.

Incisional Hernia

Increased abdominal pain on either technique is a positive _____ sign, suggesting irritation of the right ____muscle by an inflamed retrocecal appendix.

Increased abdominal pain on either technique is a positive psoas sign, suggesting irritation of the right psoas muscle by an inflamed retrocecal appendix.

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

Indicators of oropharyngeal dysphagia include delay in

Indicators of oropharyngeal dysphagia include delay in initiating swallowing, postnasal regurgitation or coughing from aspiration, and repetitive swallowing to achieve clearance.

_____ is a general term for distress associated with eating that can have many meanings

Indigestion

Box 19-4

Infectious hepatitis: Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A); parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis B); illicit injection drug use or blood transfusion (hepatitis C). Hepatitis B is also endemic in certain regions of the world and can present in patients with no risk factors. Nonalcoholic steatohepatitis in patients with metabolic syndrome Alcoholic hepatitis or alcoholic cirrhosis: screen patients carefully about alcohol use Toxic liver damage from medications, industrial solvents, environmental toxins, or some anesthetic agents Gallbladder disease or prior surgery that may result in extrahepatic biliary obstruction Hereditary disorders such as family history of hemolytic anemia or liver disease, such as hemochromatosis, α-1-antitrypsin deficiency, Wilson disease

Inspect for lower abdominal

Inspect for lower abdominal masses or hernias.

Inspect for the increased pulsations of an

Inspect for the increased pulsations of an abdominal aortic aneurysm (AAA) or increased pulse pressure.

Intrahepatic jaundice can be hepatocellular, from

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

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.

Irregular Large Liver

Itching or pruritus occurs in _______ when bilirubin levels are markedly elevated

Itching or pruritus occurs in cholestatic or obstructive jaundice when bilirubin levels are markedly elevated

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

Lipoma

A palpable liver does not necessarily indicate hepatomegaly (an enlarged liver), but more often results from a change in consistency—from the normal softness to an abnormal firmness or hardness, as in cirrhosis. Clinical estimates of liver size should be based on both percussion and palpation, although even these techniques are imperfect compared to ultrasound

Liver Enlargement: Apparent and Real

Liver dullness may be displaced downward by the low diaphragm of

Liver dullness may be displaced downward by the low diaphragm of chronic obstructive pulmonary disease. Span, however, remains normal.

Contents of RUQ

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

Localized bulges in the abdominal wall include ______ (defects in the wall through which tissue protrudes) and ____

Localized bulges in the abdominal wall include ventral hernias (defects in the wall through which tissue protrudes) and subcutaneous tumors such as lipomas

Many patients with chronic upper abdominal discomfort or pain complain of

Many patients with chronic upper abdominal discomfort or pain complain of heartburn, dysphagia, or effortless regurgitation.

Many patients with upper abdominal discomfort or pain will have _______, defined as a 3- month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease (PUD).

Many patients with upper abdominal discomfort or pain will have functional, or non-ulcer, dyspepsia, defined as a 3- month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease (PUD).

Melena may appear with as little as 100 mL of blood from upper GI bleeding; hematochezia, if more than 1,000 mL of blood, is usually from

Melena may appear with as little as 100 mL of blood from upper GI bleeding; hematochezia, if more than 1,000 mL of blood, is usually from lower GI bleeding, but if massive can have an upper GI source.

Multifactorial causes include

Multifactorial causes include delayed gastric emptying (20% to 40%), PUD with or without Helicobacter pylori (20% to 60%), peptic ulcer disease (PUD) (up to 15% if H. pylori is present), IBS, and psychosocial factors.

Nonalcoholic steatohepatitis in patients with ____

Nonalcoholic steatohepatitis in patients with metabolic syndrome

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.

Normal Variations in Liver Shape

Note that angina from inferior wall coronary artery disease may present as ______

Note that angina from inferior wall coronary artery disease may present as "indigestion," but is precipitated by exertion and relieved by rest.

Observe for the bulging flanks of ascites, the suprapubic bulge of a distended bladder or

Observe for the bulging flanks of ascites, the suprapubic bulge of a distended bladder or pregnant uterus and ventral, femoral, or inguinal hernias.

Obstipation signifies

Obstipation signifies intestinal obstruction.

Of those with suspected GERD, ∼50% to 85% have

Of those with suspected GERD, ∼50% to 85% have no disease on endoscopy

Oily residue, sometimes frothy or floating, occurs with steatorrhea (fatty diarrheal stools) from

Oily residue, sometimes frothy or floating, occurs with steatorrhea (fatty diarrheal stools) from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.

Pain of duodenal or pancreatic origin may be referred to the _______, pain from the biliary tree, to the _____ or _____

Pain of duodenal or pancreatic origin may be referred to the back, pain from the biliary tree, to the right scapular region or the right posterior thorax

Painless jaundice points to _______; painful jaundice is commonly infectious in origin, as in hepatitis A and cholangitis.

Painless jaundice points to malignant obstruction of the bile ducts, seen in duodenal or pancreatic carcinoma; painful jaundice is commonly infectious in origin, as in hepatitis A and cholangitis.

Patients who have uncomplicated GERD who fail empiric therapy, age >55 years, and "alarm symptoms" warrant endoscopy to evaluate possible

Patients who have uncomplicated GERD who fail empiric therapy, age >55 years, and "alarm symptoms" warrant endoscopy to evaluate possible esophagitis, peptic strictures, Barrett esophagus, or esophageal cancer.

Pink-purple striae are a hallmark of

Pink-purple striae are a hallmark of Cushing syndrome.

Predominantly unconjugated bilirubin occurs from the first three mechanisms, as in

Predominantly unconjugated bilirubin occurs from the first three mechanisms, as in hemolytic anemia (increased production) and Gilbert syndrome.

____ is a common pelvic "mass." Listen for the fetal heart

Pregnancy

RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for _______. In women, consider ______

RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for appendicitis. In women, consider pelvic inflammatory disease (PID), ruptured ovarian follicle, and ectopic pregnancy.

Regurgitation is a common symptom of GERD; however, it can also be a presenting symptom of

Regurgitation is a common symptom of GERD; however, it can also be a presenting symptom of esophageal stricture, Zenker diverticulum, or esophageal or gastric malignancy.

____ describes involuntary spasm of the stomach, diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth.

Retching describes involuntary spasm of the stomach, diaphragm, and esophagus that precedes and culminates in vomiting, the forceful expulsion of gastric contents out of the mouth.

Right hypogastric pain is a positive _____ sign, from irritation of the right _____ muscle by an inflamed appendix located in the pelvis. This sign has very low sensitivity.

Right hypogastric pain is a positive obturator sign, from irritation of the right obturator internus muscle by an inflamed appendix located in the pelvis. This sign has very low sensitivity.

Right-sided rectal tenderness suggests _____ but may also be caused by an _____

Right-sided rectal tenderness suggests appendicitis but may also be caused by an inflamed adnexa or seminal vesicle.

Pain in the RLQ during left-sided pressure is a positive _____ sign.

Rovsing

Secondary or organic constipation has an identified underlying cause, which may include

Secondary or organic constipation has an identified underlying cause, which may include medications, amyloidosis, diabetes, and central nervous system disorders.

Contents of LLQ

Sigmoid colon, descending colon, and left ovary

Signs of peritonitis include a

Signs of peritonitis include a positive cough test, involuntary guarding, rigidity, rebound tenderness, and percussion tenderness

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.

Smooth Large Liver

Some patients may complain of passing excessive gas, or flatus. Causes include

Some patients may complain of passing excessive gas, or flatus. Causes include excessive and repetitive air swallowing (aerophagia), ingestion of legumes or other gasproducing foods, intestinal lactase deficiency, and IBS.

Some patients with GERD have atypical respiratory symptoms such as ______. Others complain of pharyngeal symptoms, such as _____.

Some patients with GERD have atypical respiratory symptoms such as chest pain, cough, wheezing, and aspiration pneumonia. Others complain of pharyngeal symptoms, such as hoarseness chronic sore throat, and laryngitis.

Contents of LUQ

Spleen, splenic flexure of colon, stomach, and body and tail of pancreas

____ hernias merit prompt surgical evaluation.

Strangulated inguinal, femoral, or scrotal hernias merit prompt surgical evaluation.

When the patient raises the head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion (protected by the tightened muscles) decreases.

Tenderness may originate in the abdominal wall.

_____ is more severe than visceral tenderness. Muscular rigidity and rebound tenderness are frequently but not necessarily present. Generalized peritonitis causes exquisite tenderness throughout the abdomen, together with board-like muscular rigidity. These signs on palpation, especially abdominal rigidity, double the likelihood of peritonitis.39,76 Local causes of peritoneal inflammation include:

Tenderness of Peritoneal Inflammation

The bulge of a hernia will usually appear with this action (Valsalva maneuver), but should not be confused with diastasis recti, which is a

The bulge of a hernia will usually appear with this action, but should not be confused with diastasis recti, which is a benign 2- to 3-cm gap in the rectus muscles often seen in obese and postpartum patients.

The more common ventral hernias are

The more common ventral hernias are umbilical, incisional, and epigastric

The span of liver dullness is increased when the liver is _____. The span of liver dullness is decreased when the liver is ____

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

The tip of the spleen may be palpable below the left costal margin in a small percentage of adults (in contrast to readily palpable _________).

The tip of the spleen may be palpable below the left costal margin in a small percentage of adults (in contrast to readily palpable splenic enlargement, or splenomegaly).

What do these findings suggest? "Abdomen is protuberant, soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness." OR "Abdomen is flat. No bowel sounds heard. It is firm and boardlike, with increased tenderness, guarding, and rebound in the right lower quadrant. Liver percusses to 7 cm in the midclavicular line; edge not felt. Spleen and kidneys not felt. No palpable masses. No CVA tenderness. Psoas sign positive."

These findings suggest peritonitis from possible appendicitis

These symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include

These symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include reduced salivary flow, which increases mucosal acid exposure by dampening the actions of the bicarbonate buffer; obesity; delayed gastric emptying; selected medications; hiatal hernia and increased intraabdominal pressure.

Toxic liver damage from

Toxic liver damage from medications, industrial solvents, environmental toxins, or some anesthetic agents

Fluid or solids in the stomach or colon may also cause dullness in ____

Traube space.

Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis __)

Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A)

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

Tumor

A protrusion through a defective umbilical ring. When present in infants, it usually closes spontaneously within 1-2 yrs.

Umbilical Hernia

Common or Concerning Symptoms of Urinary and Renal Disorders

Urinary symptoms including suprapubic pain; dysuria, urgency, or frequency; nocturia or polyuria; urinary incontinence; hematuria Flank pain and ureteral colic

_______ pain can be suggestive of 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

Visceral periumbilical pain can be suggestive of 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

The structures shown may be tender to deep palpation. Usually the discomfort is dull with no muscular rigidity or rebound tenderness. A reassuring explanation to the patient may prove helpful

Visceral tenderness

_____ (insufficient saliva) commonly present in older adult men and women ≥70 years can give rise to the sensation of difficulty swallowing food

Xerostomia

Nonspecific diffuse _______ is symptomatic of a bowel obstruction (see pp. 626-627).

abdominal pain with abdominal distention, nausea, emesis, and lack of flatus and/or bowel movements

In ____, epigastric tenderness and rebound tenderness and localized guarding are usually present, but the abdominal wall may be soft.

acute pancreatitis

Risk factors for AAA are

age ≥65 years, history of smoking, male gender, and a first-degree relative with a history of AAA repair.

Visceral pain in the RUQ suggests liver distention against its capsule from the various causes of hepatitis, including ______

alcoholic hepatitis or biliary pathology.

Localized tenderness anywhere in the RLQ, even in the right flank, suggests _____

appendicitis.

Dullness in both flanks prompts further assessment for

ascites

RUQ pain is associated with pathology with the _____

biliary tree and the liver.

Vomiting and nausea with constipation or obstipation (severe constipation with inability to pass both stool and gas) is indicative of a _____ and warrants further imaging workup.

bowel obstruction

Induced vomiting without nausea is more indicative of ____

bulimia.

Pain may also be referred to the abdomen from the _____ further complicating the assessment of abdominal pain.

chest, spine, or pelvis,

Patients who have peritonitis require surgical evaluation urgently. Peritonitis is marked by severe diffuse abdominal pain with guarding and rigidity on examination. Patients may or may not have accompanying abdominal _____.

distention

Pain in the LLQ accompanied by diarrhea in a patient with a history of constipation is suggestive of _____

diverticulitis

difficulty swallowing

dysphagia

Pain from pleurisy or inferior wall myocardial infarction may be referred to the _____.

epigastric area

Pointing to below the sternoclavicular notch suggests

esophageal dysphagia.

Consider _____ from ingestion of aspirin or NSAIDs; caustic ingestion; radiation; or infection with Candida, cytomegalovirus, herpes simplex, or HIV.

esophageal ulceration

_____ are 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.

friction rub

blood in the urine

hematuria

parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis ___)

hepatitis B Hepatitis B is also endemic in certain regions of the world and can present in patients with no risk factors.

Acute diarrhea, especially foodborne, is usually caused by

infection

Risk factors for liver disease

infectious hepatitis A-C, alcoholic hepatitis or alcoholic cirrhosis, toxic liver damage, gall bladder disease or prior surgery, hereditary disorders, nonalcoholic steatohepatitis

Signs of peritonitis include a positive cough test, involuntary guarding, rigidity, rebound tenderness, and percussion tenderness. When positive, these signs roughly double the likelihood of peritonitis; rigidity makes peritonitis almost four times more likely.39 Causes include any

inflammatory, infectious or ischemic intraabdominal process, such as appendicitis, diverticulitis, cholecystitis, bowel ischemia or perforation.

For pain disproportionate to physical findings, suspect ________

intestinal mesenteric ischemia.

Patients with symptoms and abdominal pain and tenderness may have ____, which requires urgent cross-sectional imaging and surgical consultation.

ischemia

Change in bowel habits with a palpable mass warns of ______

late-stage colon cancer.

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

liver disease.

Lower GI complaints are also common: pain; diarrhea; constipation; change in bowel habits; and blood in the stool, which can be further classified as bright red blood or dark and tarry (______).

melena

Combining clinical examination findings with laboratory inflammatory markers and imaging (CT scan, ultrasound) markedly reduces _____

misdiagnosis and unnecessary surgery

muscular like

muscular dystrophy or myasthenia gravis;

frequent urination at night

nocturia

An __ may merge with the liver, forming a firm oval mass below the liver edge and an area that is dull to percussion.

obstructed distended gallbladder

Thin, pencil-like stool occurs in an _____ of the distal colon.

obstructing "applecore" lesion

Extrahepatic jaundice arises from _____, most commonly the common bile ducts.

obstruction of the extrahepatic bile ducts

pain with swallowing

odynophagia

or structural as seen in

or structural as seen in esophageal stricture and hypopharyngeal diverticuli (Zenker diverticulum).

Studies suggest that neuropeptides such as 5- hydroxytryptophan and substance P mediate interconnected symptoms of ______

pain, bowel dysfunction, and stress.

Nocturnal diarrhea is usually

pathologic

Involuntary guarding or rigidity typically persists despite these maneuvers, suggesting ____.

peritonitis

Splenomegaly is eight times more likely when the spleen is palpable. Causes include

portal hypertension, hematologic malignancies, HIV infection, infiltrative diseases like amyloidosis, and splenic infarct or hematoma.

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

positive splenic percussion sign (Castell's sign)

Pain with pressure or fist percussion supports _____ if associated with fever and dysuria but may also be musculoskeletal.

pyelonephritis

______ pain is felt in more distant sites that are innervated at approximately the same spinal levels as the disordered structures. ______ pain often develops as the initial pain becomes more intense and seems to radiate or travel from the initial site. Palpation at the site of referred pain often does not result in tenderness.

referred pain

In contrast to peritonitis, patients with colicky pain from a _____ move around frequently trying to find a comfortable position.

renal stone

_______ pain originates from inflammation of the parietal peritoneum, called peritonitis, which can be localized or diffuse. 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.

somatic/parietal pain

Percussion is moderately accurate in detecting __

splenomegaly

Indicators of oropharyngeal dysphagia include delay in initiating swallowing, postnasal regurgitation or coughing from aspiration, and repetitive swallowing to achieve clearance. Causes may be neurologic like

stroke, Parkinson disease, or amyotrophic lateral sclerosis;

A ____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.

venous hum

_____ pain occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched (Fig. 19-8). Solid organs such as the liver can also become painful when their capsules are stretched. _____pain is typically nonspecific and difficult to localize. It is typically palpable near the midline at levels that vary according to the structure involved, as illustrated in Figure 19-8. Ischemia also stimulates _____ pain fibers. _______ pain varies in quality and may be gnawing, cramping, or aching. As the pain progresses, systemic symptoms such as sweating, pallor, nausea, vomiting, and restlessness may follow

visceral pain