symptoms of the gastrointestinal system

Diarrhea Physical Exam

-Assess hydration status-mucous membranes, tissue turgor -Vital signs-temperature, weight loss -Observe abdominal contour-distention with an ileus from enteritis, gaseous dilation from malabsorption -Auscultate abdomen-listen in four quadrants for BS -Palpate for tenderness- peritoneal irritation- rigid abdomen, rebound tenderness (Blumberg sign) + findings on iliopsoas muscle test, obturator muscle test (r/o appendicities_, heel jar test (Markle sign) -Apprendicitis, Crohn disease, right sided-diverticulitis, or -CA-right lower quadrant tenderness in a "sick" patient with acute diarrhea -Diverticulitis, fecal impaction, colon ca-localized left lower quadrant tenderness -IBS-localized pain with chronic diarrhea -DRE-fissures, lacerations, impacted stool -Palpate lymph nodes-lymphoma, AIDS -If your butt hurts after a lot of diarrhea, what can happen as a result - fissure (hx of IBD) -HIV related enteropathy

Abdominal Pain Physical Exam

-Note general appearance -Parietal pain-lie still localized peritonitis, appendicitis rupture, perforation - severe, sharp - send to nearest hospital ER ASAP -Visceral pain-restless, colicky type pain-biliary obstruction, ureterolithiasis, gastroenteritis, or early peritonitis - might be able to treat in house, might have to send them out -Vital signs - temperature - make sure no fever, highest level, can r/o conditions -Abdominal Musculature -Rigid abdomen-peritoneal irritation -Note color of the abdomen-ecchymosis (Cullen sign) -Note distention - F's -Auscultate bowel sounds-absence or hyperactivity - listen for 15 sec each quadrant -Percuss abdomen-unexpected dullness, enlarged organ or mass -Palpation-rebound tenderness, palpate liver, spleen, kidneys, aorta and bladder to detect tenderness or involvement -Murphys sign-acute cholecystitis, press on right upper quadrant, inspiratory arrest -No bowel sounds - ileus, late obstructtion -Hyperactive bowel sounds - early obstruction, might be hungry -Rebound tenderness - blumberg's sign - pain on release of pressure -Palpate the groin -Palpate for hernias -Percuss for CVA tenderness - place your hand at the 12th fib with flat surface of ulnar surface of wrist, indicate pyelonephritis -Test for peritoneal irritation/appendicitis - -Obturator muscle test - pt lying supine, take leg and flex and internally rotate - complain of pain of abdomen - irritiation obturator muscle -Iliopsoas muscle test - appendicitis, place hand on leg, have them lift leg up and resist your pressure, increased pain in RUQ due to irritation of psoas muscle, increased abdominal pain, -Markle (heel drop) test - go up on ball of foot, and drop down, if they have increased pain in abdomen that is positive -Rovsing test - complaining of RLQ, palpate in LLQ and they complain of increased pain in RLQ, positive -Pelvic exam in women - ask about date of last gynocelogical exam, many gyn issues can be similar to GI, pelvic inflammatory disease, ectopic pregnancy, fibroids, endometriosis may present as abdominal pain, what was result of pap smear, and U/S outcome? -Genital and prostate exam in men -DRE - digital rectal exam, looking for blood, occult blood, fissures, ulcerations, hemmorhoids, prostate -Check peripheral pulses - -Examine as always-Lungs, CV. Additionally -head & neck, musculoskeletal, lymphadenopathy -Triple a - check pulses, decreased blood flow to lower extremities Video: Markle Test (Heel Jar Test) - peritonitis, -have patient in supine position and relax, -if they have peritonitis which would be inflammation of the peritoneum in their abdomen you can bump the table and that alone should cause excruciating pain for the patient in their abdomen, -or you can come to the feet of the patient and the quickly dorsiflex the feet and that causes pretty much the same motion, movement of the abdomen and the whole body, that will also cause the patient extreme pain and can indicate peritonitis book: Obturator Sign: Pain is elicited in appendicitis by inward rotation of the hip with the knee bentso that the obturator internus muscle is stretched. Psoas Sign: Place your hand on the patient's thigh just above the knee and ask the patient toraise the thigh against your hand. This contracts the psoas muscle and producespain in patients with an inflamed appendix.

Constipation Physical Exam

-Perform abdominal examination -Observe contour look for distention - constipated - rounded, distention -Auscultate bowel sounds-absence may indicate obstruction -Palpate abdomen-stool??, masses, organomegaly -Look for hernias -Perform DRE - looking for anal sphincter tone -Perform focused Neuro exam-test DTR's if there is a loss of voluntary control of defecation - innervation to nerves to that area, decreased response indicitive of decreased muscle tone -Early intestinal obstruction - hyperactive bowel sounds -Obstructed emergency - no bowel sounds, ileus

Peptic Ulcer and Dyspepsia (Book)

Book -Demonstrated ulcer usually in duodenum or stomach; dyspepsia causes similar symptoms but no ulceration. H. pylori infection often present. -Epigastric, may radiate to the back -Variable: gnawing burning, boring, aching, pressing, 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 weeks, disappears for months, then recurs. - Relieves: Food and antacids may bring relief, least commonly in gastric ulcer. -Nausea, vomiting, belching, bloating; heartburn (more common in duodenal ulcer); weight loss (more common in gastric ulcer). -Dyspepsia is more common in the young (20-29 years), gastric ulcer in those over 50 years, and duodenal ulcer in those 30-60 years. PUD includes both gastric and duodenal ulcers. Helicobacter pyloriand NSAIDsare common causes of both disorders, along with some probable genetic predis-position. Zollinger-Ellison syndrome commonly results in gastric ulcer develop-ment. The incidence of gastric ulcer is higher in persons who smoke and thosewith certain chronic diseases, including cirrhosis, hyperparathyroidism, chronicrenal failure, and lung disease.Signs and SymptomsEpigastric pain is common with both gastric and duodenal ulcers and is describedas a gnawing or burning sensation. Whereas the pain of gastric ulcer is usuallyworsened by intake, a duodenal ulcer usually causes pain on an empty stomach.It is not uncommon for the pain of duodenal ulcer to awaken the patient fromsleep at 1 a.m. to 2 a.m. Antacids typically offer relief for both types of ulcer.Pain may be episodic with symptom-free intervals. Pain may radiate to the back. Associated symptoms include bloating, belching, nausea, and loss of appetite.The physical examination is not usually positive other than potentially identifyingsome degree of abdominal tenderness. As the mucosa erodes, bleeding may occur.If rupture occurs, pain acutely changes character and is intractable.Diagnostic StudiesStool guaiac should be performed on any patient with epigastric pain. PUDshould be suspected in any patient with dyspepsia/epigastric pain who does notfit the profile associated with GERD, is older than 50 years, and has associatedweight loss or loss of appetite; direct endoscopy should be ordered. Biopsies willbe taken of any erosive site to rule out gastric malignancy. If PUD is diagnosed,testing for H. pylorishould be performed. When patients with gastric ulcers haveneither H. pylorinor a history of NSAID use, serum gastrin level should be determined, assessing for Zollinger-Ellison syndrome.

GI symptoms associated with Abdominal Pain (Book)

Book: -Patients often experience abdominal pain in conjunction with other symptoms. "How is your appetite?" is a good starting question that may lead to other concerns like indigestion, nausea, vomiting, and anorexia. -Indigestion is a general term for distress associated with eating that can have many meanings. -Anorexia, nausea, and vomiting accompany many gastrointestinal disorders; these are all seen in pregnancy, diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease, emotional states, adverse drug reactions, and other conditions. - Induced vomiting without nausea is more indicative of anorexia/bulimia.

Diarrhea Differential Diagnoses

-Acute diarrhea -Viral gastroenteritis -Shigella - can occur in people who have anal sex -Food poisoning with staphlococcus or bacillus aureus or clostridium perfringens -Samonella -Campylobacter -Vibrio cholerae -Antibiotic induced diarrhea -Chronic diarrhea -Irritable bowel syndrome (IBS) -Ulcerative colitis -Crohn disease -Celiac Sprue -Post gastrectomy dumping syndrome -Fat malabsorption -Carbohydrate malabsorption and Lactose Intolerance -Diabetic enteropathy -Medication induced diarrhea

Protuberant Abdomens (book) a. Fat b. gas c. tumor d. pregnancy e. Ascitic fluid

a. the most common cause of a protuberant abdomen. 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. b. Gaseous distention may be localized or generalized. It causes a tympanitic percussion note. Increased intestinal gas production from certain foods may cause mild distention. More serious are intestinal obstruction and adynamic (paralytic) ileus. Note the location of the distention. Distention becomes more marked in colonic than in small bowel obstruction. c. 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 myomata. Occasionally a markedly distended bladder may be mistaken for such a tumor. d. Pregnancy is a common cause of a pelvic "mass." Listen for the fetal heart (see pp. 909). e. 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). (See pp. 466-467 for the assessment of ascites.)

Spleen (book)

book -When a spleen enlarges, it expands 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. -Percussion suggests but does not confirm splenic enlargement. -Palpation can confirm the enlargement but often misses large spleens that do not descend below the costal margin.

Hematuria (book)

book: -Blood in the urine, -When visible to the naked eye, it is called gross hematuria; the urine may appear obviously bloody. -Blood may be detected only during microscopic urinalysis, known as microscopic hematuria; smaller amounts of blood may tinge the urine with a pinkish or brownish cast. -In women, be sure to distinguish menstrual blood from hematuria. -If the urine is reddish, ask about medications that might discolor the urine. -Test the urine with a dipstick and microscopic examination before you diagnose hematuria.

Abdominal Case Study

-A 68 year old male presents to your office complaining of burning, epigastric pain after meals associated with nausea, especially when lying down after eating. He lost 15 lbs. over the past month, which he attributes to poor appetite. -HPI recovering alcoholic, stopped drinking 8 months ago and has been going to AA meetings regularly. He is also a heavy smoker and has frequent episodes of bronchitis. He has cut back on his smoking significantly. -PMH gastric ulcer 1 year ago. -Medications-none -What other questions would you ask this patient? -How would you approach his physical exam? -What are your differential diagnoses? -What type of food are you eating? Nocturnal awakening? Does this still occur if you don't like down after eating, if you sit up right? Were you trying to lose weight? Describe to me what you mean by poor appetite? Who prepare meals? Do you shop? Widower? Never married? Lives alone? How much are you smoking? How much did you smoke? When did you start smoking? -Labs? COPD? Emphysema? -Question no meds -Physical Exam - Lung, Heart, GI - abdomen: I, A, Perc, Palp , percuss liver, ausculate liver for venous hum -Esophageal Varices? GERD? Cirrhosis? Another ulcer? Acute cholecystitis? Pancreatitis?

Referred Pain

-Abdominal pain -Accompanying symptoms of headache, sore throat, general aches and pains suggest viral, flulike cause. -CV-chest pain? Palpitations? Tachycardia, radiation to arm or jaw? Rule out, differentiate -GI-gas, diarrhea, changes in bowel habits, stools or eating patterns? Pain relieved with defecation? IBS classicallly is releved with defecation -GU-LMP? Could be pregnant or ectopic preg - could have rupture? vaginal symptoms?, menstrual irregularities? -Urinary symptoms-frequency, urgency, dysuria? blood in urine? flank pain? -Musculoskeletal-pain related to change in position? Joint pain? Chostocondritis? swelling? Limited ROM? Trouble walking? -Respiratory-cough or dyspnea? SOB? Bruise ribs? Referred pain to abdomen? -Psychogenic-feel unhappy or sad? Unable to eat, sleep or engage in activities? How is your energy level? Have you ever been diagnosed with a mental health condition? Depression? Anxiety? -55 yo male or female c/o chest pain, what kind?, need to have cardiac work up to make sure not cardiac origin, hopefully just reflux -Cullen sign - periumbilical ecchymosis - ruptured ectopic pregnancy or hemorrhagic pancreatitis Book -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 thus seems to radiate or travel from the initial site. -It may be felt superficially or deeply but is usually localized. -Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree, to the right shoulder or the right posterior chest. -Pain may also be referred to the abdomen from the chest, spine, or pelvis, thus complicating the assessment of abdominal pain. -Pain from pleurisy or inferior wall myocardial infarction may be referred to the epigastric area.

Abdominal Pain Differential Diagnoses

-Acute abdomen -Appendicitis -Ectopic pregnancy -Peptic ulcer perforation -Dissection of aortic aneurysm -MI -Peritonitis -Acute pancreatitis -Mesenteric adenitis -Cholecystitis/lithiasis -Ureterolithiasis -UTI/pyelonephritis -PID/salpingitis -Obstruction -Ileus -Intussusception -Volvulus -Incarcerated hernia -Pt comes in, always do rectal exam, male patient, explain what going to do, rectal exam looking for blood and other things -Chronic conditions that cause upper abdominal pain -GERD - 65-70% of practice on certain days -Peptic ulcer - relief of sx with food -Gastritis - inflamm of stomach, buring senstation of stomach -Gastroenteritis - D, fever, V -Functional dyspepsia - heartburn, done tests on them cant find anything that's cause, despite treatment and tests pt are symptomatic

Abdominal Pain Labs & Diagnostics

-CBC with diff. -hCG (Women) -ESR -Cardiac enzymes -Urinalysis -Urine for C&S if you suspect UTI -DNA probe if you suspect chlamydia, gonorrhoae, trichomonas vaginalis, gardnerella vaginalis and candida species -KOH test -Saline wet prep -Gram stain -FOBT -ECG if suspicious of cardiac origin -C-urea breath test- H. pylori suspected or stool antigen test -KUB -Abdominal/pelvic ultrasound -CT scan/MRI -Colonoscopy or sigmoidoscopy-suspect GI origin of pain Book: Normal Laboratory Values for Differential Diagnosis of thAbdomenTestAspartate aminotransferase (AST) (serum glutamic-oxaloacetic transaminase [SGOT])Alanine aminotransferase (ALT) (serum glutamate pyruvate transaminase [SGPT])Alkaline phosphataseAlbuminGlobulinAlbumin to globulin (A/G) ratioTotal serum proteinTotal bilirubinAmylaseLipaseBlood urea nitrogen (BUN)Serum creatinineUric acidWhite blood count (WBC)Hemoglobin (Hgb)Hematocrit (Hct)Cancer antigen 125 (CA-125)Carcinoembryonic antigen (CEA)Normal Value42 units/L or lessLess than 48 units/L25-150 units/L3.5-5 g/dL1.5-4.5 g/dL1.1-2.56-8.5 g/dLLess than 1.3 mg/dL30-170 units/L7-60 units/L7-30 mg/dL1.2 mg/dL or lessFemale: 2.5-7.5 mg/dLMale: 4-8.5 mg/dL3.8-10.8 ×103/µLFemale: 12-15.6 g/dLMale: 13.8-17.2 g/dLFemale: 35%-46%Male: 41%-50%Less than 35 units/mLNonsmoker: less than 2.5 ng/LSmoker: less than 5 ng/L

Acute Abdominal Pain or Discomfort

-Can you point to the area of pain? -RUQ -RLQ -LUQ -LLQ -Periumbilical -Intestinal obstruction -Acute pancreatitis - sometimes -Early appendicitis -Mesenteric appendicitis -Aortic aneurysm** -Diverticulitis -Three processes can produce abdominal pain -Tension in the GI tract from muscle contraction or distention -Ischemia -Inflammation of the peritoneum -Diagnostic reasoning: -Is this an acute or chronic condition? -Duration of pain? How long have you had the pain? -Onset gradual or sudden? -Pain wake you from sleep? Does it wake you up from sleep?** good to decide acute vs chronic, or differential -Course of pain, what makes it better or worse? -Last BM? - obstruction -Have you had this before? IBS, IBD, diverticulitis -May need surgery -Pain Characteristics -Does it radiate? Where? -Describe the pain i.e. burning, sharp, achy, crampy - helps in differential diagnoses -What makes it better or worse? Tums - better Spaghetti sauce, mexican, pizza - worse, don't eat - better -Precipitating events -Pain related to activity? i.e. worse lying down, worse at night? eating? -Triggers? What brings it on? Food, activity, position, stress, occurs more when a lot going on in life? -What does the presence of diarrhea or vomiting tell me? -Vomiting - viral, diarrhea - bacterial, depends on what your talking about. IBD - going to have D -Ruptured spleen radiate to shoulder - top of left shoulder -What else? -Meds? emycin, tetracycline, NSAIDs, and many others -Surgical history? Adhesions from c-section, -endometrioses, hysterectomy, any abdominal surgery -Involuntary weight loss? Colon CA - bloody stool, hematochezia -Have you been camping?-untreated water-parasites -Always ask - do you take any NSAIDs? Never know what talking about - advil, motrin, aleve -Ive lost 10lbs over the past 3 weeks - are you trying to lose weight? Intentional or unintentional? -First thing you think if unintentional weight loss - malignancy Book -timing of the pain. Is it acute or chronic? -patterns. Did the pain start suddenly or gradually? When did it begin? How long does it last? What is its pattern over a 24-hour period? Over weeks or months? Are you dealing with an acute illness or a chronic and recurring one? -nonspecific pain, need surgery, usually for appendicitis, intestinal obstruction, or cholecystitis.[5] -describe the pain in their own words. Pursue important details: "Where does the pain start?" "Does it radiate or travel anywhere?" "What is the pain like?" If the patient has trouble describing the pain, try offering several choices: "Is it aching, burning, gnawing ... ?" -Doubling over with cramping colicky pain indicates renal stone. Sudden knifelike epigastric pain occurs in gallstone pancreatitis.[6],[7] -Then ask the patient to point to the pain. Patients are not always clear when they try to describe in words where pain is most intense. The quadrant where the pain is located can be helpful. Often, underlying organs are involved. If clothes interfere, repeat the question during the physical examination. -Epigastric pain occurs with gastritis and gastroesophageal reflex disease (GERD). Right upper quadrant and upper abdominal pain are common in cholecystitis.[8] -Ask the patient to rank the severity of the pain on a scale of 1 to 10. Note that severity does not always help you to identify the cause. Sensitivity to abdominal pain varies widely and tends to diminish in older patients, masking acute abdominal conditions. Pain thresholds and how patients accommodate to pain during daily activities also affect ratings of severity. -As you explore factors that aggravate or relieve the pain, pay special attention to any association with meals, alcohol, medications (including aspirin and aspirinlike drugs and any over-the-counter medications), stress, body position, and use of antacids. Ask if indigestion or discomfort is related to exertion and relieved by rest. -Note that angina from inferior wall coronary artery disease may present as "indigestion," but is precipitated by exertion and relieved by rest. See Table 8-1, Chest Pain. Red Flags: Pain that awakens patient•Pain that persists more than 6 hours and progresses in intensity•Pain that changes location•Associated syncope•Pain followed by vomiting or intractable vomiting•Hematemesis•Black, tarry stools•Progressive abdominal distention•Pain worsened by movement, respirations•Radiation of the pain to shoulder (cholecystitis) or back (pancreatitis/aneurysm)•Decreased urine output•Fever, leukocytosis, granulocytosis•Pain associated with signs of hypovolemic shock Abdominal pain is one of the most common complaints in primary care and canbe functional or organic in cause and acute or chronic in nature. Even thoughthe causes of abdominal pain are often self-limiting, the pain can also indicate alife-threatening situation and must be carefully assessed.When a patient complains of abdominal pain, it is essential to rule out indi-cations for an emergency referral by carefully reviewing the history of the com-plaint, including the general description, quantity, quality, location, timing, andonset of the pain and associated symptoms. Although the physical examinationmay suggest the cause, the examination may be normal even with underlyingpathology. Laboratory studies and diagnostic testing may be necessary to pinpointthe actual cause and rule out the more serious causes. Table 10.5 presents normalvalues for some of the laboratory tests commonly used in differential diagnosisof the abdomen. There are three major categories used to classify abdominal pain: visceral, so-matoparietal, and referred. Referred pain is simply pain radiating or referringfrom a site external to the abdomen. See Table 10.6 for differentiating commoncharacteristics of visceral and somatoparietal pain. in this chapter under lower quadrant pain. Because the abdomen contains manystructures and organs, a thorough history and physical examination is necessarywith special maneuvers if warranted.HistoryBegin with the exact location of the pain, onset, timing, quality and quantity,and alleviating or aggravating factors—particularly if the pain is related to mealsor movement. Ask if there has been any fever, nausea, vomiting, diarrhea, con-stipation, anorexia, or change in urine or stool color/consistency, which may indicate liver or gallbladder disease. A pleuritic cause for the pain should be con-sidered; inquire about cough, shortness of breath, or fever. Include a smokinghistory. Ask about diet history, particularly in regard to a high-fat diet or fad dietsthat might exclude food groups or be very low in calories. This may increase thelikelihood of gallbladder disease. Inquire about sexual practices, alcohol, anddrugs (prescription and illicit) that might alert you to an increased risk for liverdisease, particularly hepatitis. Ask about foreign travel because hepatitis is en-demic in some areas, and often the standards for food preparation are not thesame as in North America. Ask about patient and family history of breast or coloncancer, gallbladder or liver disease, and general disorders of the digestive tract.Physical ExaminationA thorough abdominal examination should be performed with particular atten-tion to the RUQ, assessing for tenderness, rebound, masses, and organ enlarge-ment or nodularity. A respiratory examination should include auscultation for252Advanced Assessment|Advanced Assessment and Differential Diagnosis by Body Regions Table 10.6D

Gerontological Considerations

-Changes in the mouth-few taste buds, decline in sense of taste, decreased saliva production, dry mouth -Decreased esophageal, gastric and intestinal motility -Decreased hydrochloric acid in the stomach -Decreased intestinal absorption, motility and blood flow -Decreased liver size and blood flow -Effects of aging on absorption & metabolism of medications -Dry mouth & difficulty swallowing -Decreased motility & absorption of some meds in the GI tract -Decreased activity of the cytochrome P450 system in liver -Decreased metabolism of some drugs; increased frequency of interactions and toxicity -Decreased immune function in the GI tract leading to increased susceptibility to infection. -Increased risk for GI infectious diseases esp. food-borne illnesses -Add more salt or more spices, your dying and to them its normal -Everything slows down -Difficulty swallowing - not dysphagia, takes more time to swallow -metabolism of meds is slower -Very young and very old more susceptible to food borne illness

Diarrhea

-Classified according to its pathophysiological pattern- -Osmotic(malabsorptive) occurs when nonabsorbable water-soluble solutes remain in the bowel and retain water. Ex. Lactose intolerance -Secretory-balance between fluid secretion and absorption across the intestinal mucosa is altered ex. Travelers diarrhea -Exudative-occurs when there is mucosal inflammation or ulceration resulting in the outpouring of plasma, serum proteins, blood and mucus. Ex. Ulcerative colitis, CA -Diarrhea from abnormal intestinal motility results in altered contact between the luminal contents and the mucosal surface. Ex. IBS and laxative use -Infectious bacteria can be caused by bacterial, viral or parasitic agents -Diagnostic reasoning: -How frequent are the stools? -Volume? Formed or liquid? -At what intervals does the diarrhea occur? -Consider dehydration- elderly (dry mouth, sunken eyes) -How many times have you urinated in the past 24 hours? -Are you thirsty? -Dry mouth or eyes? -Fluid intake? Make sure drinking -Have diarrhea when its not really diarrhea, just loose stool, formed stools in there -Flare ups of IBD (crohns and uc) - 12-14 crampy diarrhea bowel movements daily -Water makes me gag, nauseated, I hate water - flavored water, crystal light, decaff tea, drink with a straw, vitamin water, -Do you notice blood in the stool or toilet paper? -If present, what color is the blood? What color are your stools? -Pain or gas with diarrhea? Location? Describe the pain? -Constant or come & go (intermittent)? Does the pain wake you up at night (significant)? Does it interfere with your activities? -Associated symptoms-Do you have fever? -Vomiting? If present, which came first, diarrhea or vomiting? -With appendicitis - pain precedes vomiting -Nocturnal awakening with abdominal pain - denies or reports nocturnal awakening -Leads to fatigue, only sleeping 3-4 nights, wake up to go to work next day or take care of children or both IBS, IBD, gastroenteritis -Sick contacts? -Do you have any pets? -Exposure to contaminated water- -Have you traveled recently? where? - traveler's diarrhea -Sexual activity- -Anal sex -Immune disorder? -Have you been diagnosed with an immune disorder? -Frequent colds or illnesses? Chemo? -Medications -Antibiotics? Notorious for causing GI upset. What prescription medications do you take? OTC? Metformin original, laxatives, esp abuse, -Surgery -Recent GI surgery? Gastric bypass or banding can get dumping syndrome -Diet-related -Fruit juice, milk, wheat products, what have you eaten in the last 3 days? -Family history -Ulcerative colitis, IBD, chronic diarrhea? -Outbreak of norovirus on a cruise ship -Depression meds cause diarrhea -Taking metamucil, miralax, dulcolax and an occasional enema -Wheat insensitivity - celiacs - unknown etioligies even enemia a lot of GI and non GI presentations, always rule out Book: -Increased water content of the stool results in diarrhea, or stool volume >200 g in 24 hours. -Patients, however, usually focus on the change to loose watery stools or increased frequency. -Acute Diarrhea19(≤14 days) -Secretory Infection (non-inflammatory) -Infection by viruses, preformed bacterial toxins (such as S. aureus, B. cereus, C. perfringens, toxigenic E. coli, Vibrio cholerae), cryptosporidium, Giardia lamblia, rotavirus -Watery, without blood, pus, or mucus -Duration of a few days, possibly longer. -Lactase deficiency may lead to a longer course. -Nausea, vomiting, periumbilical cramping pain. -Temperature normal or slightly elevated -Often travel, a common food source, or an epidemic -Inflammatory Infection -Colonization or invasion of intestinal mucosa (nontyphoid Salmonella, Shigella, Yersinia, Campylobacter, enteropathic E. coli, Entamoeba histolytica, C. difficile) -Loose to watery, often with blood, pus, or mucus -An acute illness of varying duration -Lower abdominal cramping pain and often rectal urgency, tenesmus; fever -Travel, contaminated food or water. -Frequent anal intercourse. -Drug-Induced Diarrhea -Action of many drugs, such as magnesium-containing antacids, antibiotics, antineoplastic agents, and laxatives -Loose to watery -Acute, recurrent, or chronic -Possibly nausea; usually little if any pain -Prescribed or over-the-counter medications -Chronic Diarrhea (≥30 days) -Diarrheal Syndrome •Irritable bowel syndrome: Change in frequency and form of bowel movements without chemical or structural abnormality Loose; ~50% with mucus; small to moderate volume. -Small, hard stools with constipation. May be mixed pattern. -Worse in the morning; rarely at night. -Crampy lower abdominal pain, abdominal distention, flatulence, nausea. -Urgency, pain relieved with defecation. -Young and middle-aged adults, especially women •Cancer of the sigmoid colon Partial obstruction by a malignant neoplasm May be blood-streaked Variable Change in usual bowel habits, crampy lower abdominal pain, constipation Middle-aged and older adults, especially older than 55 years Inflammatory Bowel Disease •Ulcerative colitis Inflammation of the mucosa and submucosa of the rectum and colon with ulceration; typically extends proximally from the rectum Soft to watery, often containing blood Onset ranges from insidious to acute. Typically recurrent; may be persistent. May awaken at night. Milder cramping, lower or generalized abdominal pain, anorexia, weakness; fever if severe. May include episcleritis, uveitis, arthritis, erythema nodosum. Often young people. Increases risk of colon cancer. •Crohn's disease of the small bowel (regional enteritis) or colon (granulomatous colitis) Chronic transmural inflammation of the bowel wall, in a skip pattern typically involving the terminal ileum and/or proximal colon -Small, soft to loose or watery, usually free of gross blood (enteritis) or with less bleeding than ulcerative colitis (colitis) -Insidious onset; chronic or recurrent. -Diarrhea may wake the patient at night. -Crampy periumbilical or right lower quadrant (enteritis) or diffuse (colitis) pain, with anorexia, low fever, and/or weight loss. -Perianal or perirectal abscesses and fistulas. -May cause small or large bowel obstruction -Often young people, especially in late teens, but also in middle age. More common in people of Jewish descent. Increases risk of colon cancer -Voluminous Diarrhea •Malabsorption syndrome -Defective membrane transport or absorption of intestinal epithelium (Crohn's, celiac disease, surgical resection); impaired luminal digestion (pancreatic insufficiency); epithelial defects at brush border (lactose intolerance) -Typically bulky, soft, light yellow to gray, mushy, greasy or oily, and sometimes frothy; particularly foul-smelling; usually floats in toilet - Onset of illness typically insidious - Anorexia, weight loss, fatigue, abdominal distention, often crampy lower abdominal pain. -Symptoms of nutritional deficiencies such as bleeding (vitamin K), bone pain and fractures (vitamin D), glossitis (vitamin B), and edema (protein) Variable, depending on cause •Osmotic diarrhea -Lactose intolerance -Deficiency in intestinal lactase -Watery diarrhea of large volume -Follows the ingestion of milk and milk products; relieved by fasting -Crampy abdominal pain, abdominal distention, flatulence -In >50% of African Americans, Asians, Native Americans, Hispanics; in 5%-20% of Caucasians -Abuse of osmotic purgatives -Laxative habit, often surreptitious -Watery diarrhea of large volume -Variable -Often none -Persons with anorexia nervosa or bulimia nervosa •Secretory diarrhea -Variable: bacterial infection, secreting villous adenoma, fat or bile salt malabsorption, hormone-mediated conditions (gastrin in Zollinger-Ellison syndrome, vasoactive intestinal peptide) -Watery diarrhea of large volume -Variable -Weight loss, dehydration, nausea, vomiting, and cramping abdominal pain -Variable depending on cause -Ask about the duration. -Acute diarrhea lasts up to 2 weeks. -Chronic diarrhea is defined as lasting 4 weeks or more. -Acute diarrhea, especially foodborne, is usually caused by infection;19,20 chronic diarrhea is typically noninfectious in origin, as in Crohn's disease and ulcerative colitis. -Ask about the characteristics of the diarrhea, including volume, frequency, and consistency. -High-volume, frequent watery stools usually are from the small intestine; small-volume stools with tenesmus, or diarrhea with mucus, pus, or blood occur in rectal inflammatory conditions. -Is there mucus, pus, or blood? Is there associated tenesmus, a constant urge to defecate, accompanied by pain, cramping, and involuntary straining? -Does diarrhea occur at night? -Nocturnal diarrhea usually has pathologic significance. -Are the stools greasy or oily? Frothy? Foul-smelling? Floating on the surface because of excessive gas? -Oily residue, sometimes frothy or floating, occurs with steatorrhea, or fatty diarrheal stools, from mal absorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth. -Associated features are important in identifying possible causes. - Pursue current medications, including alternative medicines, and especially antibiotics, recent travel, diet patterns, baseline bowel habits, and risk factors for immunocompromise. -Diarrhea is common with use of penicillins and macrolides, magnesium-based antacids, metformin, and herbal and alternative medicines. -Another common symptom is constipation. -Recent definitions stipulate that constipation should be present for at least 12 weeks of the prior 6 months with at least two of the following conditions: fewer than 3 bowel movements per week; 25% or more defecations with either straining or sensation of incomplete evacuation; lumpy or hard stools; or manual facilitation.[21] -Mechanisms include slow transit and outlet delay from impaired expulsion. -Ask about frequency of bowel movements, passage of hard or painful stools, straining, and a sense of incomplete rectal emptying or pressure. -Check if the patient actually looks at the stool and can describe its color and bulk. -Thin, pencil-like stool occurs in an obstructing "apple-core" lesion of the sigmoid colon. -What remedies has the patient tried? Do medications or stress play a role? Are there associated systemic disorders? -Consider medications such as anticholinergic agents, calcium-channel blockers, iron supplements, and opiates. Constipation also occurs with diabetes, hypothyroidism, hyper calcemia, multiple sclerosis, Parkinson's disease, and systemic sclerosis. -Occasionally there is no passage of either feces or gas, or obstipation. -Obstipation signifies intestinal obstruction. -Inquire about the color of stools. Is there melena, or black tarry stools, or hematochezia, stools that are red or maroon-colored? Pursue such important details as quantity and frequency of any blood. The causes of diarrhea are numerous and include bacterial, viral, organic, and func-tional. The mechanisms are due to (1) abnormal transport mechanisms; (2) a changein the osmotic mechanism, resulting in variations in absorption; (3) increased motil-ity; and (4) exudative blood or pus, which decreases absorption.Most cases are self-limiting and resolve within days without medical interven-tion. When high fever, intractable vomiting, or severe dehydration is present,prompt attention is necessary, and hospitalization frequently is required—especiallyin children or geriatric patients.HistorySymptoms vary according to the cause of the diarrhea. A thorough symptomanalysis should identify the time of onset, whether onset was sudden or gradual, and the duration of the symptoms. Determine severity according to whether thediarrhea is intermittent or persistent and according to the number of stools perday. Inquire as to associated symptoms, such as abdominal pain, fever, nausea,or vomiting, as well as whether there is any relation to meals. Ask the patient to describe the color of the stool, looking for reports of dark or bloody stools;consistency (i.e., formed, watery, fatty, or greasy); and the presence of mucus orodor. It is important to ask about recent meals or travel and if accompanyingothers may have similar symptoms; recent antibiotics or other new medications,either prescription or OTC; and history of alcohol abuse or PUD that could indicate a GI bleed. Dehydration and electrolyte depletion are concerns, and thevolume of fluid intake should be determined. If diarrhea has been chronic,changes in weight or appetite should be recorded. Stress or anxiety may be acausative factor; therefore, psychosocial issues should be investigated.Physical ExaminationThe physical examination should begin with vital signs, particularly deter-mining the presence of fever, which might indicate infection, and tachycardiaor orthostatic hypotension, which might indicate dehydration. Other signs ofdehydration include dry mucous membranes, lightheadedness, syncope,lethargy, and oliguria. If there is accompanying electrolyte imbalance, cardiacarrhythmias, muscle weakness, tetany, or vascular collapse may occur, partic-ularly in young children, the elderly, or patients who are already debilitated.Listen for hypoactive or hyperactive bowel sounds, which could indicate earlyobstruction; palpate for abdominal tenderness, indicating infection or inflam-mation; perform a digital rectal examination, checking for heme-positive stool. A CBC showing anemia might indicate malignancy; leukocytosis mightindicate inflammatory bowel disease. Significant unexplained weight lossshould be investigated. Sigmoidoscopy or colonoscopy is warranted if symp-toms persist.

Chronic Upper Abdominal Pain or Discomfort

-Differential Diagnoses: -IBS -Lactose intolerance - ask them about dietary history, occurs when eat diary, do breath test to rule in or out -Diverticular disease -Constipation-simple or habitual -Dysmenorrhea -Uterine fibroids -Hernia -Ovarian cysts -Abdominal wall disorder Book: -Dyspepsia is defined as chronic or recurrent discomfort or pain centered in the upper abdomen.[3] -Discomfort is defined as a subjective negative feeling that is nonpainful. -It can include various symptoms such as bloating, nausea, upper abdominal fullness, and heartburn. -Note that bloating, nausea, or belching can occur alone and can be seen in other disorders. -When these conditions occur alone, they do not meet the criteria for dyspepsia. -Bloating may occur with inflammatory bowel disease; belching from aerophagia, or swallowing air. -Many patients with upper abdominal discomfort or pain will have functional, or nonulcer, dyspepsia, defined as a 3-month history of nonspecific upper abdominal discomfort or nausea not attributable to structural abnormalities or peptic ulcer disease. -Symptoms are usually recurring and typically present for more than 6 months.[3] -Multifactorial causes include delayed gastric emptying (20%-40%), gastritis from H. pylori (20%-60%), peptic ulcer disease (up to 15% if H. pylori is present), and psychosocial factors.[3] -Many patients with chronic upper abdominal discomfort or pain complain primarily of heartburn, acid reflux, or regurgitation. - If patients report these symptoms more than once a week, they are likely to have gastroesophageal reflux disease (GERD) unless proven otherwise.[3],[9] -These symptoms or mucosal damage on endoscopy are the diagnostic criteria for GERD. Risk factors include reduced salivary flow, which prolongs acid clearance by damping action of the bicarbonate buffer; delayed gastric emptying; selected medications; and hiatal hernia. -Heartburn is a rising retrosternal burning pain or discomfort occurring weekly or more often. -It is typically aggravated by food such as alcohol, chocolate, citrus fruits, coffee, onions, and peppermint; or positions like bending over, exercising, lifting, or lying supine. -Note that angina from inferior wall coronary ischemia along the diaphragm may present as heartburn. See Table 8-1, Chest Pain. -Some patients with GERD have atypical respiratory symptoms such as cough, wheezing, and aspiration pneumonia. -Others complain of pharyngeal symptoms, such as hoarseness chronic sore throat, and laryngitis.[10] -Thirty percent to 90% of patients with asthma and 10% with specialty referral for throat conditions have GERD-like symptoms. -Some patients may have "alarm symptoms," such as difficulty swallowing (dysphagia), pain with swallowing (odynophagia), recurrent vomiting, evidence of gastrointestinal bleeding, weight loss, anemia, or risk factors for gastric cancer, a palpable mass, or jaundice. -Patients with uncomplicated GERD who do not respond to empiric therapy, patients older than 55 years, and those with "alarm symptoms" warrant endoscopy to detect esophagitis, peptic strictures, or Barrett's esophagus. In this condition, the squamocolumnar junction is displaced proximally and replaced by intestinal metaplasia, increasing the risk of esophageal adenocarcinoma 30-fold.[9],[11]-[14] -Approximately 50% of patients with GERD will have no disease on endoscopy.[15]

Constipation Labs & Diagnostics

-FOBT -CBC -Serum electrolytes - -Serum TSH-elevated can suggest hypothyroidism -Flexible sigmoidoscopy or colonoscopy -Barium enema-diverticula, polyps, masses -Hypercalcemia, hypokalemia - constipation -Flex sig - younger, teens early 20's, there is no family hx of colon cancer, looksy with flex sig

Diarrhea Labs & Diagnostics

-Fecal leukocytes-bacterial diarrhea -FOBT -Fecal fat-malabsorption syndrome -d-Xylose Absorption Test-malabsorption or maldigestion -C. difficile toxin assay -Stool culture-detect bacteria such as E.coli, Proteus, pseudomonas, staph aureus, -Stool for O & P-hookworm, tapeworm -CBC with diff. -BUN & creatitine (dehydrated pts) -Endoscopic studies -20-30 years ago undercooked pork get a tape worm

Contour Types

-Flat -Scaphoid -Rounded -Protuberant -Get down at seat level to see contour protuberant, instead of obese - difficult to palpate and percuss

Techniques for Exam

-General Guidelines: -Good lighting -Empty Bladder - patient going to be poking and prodding area, not going to be comfortable -Warm hands, stethoscope -Short fingernails - esp with percussing -Warm room, adequate covering, no shivering -Full exposure of abdomen from xiphoid process to the symphysis pubis. -Ask pt. To point to areas of pain -Examine tender areas last!!! - don't want to start poking area most painful bc they won't be hapy -Watch pts face as you examine. -Sequence: INSPECTION, AUSCULTATION, PERCUSSION, PALPATION book: -For a skilled abdominal examination, you need good light and a relaxed and well-draped patient, with exposure of the abdomen from just above the xiphoid process to the symphysis pubis. -The groin should be visible. -The genitalia should remain draped. -The abdominal muscles should be relaxed to enhance all aspects of the examination, but especially palpation. -Check if the patient has an empty bladder. -Make the patient comfortable in the supine position, with a pillow under the head and perhaps another under the knees. -Slide your hand under the low back to see if the patient is relaxed and lying flat on the table. -An arched back thrusts the abdomen forward and tightens the abdominal muscles. -Ask the patient to keep the arms at the sides or folded across the chest. -When the arms are above the head, the abdominal wall stretches and tightens, making palpation difficult. -Move the gown to below the nipple line, and the drape to the level of the symphysis pubis. -Before you begin palpation, ask the patient to point to any areas of pain so that you can examine these areas last. -Warm your hands and stethoscope. -To warm your hands, rub them together or place them under hot water. -You can also palpate through the patient's gown to absorb warmth from the patient's body before exposing the abdomen. -Approach the patient calmly and avoid quick, unexpected movements. -Watch the patient's face for any signs of pain or discomfort. -Avoid having long fingernails when examining the patient. -Distract the patient, if necessary, with conversation or questions. -If the patient is frightened or ticklish, begin palpation with the patient's hand under yours. -After a few moments, slip your hand underneath to palpate directly. -Visualize each organ in the region you are examining. -Stand at the patient's right side and proceed in an orderly fashion with inspection, auscultation, percussion, and palpation. -Assess the liver, spleen, kidneys, and aorta. The abdominal examination begins with inspection, followed by auscultation,percussion, and palpation. Auscultating before percussion or palpation allows theexaminer to listen to the abdominal sounds undisturbed. Moreover, if pain ispresent, it is best to leave palpation until last and to gather other data before pos-sibly causing the patient discomfort. When examining the abdomen, it oftenhelps to break the abdomen down into quadrants, or regions, in order to considerwhich organs are involved (Fig. 10.1).

Inspection

-Have pt supine with one pillow under head, arms at sides, breath through mouth. -Note: Contour of the abdomen (flat, rounded, protuberant, or scaphoid). -Distention: caused by Six "F"'s Fluid, fat, flatuence, feces, fetus, fatal growths/tumor, fibroid tumors, full bladder -Umbilicus: contour, location, signs of hernia or inflammation. -Males have umbilical hernia all the time -Can reduce it, doesn't cause pain, they don't have change in bowel habits -Bulge in the belly button mention it to patient, I see you have this hernia, has anyone ever mentioned it to you -Skin: scars:describe location & determine origin. -Striae: silver striae or stretch marks on abdomen, d/t abdominal distention, pregnancy, obesity, tumors. -Dilated veins: Few small veins normal. -Varices - cirrhosis -Symmetry: -Asymmetry of an enlarged organ or masses. -Enlarged Organs: As pt breathes, watch for an enlarged liver or spleen to descend below the rib cage. -Masses/Pulsations:Normal aortic pulsation is frequently visible in the epigastrium (esp. in thin individuals). -Peristalsis: May be visualized in very thin people. Increase in amplitude & strength early intestinal obstruction -Very large pulsation - might be aortic aneurysm -Video: for shape, looking for pulsations, movements, pulsations from aorta, peristalsis - waves of bowels, breaths Book: -Starting from your usual standing position at the right side of the bed, inspect the abdomen. -As you look at the contour of the abdomen, watch for peristalsis. -It is helpful to sit or bend down so that you can view the abdomen tangentially. -Inspect the surface, contours, and movements of the abdomen, including the following: -The skin. Note: -Scars. Describe or diagram their location. -Striae. Old silver striae or stretch marks are normal. -Pink-purple striae indicate Cushing's syndrome. -Dilated veins. A few small veins may be visible normally. -Dilated veins can be indicative of hepatic cirrhosis or of inferior vena cava obstruction. -Rashes or ecchymoses -Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperitoneal hemorrhage. -The umbilicus. Observe its contour and location and any inflammation or bulges suggesting a ventral hernia. -The contour of the abdomen -Is it flat, rounded, protuberant, or scaphoid (markedly concave or hollowed)? -Do the flanks bulge, or are there any local bulges? Also survey the inguinal and femoral areas. -Observe for bulging flanks of ascites; suprapubic bulge of a distended bladder or pregnant uterus; hernias. -Is the abdomen symmetric? -Asymmetry suggests an enlarged organ or mass. -Are there visible organs or masses? Look for an enlarged liver or spleen that has descended below the rib cage. -Look for the lower abdominal mass of an ovarian or a uterine cancer. -Peristalsis. Observe for several minutes if you suspect intestinal obstruction. Normally, peristalsis may be visible in very thin people. -Look for the increased peristaltic waves of intestinal obstruction. -Pulsations. The normal aortic pulsation is frequently visible in the epigastrium. -Look for the increased pulsation of an aortic aneurysm or of increased pulse pressure. Inspect for scars, striae, venous pattern, rashes, contour, symmetry, masses,peristalsis, pulsations, or discolorations. Tangential lighting is helpful whenobserving for peristalsis and pulsations. See Table 10.1 for abnormalities foundon inspection. Abnormalities on InspectionPhysical FindingScarsStriaeVenous patternDiscolorationVisible peristalsisPulsationsDistentionCauseIndicates past surgery or trauma.Includes obesity, ascites, pregnancy, tumor, Cushing's disease, and steroid use.May be prominent in air-skinned people or due to congested portal circulation.Consider jaundice, Addison's disease, von Recklinghausen's disease, trauma, or otherrashes or lesions.In an older adult, consider bowel obstruction. In newborns, upper abdominal peristalsisis diagnostic or pyloric stenosis.Visible aortic pulsations may be normal in thin individuals but in others may indicate aortic aneurysm.For changes in contour or symmetry, consider the Fs o abdominal distention: at, fuid,eces, etus, fatus, broid, ull bladder, atal tumor, alse pregnancy.

Light Palpation

-Rebound tenderness. -Light palpation. -Deep palpation. -Organ palpation: -liver -spleen -right and left kidney. -Assess kidney tenderness (CVA tenderness). Video: -light palpation using pads of fingers, RUQ, LUQ, LLQ, RLQ -gets the pt used to your touch, get giggles out, coldness of hands, gets them familiar with that, allows muscle to relax in their stomach so you can do deep palpation book: -especially helpful for eliciting abdominal tenderness, muscular resistance, and some superficial organs and masses. -It also serves to reassure and relax the patient. -Keeping your hand and forearm on a horizontal plane, with fingers together and flat on the abdominal wall, palpate the abdomen with a light, gentle, dipping motion. -As you move your hand to different quadrants, raise it just off the skin. -Gliding smoothly, palpate in all four quadrants. -Identify any superficial organs or masses and any area of tenderness or increased resistance to your hand. -If resistance is present, try to distinguish voluntary guarding from involuntary muscular spasm. -To do this: Involuntary rigidity (muscular spasm) typically persists despite these maneuvers, suggesting peritoneal inflammation. -Try all the methods you know to help the patient relax (see p. 452). -Feel for relaxation of abdominal muscles that normally accompanies exhalation. -Ask the patient to mouth-breathe with the jaw dropped open. -Voluntary guarding usually decreases with these maneuvers. Both light and deep palpation are necessary to detect tenderness, tumors, or changesin underlying structures. Note areas of tenderness, changes in contour, and thepresence of masses—and if masses are present, their consistency, size, shape, loca-tion, and delineation. See Table 10.4 for abnormalities found on palpation.• Light palpation is helpful in detecting tenderness and guarding.• Deep palpation is usually required in order to delineate masses. Abnormalities on PalpationConditionHepatomegalySplenomegalyAortic aneurysmTumorDescriptionLiver enlargement can be detected by percussion and/or palpation and canbe caused by cirrhosis, hepatitis, rightheart ailure, cysts, and malignancy.The causes o an enlarged spleen include inectious or infammatory diseases, such as mononucleosis, in-ectious hepatitis, subacute bacterial endocarditis, psittacosis, tuberculosis, malaria, sarcoidosis, amyloidosis, and systemic lupus erythematosus;lymphoprolierative and myeloproli-erative diseases, such as lymphoma,leukemia, polycythemia, and myelobrosis; hemolytic anemias and hemoglobinopathies; spleniccysts; and storage diseases, such asGaucher's, Niemann-Pick, and Hand-Schuller-Christian.Arteriosclerosis is the most commoncause o aortic aneurysm. Aging, cigarette smoking, and hypertensionare contributing actors. Trauma;syphilis; congenital connective tissuedisorders, such as Maran's disease;and positive history o aneurysm alsoincrease the incidence.Caused by any benign or malignantgrowth in any o the abdominal organs.CharacteristicsCirrhosis produces an enlarged, rm, non-tender liver. Hepatitis and right heart ailureare characterized by a smooth, tender liver.Cysts may not be palpable but will produceright upper quadrant pain and tenderness. A malignancy typically produces a rm, irregular liver surace.In addition to an enlarged and usually tenderspleen, other symptoms are early eeding satiety, splenic riction rub, epigastric andsplenic bruits, and cytopenias.A prominent lateral pulsation suggests ananeurysm.Vary according to the aected organ but in-clude pain, bloating, obstruction, anorexia, andchanges in bowel or genitourinary unctioning.

Constipation Differential Diagnoses

-Simple constipation -IBS -Fecal impaction -Idiopathic slow transit -Secondary constipation from anorectal lesion -Drug induced constipation-medications or hx of chronic -laxative use -Tumors

Percussing the Liver

-Start RMCL & percuss down from lung resonance down to liver dullness (upper border of liver) mark it, usually @ 5-7th ICS. -To ascertain the liver border start RMCL @ level below the umbilicus (in area of tympany) percuss up toward the liver until dullness (Right costal margin). -Measure in cm the liver span. Normal liver span is 6-12 cm. -video: start at mid clavicular line around umbilicus, percuss upward until sound changes from tympanic to dull and mark that level - start superiorly and go between rib margins, if you percuss rib they will be dull sounded, and percuss between ribs until you hear dullness -mark that boarder should be between 4-7cm book: -Measure the vertical span of liver dullness in the right midclavicular line. -First locate the midclavicular line carefully to avoid inaccurate measurement. -Use a light to moderate percussion strike, because examiners with a heavier strike underestimate liver size.[53] -Starting at a level below the umbilicus in the right lower quadrant (in an area of tympany, not dullness), percuss upward toward the liver. Identify the lower border of dullness in the midclavicular line. -Estimated liver span by percussion is relatively accurate with a 60% to 70% correlation with actual span. -Next, identify the upper border of liver dullness in the midclavicular line. -Starting at the nipple line, lightly percuss from lung resonance down toward liver dullness. -Gently displace a woman's breast as necessary to be sure that you start in a resonant area. -The course of percussion is shown on next page. -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 free air is present below the diaphragm, as from a perforated hollow viscus. -Serial observations may show a decreasing span of dullness with resolution of hepatitis or heart failure or, less commonly, with progression of fulminant hepatitis. -Liver dullness may be displaced downward by the low diaphragm of chronic obstructive pulmonary disease. -Span, however, remains normal. -Now measure in centimeters the distance between your two points—the vertical span of liver dullness. -Normal liver spans, shown below, are generally greater in men than women and in tall people compared to short people. -If the liver seems enlarged, outline the lower edge by percussing medially and laterally. -Dullness of a right pleural effusion or consolidated lung, if adjacent to liver dullness, may falsely increase the estimate of liver size. -Gas in the colon may produce tympany in the right upper quadrant, obscure liver dullness, and falsely decrease the estimate of liver size. -Measurements of liver span by percussion are more accurate when the liver is enlarged with a palpable edge.[55] -Only about half of livers with an edge below the right costal margin are palpable, but when the edge is palpable, the likelihood of hepatomegaly roughly doubles.53

Percussion

-Used to measure the liver & sometimes the spleen and for identifying fluid, solid or fluid filled masses & air in the stomach or bowel. -Percuss in 4 quadrants -Dullness heard when percussing over dense abdominal organs -Tympany heard when percussing over air filled structures. -Heard over most of the abdomen because stomach & bowel contain air & gas. -Videos: use dominant hand's middle finger and strike distal joint of non dominant hand's middle finger, -strike strike in all 4 quadrants -listen for tympany - sound of drum, a lot of air in stomach, -there shouldn't be fluid or structures that cause it to be dull book: -helps you to assess the amount and distribution of gas in the abdomen, possible masses that are solid or fluid-filled, and the size of the liver and spleen. -Percuss the abdomen lightly in all four quadrants to assess the distribution of tympany and dullness. -Tympany usually predominates because of gas in the gastrointestinal tract, but scattered areas of dullness from fluid and feces are also typical. -A protuberant abdomen that is tympanitic throughout suggests intestinal obstruction.- -Note any large dull areas suggesting an underlying mass or enlarged organ. - This observation will guide your palpation. -Dull areas can indicate a pregnant uterus, an ovarian tumor, a distended bladder, or a large liver or spleen. -On each side of a protuberant abdomen, note where abdominal tympany changes to the dullness of solid posterior structures. -Dullness in both flanks prompts further assessment for ascites (see Assessing Possible Ascites). -Briefly percuss the lower anterior chest above the costal margins. -On the right, you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and the splenic flexure of the colon. -In the rare condition of situs inversus, organs are reversed—air bubble on the right, liver dullness on the left. Percuss for areas of dullness, indicating fluid or solid rather than air. S Normal Tones Produced by PercussionMost Dense Least DenseToneFlat Dull Resonant Hyperresonant TympanicIntensitySot Medium Loud Very loud LoudPitchHigh Medium Low Very low HighDurationShort Medium Long Very long MediumAreaMuscle, bone Liver, spleen Lung Emphysematous lung Gastric air bubble

Auscultation

-Useful in assessing bowel motility & abdominal complaints: -Remember to auscultate before percussing or palpating. -Use diaphragm as bowel sounds are high pitched. -Begin in any quadrant & proceed systematically to all 4 quadrants. -Normal sounds consist of clicks & gurgles, the frequency of which has been estimated @ 5-34/min. -May hear borborygmi -If you don't hear bowel sounds in one quadrant, move to another. If you don't hear for 2 minutes, you'll describe them as absent. -High pitched, tinkling, & splashing sounds may indicate an early intestinal obstruction -Video: listening for bowel sounds in each quadrant, 4 quadrants, RUQ, LUQ, RLQ, LLQ - listening for tinkering and pinging of bowel sounds -listen over spleen and livers for any friction ribs - right side hepatic friction rubs, left side splenic rubs -listen to aorta which branches down above umbilicus with both bell and diaphragm -listen over iliac and renal arteries and femoral above legs - with diaphragm and bell for bruits which are turbulent sounds Book: -provides important information about bowel motility. -Listen to the abdomen before performing percussion or palpation because these maneuvers may alter the frequency of bowel sounds. -Practice until you are thoroughly familiar with variations in normal bowel sounds and can detect changes suggestive of inflammation or obstruction. -may also reveal bruits, or vascular sounds resembling heart murmurs, over the aorta or other arteries in the abdomen. -Bruits suggest vascular occlusive disease. -Place the diaphragm of your stethoscope gently on the abdomen. - Listen for bowel sounds and note their frequency and character. -Normal sounds consist of clicks and gurgles, occurring at an estimated frequency of 5 to 34 per minute. -Occasionally you may hear borborygmi, prolonged gurgles of hyperperistalsis, the familiar "stomach growling." -Because bowel sounds are widely transmitted through the abdomen, listening in one spot, such as the right lower quadrant, is usually sufficient. -Bowel sounds may be altered in diarrhea, intestinal obstruction, paralytic ileus, and peritonitis. Perform auscultation before palpation so as to hear unaltered bowel sounds.Listen for bruits over the aorta and the iliac, renal, and femoral arteries. SeeTable 10.2 for abnormalities found on auscultation. Abnormalities on AuscultationPhysical FindingBruitsPops/tinklesRushesBorborygmiRubsVenous humSuccussion splashDecreased/absent soundsCauseA swishing sound heard over the aortic, renal, iliac, and emoral arteries, indicating narrowing or aneurysm.High-pitched sounds suggesting intestinal fuid and air under pressure, as in early obstruction.Rushes o high-pitched sounds that coincide with cramping suggest intestinal obstruction.Increased, prolonged gurgles occur with gastroenteritis, early intestinal obstruction, and hunger.Grating sounds that vary with respiration. Indicate infammation o the peritoneal surace o an organ rom tumor, inection, or splenic inarct.A sot humming noise oten heard in hepatic cirrhosis that is caused by increased collateral circulation between portal and systemic venous systems.A splashing noise produced by shaking the body when there is both gas and fuid in acavity or ree air in the peritoneum or thorax.Occurs with peritonitis or paralytic ileus.

Assessing Ascites

-Video: percuss around the abdomen, you would expect the protuberant abdomen to be tympanic bc it would be all airfilled bc as the patient lays down the fluid from the ascites would shift to each lower area, -then percuss the flank or the borders on each side and that would be dull bc that's where the fluid sits, -you would then have the patient roll to one side, then the fluid shifts to the dependent side, percuss the flank on higher side and it would be tympanic, -fluid wave: if the patient had a round protuberant abdomen, take the patients hand press in midline, with right hand sharply push fluid on one side and see if it causes a wave to the other side, -with one hand push on stomach, and see if fluid travels through stomach to other side of hand, - fluid shift test, fluid wave test book: -A protuberant abdomen with bulging flanks suggests possible ascites. -Because ascitic fluid characteristically sinks with gravity, whereas gas-filled loops of bowel rise, percussion gives a dull note in dependent areas of the abdomen. -Look for such a pattern by percussing outward in several directions from the central area of tympany. -Map the border between tympany and dullness. -Ascites occurs in increased hydrostatic pressure in cirrhosis, heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. -It may signal decreased osmotic pressure in nephrotic syndrome and malnutrition, or ovarian cancer. -Two additional techniques help to confirm ascites, although both signs may be misleading. -Test for shifting dullness. -After percussing the border of tympany and dullness with the patient supine, ask the patient to turn onto one side. -Percuss and mark the borders again. -In a person without ascites, the border between tympany and dullness usually stay relatively constant. -In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top. -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 of a wave through fat. -While you tap one flank sharply with your fingertips, feel on the opposite flank for an impulse transmitted through the fluid. -Unfortunately, this sign is often negative until ascites is obvious, and it is sometimes positive in people without ascites. -An easily palpable impulse suggests ascites. -A positive fluid wave, shifting dullness, and peripheral edema make the diagnosis of ascites highly likely with ratios of 3 to 6.[ To differentiate ascites, test for shifting of the peritoneal fluid to the dependentside by rolling the patient side to side and percussing for dullness on the depend-ent side of the abdomen. Note: This maneuver is nonspecific and has, for themost part, been replaced by ultrasonography of the abdomen.

Constipation

-Wide variation in what is considered normal and what constitutes constipation. -Failure to completely evacuate the lower colon. Also refers to hardness of stool or a feeling of incomplete evacuation - tenesmus -Associated with difficulty in defecating, infrequent bowel movements, straining, abdominal pain, or pain on defecation. -Acute constipation refers to a sudden change which suggests mechanical obstruction, adynamic ileus. Could also be related to medications, or following anesthesia. -Chronic constipation results from disruption of the storage, transport, and evacuation mechanisms of the colon. Causes include poor bowel habits, inadequate fiber, bulk and fluid intake, and anal fissure pain. -Fewer then 3 BM a week -Poop once a week - no abdominal pain or distention - that's their norm -Everyone now and then has constipation - drink more fluids - 8 glasses (8oz) water a day, eat more fiber (25-30g daily), slowly increase fiber intakes - gas, bloating, distention with too much fiber, peas have a lot of fiber -Exercise is good -Diagnostic reasoning -How many stools are there per day? Little pieces - 5-6x per day -Consistency of stool? Rock hard, turd like, little pellets -Rectal bleeding? Pushing, straining, any blood come out? -Concerned about blood - dark blood melena - upper GI bleed, bright red blood - lower GI, hemorrhoidal, malignancy, other things -Have you had unintentional weight loss greater than 10 lbs? -Acute vs Chronic? -When did it start? -Individual episode or chronic? -If acute, any recent illness? Fever? Chronic health problems? -If chronic, what do you usually eat? -Glasses of liquid/day? -Usually bowel habits? Activity? medications? Do you take laxatives? How often? How long? When I go away to my daughters house I cant have a BM, I hate going there, im bloated, distended, can't close my pants - change in travel is a cause, are you doing your usual routine, drinking water, fiber, exercise, activities? -Medications can cause - opiates -Whats your usual bowel habit? -Pt who went away to school, traditional student, go home every weekend to have a BM, her school was 2-3 hours away, couldn't have a BM at school -Miralax, metamucil - what happens sometimes when you go beyond the laxatives - rebound, or don't have urge to have BM, ignore the urge to have BM, don't have time to have a BM, Im at work right now, once the urge comes time to go, move and groove -Morning coffee and then I go - good -Patients take stool softeners, all kinds of laxatives, miralax, metamucil - I don't know why I have terrible cramps in my stomach, have to move my bowels 2-3 times a day, from abuse of these meds -Focus in... -Appearance of stool? Hard pellet like? Rocks? -Stool size, large or small? -General shape? Small round, ribbonlike? IBS - ribbon like, motility disorders -Formed or liquid? -Involuntary loss of stool?*** good question to ask - DRE looking for rectal sphincter tone - if good insert finger sometimes you can't even get it out, sometime its like an overcooked lasagna noodle -Do you alternate constipation with diarrhea? - IBS mixed type -What else? -Do you have an urge to defecate? - go for it, no matter where you are -Urinary tract symptoms? -N/V? -Bleeding with defecation?, how much? Color of your stools? Are they very dark or black? -Family history of constipation? Unusual issues with bowel habits Book: Life Activities and Habits -Inadequate Time or Setting for the Defecation Reflex Ignoring the sensation of a full rectum inhibits the defecation reflex. - Hectic schedules, unfamiliar surroundings, bed rest -False Expectations of Bowel Habits - Expectations of "regularity" or more frequent stools than a person's norm -Beliefs, treatments, and advertisements that promote the use of laxatives -Diet -Deficient in Fiber -Decreased fecal bulk -Other factors such as debilitation and constipating drugs may contribute. -Irritable Bowel Syndrome: Functional change in frequency or form of bowel movement without known pathology; possibly from change in intestinal bacteria. -Three patterns: diarrhea—predominant, constipation—predominant, or mixed. -Symptoms present ≥6 months and abdominal pain for ≥3 months plus at least 2 of 3 features (improvement with defecation; onset with change in stool frequency; onset with change in stool form and appearance) -Mechanical Obstruction -Cancer of the Rectum or Sigmoid Colon: Progressive narrowing of the bowel lumen from adenocarcinoma -Change in bowel habits; often diarrhea, abdominal pain, bleeding, occult blood in stool. -In rectal cancer, tenesmus and pencil-shaped stools. -Weight loss. -Fecal Impaction: A large, firm, immovable fecal mass, most often in the rectum -Rectal fullness, abdominal pain, and diarrhea around the impaction; common in debilitated, bedridden, and often elderly patients -Other Obstructing Lesions (such as diverticulitis, volvulus, intussusception, or hernia) -Narrowing or complete obstruction of the bowel -Colicky abdominal pain, abdominal distention, and in intussusception, often "currant jelly" stools (red blood and mucus) -Painful Anal Lesions -Pain may cause spasm of the external sphincter and voluntary inhibition of the defecation reflex. -Anal fissures, painful hemorrhoids, perirectal abscesses -Drugs -A variety of mechanisms Opiates, anticholinergics, antacids containing calcium or aluminum, and many others -Depression -A disorder of mood. -Fatigue, anhedonia, sleep disturbance, weight loss -Neurologic -Disorders Interference with the autonomic innervation of the bowel -Spinal cord injuries, multiple sclerosis, Hirschsprung's disease, and other conditions -Metabolic Conditions -Interference with bowel motility -Pregnancy, hypothyroidism, hypercalcemia Constipation is a common complaint generally used to describe excessively dry,small, or infrequent stools. According to a more specific definition, constipationis the presence of more than one of the following conditions for at least 3 months:• Straining with bowel movements more than 25% of the time• Hard stools more than 25% of the time• Incomplete evacuations more than 25% of the time• Fewer than three bowel movements per weekThe term constipation covers more than infrequent stools and must be addressed from the patient's viewpoint. Constipation is often a chronic condition.Patients often self-treat both real and perceived constipation; its presence may beidentified when the history reveals frequent or chronic use of laxatives or cathar-tics. Lifestyle factors (e.g., nutritional and fluid intake, activity) often contributeto chronic constipation. The altered colonic transit time may also be associatedwith medications, endocrine disorders, neurological deficits, and various GI disorders; constipation may be one sign of an eating or psychiatric disorder.Acute-onset constipation may stem from bowel obstruction or ileus.HistoryEstablish what the term constipationmeans to the patient. Ask how long it hasexisted and whether it is constant or intermittent. Determine how, if at all, thepatient's previous bowel patterns differed. Explore the current bowel history:frequency of bowel movements; changes in caliber, color, quantity, or consistency(are the movements hard?); the need to strain; and whether there is completeevacuation. Ask about associated symptoms: abdominal bloating/fullness, rectalpain or bleeding, blood or mucus in the stool, altered appetite, and abdominalpain. Establish whether the constipation alternates with normal bowel patternor diarrhea or is progressive. Find out whether the patient has experienced anyweight loss because the potential for a malignancy must be considered. Establishthe presence of any associated complications: hemorrhoids, fissures, or fecal incontinence. Obtain a history of endocrine, neurological, or GI problems; abdominal surgeries; and currently prescribed or OTC medications. Obtain ahistory of dietary and fluid intake, activity, and recreational drug use.Physical ExaminationThe physical examination should start with a general survey: Note the patient'soverall appearance and whether she or he appears healthy or ill, has any obviousdeficits, or exhibits physical signs of systemic disorders. Obtain a weight. Observethe skin and mucous membranes for signs of dehydration. Depending on thehistory and your general survey, you should examine other systems. Otherwise,the examination can focus on the abdomen and rectum.Inspect and auscultate the abdomen first, noting any scars, distention, visiblemasses, and discoloration. If bowel sounds are not immediately evident, continuelistening for at least 15 seconds in each quadrant before you conclude that theyare absent; if sounds are present, determine the pitch and frequency. Identifyareas of dullness over organs, and estimate organ size. Note any areas of dullnessover the bowel. Palpate superficially at first, noting any guarding, rigidity, or ten-derness. Palpate more deeply to assess organs and any other areas of firmness ormass. For any palpable mass, determine the consistency, size, shape, mobility,and margins. Perform an anorectal examination, inspecting the anus for tone,fissures, external hemorrhoids, or other defects. Palpate the rectum for massesand stool, noting the consistency of anything palpated; perform guaiac on anypalpated stool.

right upper quadrant

-acute cholecystitis, usually this -duodenal ulcer -hepatitis -congestive hepatomegaly -pyelonehpritis -appendicitis -(R) pneumonia Video: deep palpate for any structure, liver, gallbladder, press down and up underneath ribs, deep breath in, liver will sometimes come down and the border will hit the tip of your fingers book: -the soft consistency of the liver makes it difficult to feel through the abdominal wall. -The lower margin of the liver, the liver edge, is often palpable at the right costal margin. -The gallbladder, which rests against the inferior surface of the liver, and the more deeply lying duodenum are generally not palpable. -At a deeper level, the lower pole of the right kidney may be felt, especially in thin people with relaxed abdominal muscles. -Moving medially, the examiner encounters the rib cage, which protects the stomach; occasionally patients misidentify the stony hard xiphoid process in the midline as a tumor. -The abdominal aorta often has visible pulsations and is usually palpable in the upper abdomen. A complaint of right upper quadrant (RUQ) pain encompasses a variety of pos-sible causes, most commonly diseases of the liver, gallbladder, pancreas, or lung.In the abdomen, it is important also to consider referred pain from a differentarea in the abdomen or from a different body system. Also consider diseases ofthe colon or kidney, or the gynecological system for women, which are covered in this chapter under lower quadrant pain. Because the abdomen contains manystructures and organs, a thorough history and physical examination is necessarywith special maneuvers if warranted.HistoryBegin with the exact location of the pain, onset, timing, quality and quantity,and alleviating or aggravating factors—particularly if the pain is related to mealsor movement. Ask if there has been any fever, nausea, vomiting, diarrhea, con-stipation, anorexia, or change in urine or stool color/consistency, which may indicate liver or gallbladder disease. A pleuritic cause for the pain should be con-sidered; inquire about cough, shortness of breath, or fever. Include a smokinghistory. Ask about diet history, particularly in regard to a high-fat diet or fad dietsthat might exclude food groups or be very low in calories. This may increase thelikelihood of gallbladder disease. Inquire about sexual practices, alcohol, anddrugs (prescription and illicit) that might alert you to an increased risk for liverdisease, particularly hepatitis. Ask about foreign travel because hepatitis is en-demic in some areas, and often the standards for food preparation are not thesame as in North America. Ask about patient and family history of breast or coloncancer, gallbladder or liver disease, and general disorders of the digestive tract.Physical ExaminationA thorough abdominal examination should be performed with particular atten-tion to the RUQ, assessing for tenderness, rebound, masses, and organ enlarge-ment or nodularity. A respiratory examination should include auscultation for adventitious breath sounds and the presence of friction rubs or voice sounds.Table 10.7 summarizes differential diagnosis for RUQ and left upper quadrant(LUQ) pain.The conditions of the underlying organs are key to identifying the etiology ofRUQ pain. Consider diseases of the gallbladder, liver, pancreas, or lung as themost likely cause of pain. In the case of the RUQ, laboratory testing can be mosthelpful and often diagnostic (Table 10.8). Differential Diagnosis for Right and Left Upper Quadrant PaiDiseaseCholecystitisLiver diseasePancreatitisPleurisyHypersplenismALT = alanine aminotransferase; AST = aspartate aminotransferase; CBC = complete blood count; CT = computedtomography; HIDA = hepatobiliary iminodiacetic acid; IgM = immunoglobulin M; LFT = liver function tests; LUQ = left upper quadrant; RUQ = right upper quadrant; SPE = serum protein electrophoresis; US = ultrasoundHistoryRUQ pain, anorexia, nausea, vomiting, everRUQ pain, sexual practices,travel, alcohol use, historyo malignancy, nausea,vomiting, anorexia, drugs,raw shellsh ingestion,change in color o urine or stools, weight loss, abdominal distentionEpigastric pain, alcoholabuse, liver or gallbladderdisease, jaundice, hyperlipidemiaRespiratory disease, suchas upper respiratory inection or pneumonia,shortness o breath, chesttrauma, other systemicdiseaseLUQ pain, anorexia, ever,atigue, weight loss, recent inection, bruising or bleeding, lymphadenopathy, jaundiceDiagnostic StudiesCBC, LFTs, amylase, gallbladder US, HIDA scanLFTs, hepatitis prole, abdominal US or CTAmylase, lipase, LFTs, plainabdominal lms, abdominalUS or CT, chest x-rayChest x-rayCBC, platelet, SPE, amylase,B12, uric acid, bone marrowaspiration, abdominal CTPhysical Findings↑Neutrophilic leukocytes,↑AST/ALT, ↑amylase with common duct obstruction; USwill show nonvisualization o thegallbladder and wall thickening↑LFTs, ↑IgM, and specic antigens will be present or hepatitis A, B, and C; US or CTmay show cysts or tumors, obstruction↑Amylase and lipase, ↑LFTs, ↑WBC, epigastric tenderness,pancreatic or biliary obstructionon US or CTI there is air or fuid in the pleural space, investigate othermore serious diagnosesVary depending on underlyingcause: cytopenias or myeloproli-eration or lymphoprolieration,↑B12in leukemias and poly-cythemia, ↑uric acid in prolier-ative disorders, monoclonalgammopathy or ↑immunoglob-ulins on SPE, abnormalities on CT and bone marrow aspirate

anatomy & physiology

-many organs are compacted into a small area -Palpation or percussion - liver is one the right side, make sure you stand on patients right side when doing ab exam -Inspection, ausculation, percussion, palpation -right: liver, gallbladder -left: spleen, stomach -Throughout large intestine and small intestine -Whenever writing soap note or h&p, don't write abdominal pain, must write area where the pain is located -Epigastric pain - heartburn/pyrosis -Hypogastric or suprapubic - same thing -Important to know where specifically the pain is, will help you zero in on differentials -epigastric, RUQ, LUQ, periumbilical/umbilical, RLQ, LLQ, suprapubic/hypogastric -epigastrum: -myocardial infarct, peptic ulcer, acute cholecystitis, perforated esphagus -pain can radiate Book: -rectus abdominis muscles become more prominent when the patient raises the head and shoulders from the supine position -Another system divides the abdomen into nine sections. Terms for three of them are commonly used: epigastric, umbilical, and hypogastric or suprapubic. -moving in a clockwise rotation igestive diseases encompass more than 40 acute and chronic conditions ofthe gastrointestinal (GI) tract and affect an estimated 60 to 70 million citi-zens in the United States annually (Everhart & Ruhl, 2009). Abdominal pain is themost common GI symptom prompting a clinic visit, and gastroesophageal refluxdisease (GERD) is the most common GI diagnosis. Hospitalizations and mortalityfrom Clostridium difficileinfection have doubled in the last 10 years. Acute pancre-atitis is the most common reason for hospitalization. Colorectal cancer accounts formore than half of all GI cancers and is the leading cause of GI-related mortality(Peery et al., 2012). Colorectal cancer ranks third in prevalence for new cancer casesand third in cause of death from cancer (American Cancer Society, 2012). Digestivedisease is the second leading cause of disability due to illness in the United Statesand the leading cause of lost work for male employees (Parker, 2008).The causes of abdominal complaints can range from very mild, self-limitedproblems to those that can be disabling or result in mortality. In addition to digestive diseases, abdominal complaints may be indicative of musculoskeletal,neurological, genitourinary, reproductive, cardiovascular, or respiratory disorders. Abdominal RegionsRight Upper Quadrant Epigastric Left Upper QuadrantLiver Stomach SpleenGallbladder Pancreas PancreasTip of right kidney Tip of left kidneyDiaphragmRight Lumbar Umbilical Left LumbarUterusBowelAortaRight Lower Quadrant Suprapubic Left Lower QuadrantAppendix Bladder Left ovaryRight ovary Uterus BowelBowel

right lower quadrant

-most likely appendicitis -salpingitis -tubo-overian abscess -ruptured ectopic pregnancy -renal/ureteric stone -incarcerated hernia -mesenteric adenitis -Meckel's diverticulitis -Crohn's disease -Perforated caecum -Psoas abscess Book: -bowel loops and the appendix at the tail of the cecum near the junction of the small and large intestines. - In healthy people, these are not palpable. Differential Diagnosis of Lower Abdominal PaiDiseaseAppendicitisEctopic pregnancyColorectal cancerUrinary calculiOvarian tumorHerniaIntestinal obstructionDiverticulitisGastroenteritisBE = barium enema; BUN = blood urea nitrogen; CA-125 = cancer antigen 125; CEA = carcinoembryonic antigen;CBC = complete blood count; CT = computed tomography; hCG = human chorionic gonadotropin; IVP = intra-venous pyelogram; LLQ = left lower quadrant; RLQ = right lower quadrant; SG = specific gravity; U/A = urinalysis;US = ultrasoundHistoryAnorexia, nausea, vomiting,ever, midline or RLQ painworsening with cough orwalkingAmenorrhea, severe RLQ or LLQ painWeight loss, atigue,change in bowel habits,anemia, + hemoccult+ History o stones, severecolicky fank pain+ Family history, abdomi-nal bloating, pain, or heavinessHistory o straining orheavy liting, previous abdominal surgery, lowerabdominal or groin painHistory o abdominal surgery or infammatorybowel disease, radiation, or impaction; abdominalpain or distention, vomiting; obstipation+ History o diverticulosisSudden-onset diarrhea, abdominal cramping, nausea, vomiting, everDiagnosisCBC, abdominal CT or USPelvic US, urine andserum hCGHemoccult, CBC, CEA,fexible sigmoidoscopy,colonoscopyU/A, plain abdominalx-ray, renal US, IVPPelvic examination,pelvic US, CT, CA-125Physical examinationor USFlat and upright ab-dominal x-ray, BE, CBC, electrolytes, BUN, creatinine, U/ACBC, fexible sigmoidoscopy, BE, abdominal CTCBC, stool or ova andparasites, culture andsensitivityFindings+ Rebound tenderness,ever, leukocytosis o10,000-20,000/mL, US or CT may be positive orperoration/abscessA pregnancy outside theuterus, usually the tube, + hCG, + US, + reboundtenderness+ Hemoccult, ↑CEA, ↓hematocrit and hemoglobin, + lexiblesigmoidoscopy orcolonoscopyHematuria, + stone visualization with x-ray or US↑CA-125, mass on exami-nation, CT, or USPalpable mass in the in-guinal ring or emoral area+ Mass on examination,BE, or x-ray; tinkles,rushes, borborygmi, or absent bowel sounds,↑SG, ↑BUN and creatinine; electrolyte imbalance; leukocytosisLeukocytosis, abdominalmass, stricture, hypertro-phy o colonic muscula-ture, possible ree air in the abdomenAbdominal tenderness,borborygmi, possibly positive stool culture Laboratory Studies for Lower Abdominal and SuprapubicPainStudyComplete blood countSerum/urine pregnancyUrinalysis (U/A)Prostate-specic antigen (PSA)Wet prep, gonococcal/chlamydia cultureCarcinoembryonic antigen (CEA)Cancer antigen 125 (CA-125)DescriptionWhite blood cell (WBC) count is elevated in appendicitis and diverticulitis,and the hematocrit and hemoglobin may be decreased in colon cancer.In ectopic pregnancy, human chorionic gonadotropin may not be at thelevels appropriate or the number o weeks as estimated by last menstrualperiod.A dipstick or complete U/A identiies WBCs and blood, indicating inection, renal calculi, or malignancy; increased speciic gravity withdehydration.A PSA is a useul screening and diagnostic tool or prostate disease; i elevated, a prostate ultrasound and biopsy is recommended.A wet prep can identiy WBCs, but a culture is necessary to identiy the oending organism. A gonococcal/chlamydial culture may be positive insalpingitis/pelvic infammatory disease (PID). I positive or STD, other testconsiderations include rapid plasma reagin, HIV, and hepatitis prole.The CEA will be elevated in colon cancer.A CA-125 is a tumor marker or progression or regression o ovarian tumors but can be helpul or initial diagnosis. False negatives occur in approximately 20% o patients with ovarian cancer. False positives canoccur in patients with endometriosis, benign ovarian cysts, rst-trimesterpregnancy, PID, cirrhosis, and pancreatic cancer. It is more specic in postmenopausal than premenopausal women.

Palpation of the Left Kidney

-not normally palpable book: -Move to the patient's left side. -Place your right hand behind the patient, just below and parallel to the 12th rib, with your fingertips just reaching the costovertebral angle. -Lift, trying to displace the kidney anteriorly. -Place your left hand gently in the left upper quadrant, lateral and parallel to the rectus muscle. -Ask the patient to take a deep breath. -At the peak of inspiration, press your left hand firmly and deeply into the left upper quadrant, just below the costal margin. -Try to "capture" the kidney between your two hands. -Ask the patient to breathe out and then to stop breathing briefly. -Slowly release the pressure of your left hand, feeling at the same time for the kidney to slide back into its expiratory position. -If the kidney is palpable, describe its size, contour, and any tenderness. -Attributes indicating an enlarged kidney rather than an enlarged spleen include preservation of normal tympany in the left upper quadrant and the ability to probe with your fingers between the mass and the costal margin, but not deep to its medial and lower borders. -Alternatively, try to feel for the left kidney using a method similar to palpating the spleen. -Standing at the patient's right side, with your left hand, reach over and around the patient to lift up beneath the left kidney, and with your right hand, feel deep in the left upper quadrant. -Ask the patient to take a deep breath, and feel for a mass. A normal left kidney is rarely palpable.

left upper quadrant

-ruptured spleen -pancreatitis -gastric ulcer -aortic aneurysm -perforated colon -pyelonephritis -(L) pneumonia video: spleen, splenic border is not normal finding, shouldn't be able to palpate. press down and underneath the rib margins, if you can palpate spleen is enlarged Book: - the spleen is lateral to and behind the stomach, just above the left kidney in the left midaxillary line. -Its upper margin rests against the dome of the diaphragm. -The 9th, 10th, and 11th ribs protect most of the spleen. -The tip of the spleen may be palpable below the left costal margin in a small percentage of adults. -In healthy people the pancreas cannot be detected. Diseases and disorders of the spleen, stomach, and pancreas are the most likelycauses of LUQ pain (see Table 10.7). Also consider colon and kidney disease,which are covered in this chapter under lower quadrant pain. For disorders ofthe spleen and pancreas, laboratory evaluation is helpful along with the historyand physical. For the stomach, more definitive diagnostic tests may be needed.HistoryLUQ pain is often associated with causes that are outside the abdomen.Hematopoietic malignancies, such as lymphomas and leukemias, and otherhematologic disorders, such as thrombocytopenia, polycythemia, myelofibro-sis, and hemolytic anemia, often cause enlargement of the spleen, leading toLUQ pain. In addition to questions about the specific characteristics of thepain, it is important to ask the patient about fever, unusual bleeding or bruis-ing, recent diagnosis of mononucleosis, fatigue, malaise, lymphadenopathy,cough, arthralgias, anorexia, weight loss, jaundice, high blood pressure, andheadache.Physical ExaminationA thorough abdominal examination is necessary with special attention to the LUQ. A respiratory examination should be included to rule out referredpain. A hematopoietic cause can be explored only through laboratory tests(see Table 10.8).

left lower quadrant

-usually diverticulitis -sigmoid diverticulitis -salpingitis -tubo-ovarian abscess -ruptured ectopic pregnancy -incarerated hernia -perforated colon -Crohn's disease -Ulcerative colitis -Renal/ureteral stone video: colon, can be tender, shouldn't be painful Book: - you can often feel the firm, narrow, tubular sigmoid colon. -Portions of the transverse and descending colon may also be palpable. -In the lower midline are the bladder, the sacral promontory, the bony anterior edge of the S1 vertebra, sometimes mistaken for a tumor, and, in women, the uterus and ovaries. Lower abdominal pain can have a multitude of causes, including diseases or dis-orders of the appendix, colon, kidney, bladder, ureter, ovary, uterus, and prostate.Pinpointing the specific location of the pain is crucial to beginning the differentialdiagnosis; however, caution is recommended because abdominal pain can be referred from areas of the abdomen other than the point of origin. Because ofthe complexity of the differential diagnosis for lower abdominal pain, diagnostictests are often necessary to confirm the findings of the history and physical.HistoryThere are a multitude of etiologies for lower abdominal complaints. It is im-portant to begin with a thorough history. Although abdominal pain can oftenradiate to other areas or can present a vague and confusing picture, pinpointingthe location of the pain is a prudent place to start. Question the patient aboutthe onset of the pain and whether it is accompanied by fever, anorexia, nausea,or vomiting, which might suggest appendicitis, gastroenteritis, or obstruction.It is imperative to ask about the last menstrual period (LMP) and about birthcontrol methods in order to rule out ectopic pregnancy. A history of miscarriagesand/or sexually transmitted diseases (STDs) can give more clues for the risk ofectopic pregnancy. Safe sex practices and the number of sexual partners can alert the practitioner to the risk for pelvic inflammatory disease (PID). Ovariantumors can go undetected for months, and the examiner must be alert to vaguesymptoms that might indicate a need for further investigation, such as bloating, gas, dyspepsia, and pressure type pain. These complaints in a postmenopausalwoman should not be trivialized. A positive family history of ovarian cancer ina patient presenting with these complaints is a red flag. Urinary symptoms suchas dysuria, hematuria, and a history of kidney stones indicate a risk for kidneystones. Persistent, asymptomatic hematuria is concerning for bladder inflam-mation or malignancy. If the patient complains of pain with movement or exercise and gives a history of heavy lifting, then hernia may be suspected. Sudden onset of severe lower abdominal pain, nausea, and vomiting in a youngmale should alert the examiner to the possibility of testicular torsion. A com-plaint of fatigue, weakness, weight loss, or change in bowel or bladder habits isworrisome, and a malignancy should be on the top of the list of differential diagnoses. Occasionally, hip disorders can present as lower abdominal pain.Physical ExaminationAn entire abdominal examination is necessary with the addition of the genitouri-nary system. It is warranted in both males and females but is of particular im-portance in females. No complaint of lower abdominal pain in a female should beevaluated without performing a pelvic examination.A rectal examination shouldbe performed for occult blood, palpation of the uterus or prostate, and the pres-ence of masses or tenderness. Although an unusual cause of lower abdominalpain, a musculoskeletal history and examination should be included, particularlywhen the pain is in the groin or hip area.For clarity, the lower abdominal complaints are broken down into the follow-ing regions: right lower quadrant (RLQ), left lower quadrant (LLQ), periumbil-ical, and suprapubic. For an overview and summary of the differential diagnosisof lower abdominal pain as well as laboratory studies, see Tables 10.9 and 10.10.

Upper Abdominal Pain, Discomfort, and Heartburn (Book)

Book -Studies suggest that neuropeptides, such as 5-hydroxytryptophan and substance P, mediate interconnected symptoms of pain, bowel dysfunction, and stress.4 Laboratory Studies for Upper Abdominal PainStudyComplete blood count (CBC)Platelet countAlanine aminotranserase (ALT)Aspartate aminotranserase (AST)Alkaline phosphataseGamma glutamic transpeptidase (GGT)Lactate dehydrogenase (LDH)BilirubinAlbuminAmylaseLipaseHepatitis proleProthrombin time (PT)Serum protein electrophoresis (SPE)Helicobacter pyloriDescriptionCBC determines elevated white blood cells in inection; decreased hemat-ocrit and hemoglobin, indicating the possibility o a gastrointestinalbleed; and cytopenic or myeloprolierative disorders, indicating hepatic or splenic involvement.Thrombocytopenia or thrombocytosis may indicate diseases involving theliver or spleen.ALT primarily helps diagnose liver disease but also detects biliary obstruction.AST primarily helps diagnose liver disease; however, elevations are alsoassociated with acute common bile duct obstruction. AST levels may beaected by statin drugs, acetaminophen, and alcohol.Alkaline phosphatase is used as a tumor marker and an index o liver andbone disease or metastasis in correlation with other ndings.GGT determines liver cell dysunction and detects alcohol-induced liverdisease. The GGT can be helpul as a conrmatory test.LDH is a widely distributed enzyme that is elevated with cellular damageo the liver, kidney, skeletal muscle, and heart.Bilirubin evaluates liver unction, biliary obstruction, and hemolytic anemia.Albumin is infuenced by nutritional state and hepatic and renal unction.Amylase helps distinguish pancreatitis rom other causes o abdominalpain.Lipase helps diagnose pancreatitis and stays elevated longer than amylase. However, lipase is not specic and may also be elevated in biliary and hepatic disease, diabetes mellitus, and gastric malignancy.A hepatitis prole detects acute or chronic, active and previous disease,carrier state, and immunity to hepatitis A, B, and C.An increased PT indicates clotting dysunction, which may be attributedto liver disease.An SPE is an evaluation o proteins (e.g., albumin, alpha globulins, betaglobulins, and gamma globulins) present in the serum. SPE may help diag-nose autoimmune liver disease, cirrhosis, and α1-antitrypsin deciency.H. pyloriis a serum blood test that detects common bacteria causing peptic ulcer disease.

Visceral Pain (Book)

Book -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. -may be difficult to localize. -It is typically palpable near the midline at levels that vary according to the structure involved, as illustrated on the next page. Ischemia also stimulates visceral pain fibers. -in the right upper quadrant may result from liver distention against its capsule in alcoholic hepatitis. -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. -periumbilical pain may signify early acute appendicitis from distention of an inflamed appendix. -It gradually changes to parietal pain in the right lower quadrant from inflammation of the adjacent parietal peritoneum. -right upper quadrant or epigastric pain from the biliary tree and liver -suprapubic or sacral pain from the rectum -epigastric pain from the stomach, duodenum, or pancreas -periumbilical pain from the small intestine, appendix, or proximal colon -hypogastric pain from the colon, bladder, or uterus. -Colonic pain may be more diffuse than illustrated.

Pareital Pain (Book)

Book -originates from inflammation in the parietal peritoneum. - 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 this type of pain usually prefer to lie still.

Change in bowel function (book)

Book: "How are your bowel movements?" "How frequent are they?" "Do you have any difficulties?" "Have you noticed any change?" -The range of normal is broad. -Current parameters suggest a minimum may be as low as two bowel movements per week. -Some patients may complain of passing excessive gas, or flatus, normally about 600 mL/day. -Consider aerophagia, legumes or other gas-producing foods, intestinal lactase deficiency, or irritable bowel syndrome.

Urinary Incontience (Book)

Book: -, an involuntary loss of urine that may become socially embarrassing or cause problems with hygiene. -ask when it happens and how often. -Find out if the patient is leaking small amounts of urine with increased intra-abdominal pressure from coughing, sneezing, laughing, or lifting. -Or following an urge to void, is there an involuntary loss of large amounts of urine? Is there a sensation of bladder fullness, frequent leakage, or voiding of small amounts but difficulty emptying the bladder?

Acute Diverticulitis (Book)

Book: -Acute inflammation of a colonic diverticulum, a saclike mucosal outpouching through the colonic muscle -Left lower quadrant -May be cramping at first, but becomes steady -Often a gradual onset -Fever, constipation. -There may be initial brief diarrhea.

Acute Appendicitis (Book)

Book: -Acute inflammation of the appendix with distention or obstruction -Poorly localized periumbilical pain, followed usually by -Mild but increasing, possibly cramping -Lasts roughly 4-6 hours -Right lower quadrant pain -Steady and more severe -Aggrevates: Movement or cough -If it subsides temporarily, suspect perforation of the appendix. -Anorexia, nausea, possibly vomiting, which typically follow the onset of pain; low fever Other than hernia, appendicitis is the most common cause of acute abdominalpain. It occurs most commonly between the ages of 10 and 30 years. Becausegangrene, perforation, and peritonitis can develop within 36 hours if untreated,approximately 15% of patients sent to surgery with a diagnosis of appendicitisare falsely positive. Ultrasound and CT have decreased the incidence of overdiag-nosis, but in some cases, laparotomy or laparoscopy are still required for a defin-itive diagnosis. Gynecologic disorders and gastroenteritis are the most commoncauses of misdiagnosis.Signs and SymptomsThe pain of appendicitis usually evolves over a few hours and initially is poorlylocalized, midline, and vague and is associated with some degree of nauseaand/or loss of appetite. In a matter of hours, the pain migrates to the RLQ,becoming more intense and localized, and may increase with coughing orwalking. Low-grade fever typically develops. The various tests for peritonealirritation (i.e., rebound tenderness, Rovsing's sign, heel strike, psoas, and obturator) are positive. Diagnostic StudiesAn elevated WBC and the physical examination are the two most important diagnostic tools. If the diagnosis is still uncertain, an abdominal CT with contrastis helpful.

Acute Bowel Obstruction (Book)

Book: -Obstruction of the bowel lumen, most commonly caused by (1) adhesions or hernias (small bowel), or (2) cancer or diverticulitis (colon) -Small bowel: periumbilical or upper abdominal -Cramping -Paroxysmal; may decrease as bowel mobility is impaired -Vomiting of bile and mucus (high obstruction) or fecal material (low obstruction). -Obstipation develops. -Colon: lower abdominal or generalized -Cramping -Paroxysmal, though typically milder -Obstipation early. Vomiting late if at all. Prior symptoms of underlying cause.

Acute Pancreatitis (Book)

Book: -Acute inflammation of the pancreas -Epigastric, may radiate to the back or other parts of the abdomen; may be poorly localized -Usually steady -Acute onset, persistent pain -Aggrevate: Lying supine -Relieve: Leaning forward with trunk flexed -Nausea, vomiting, abdominal distention, fever. -Often a history of previous attacks and alcohol abuse or gallstones Biliary tract disease and alcoholism account for 80% or more of the pancreatitisadmissions. Other causes include hyperlipidemia, drugs, toxins, infection,structural abnormalities, surgery, vascular disease, trauma, hyperparathyroidismand hypercalcemia, renal transplantation, and hereditary pancreatitis. The mostcommon cause of pancreatitis is alcohol abuse.Signs and SymptomsPancreatitis is characterized by severe abdominal pain, often with radiation to theback and usually accompanied by nausea and vomiting. The pain is steady and boring(piercing, penetrating), often refractory to narcotic pain medicines, and persistent formany days. Fever is present within a few hours, and other signs include tachycardia,rapid and shallow respirations, postural hypotension, diaphoresis, blunted sensorium,abdominal distention, tenderness, hypoactive bowel sounds, and possibly ascites.Diagnostic StudiesThere is no single test to diagnose pancreatitis, but several tests support the clin-ical impression, including serum amylase and lipase, white blood count (WBC),supine and upright plain films of the abdomen, chest x-ray, and ultrasound. Lipase and amylase are usually quite elevated, as is the WBC. Ultrasound imagingwill detect an enlarged pancreas as well as gallstones and biliary obstruction. A CT scan can be used in lieu of ultrasound to image the pancreas, but it is lesshelpful in identifying gallstones as the potential cause.F

Lower Abdominal Pain and Discomfort - Acute (Book)

Book: -Asking the patient to point to the pain and characterize all its features, combined with findings on the physical examination, will help you identify possible causes. -Some acute pain, especially in the suprapubic area or radiating from the flank, originates in the genitourinary tract - localized to the right lower quadrant. -Find out if it is sharp and continuous, or intermittent and cramping, causing them to double over. -Right lower quadrant pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, is most likely to predict appendicitis. - In women, consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy.16 -Cramping pain radiating to the right or left lower quadrant may be a renal stone. -When patients report acute pain in the left lower quadrant or diffuse abdominal pain, investigate associated symptoms such as fever and loss of appetite. -Left lower quadrant pain with a palpable mass may be diverticulitis. -Diffuse abdominal pain with absent bowel sounds and firmness, guarding, or rebound on palpation is seen in small or large bowel obstruction (Table 11-1).

Mesenteric Ischemia (Book)

Book: -Blood supply to the bowel and mesentery blocked from thrombosis or embolus (acute arterial occlusion), or reduced from hypoperfusion -May be periumbilical at first, then diffuse -Cramping at first, then steady -Usually abrupt in onset, then persistent -Vomiting, diarrhea (sometimes bloody), constipation, shock; older age

Polyuria (book)

Book: -Deficiency of antidiuretic hormone (diabetes insipidus) -A disorder of the posterior pituitary and hypothalamus -Thirst and polydipsia, often severe and persistent; nocturia -Renal unresponsiveness to antidiuretic hormone (nephrogenic diabetes insipidus) -A number of kidney diseases, including hypercalcemic and hypokalemic nephropathy; drug toxicity, e.g., from lithium -Thirst and polydipsia, often severe and persistent; nocturia -Solute diuresis •Electrolytes, such as sodium salts -Large saline infusions, potent diuretics, certain kidney diseases Variable •Nonelectrolytes, such as glucose -Uncontrolled diabetes mellitus Thirst, polydipsia, and nocturia -Excessive water intake -Primary polydipsia -Polydipsia tends to be episodic. -Thirst may not be present. -Nocturia is usually absent. - refers to a significant increase in 24-hour urine volume, roughly defined as exceeding 3 L. - It should be distinguished from urinary frequency, which can involve voiding in high amounts, seen in polyuria, or in small amounts, as in infection.

Suprapubic pain (book)

Book: -Disorders in the urinary tract may cause pain in either the abdomen or the back. -Bladder disorders may cause suprapubic pain. -In bladder infection, pain in the lower abdomen is typically dull and pressurelike. -In sudden overdistention of the bladder, pain is often agonizing; in contrast, chronic bladder distention is usually painless. -Pain of sudden overdistention accompanies acute urinary retention.

Kidney or Flank Pain; Ureteral Colic (book)

Book: -Disorders of the urinary tract may also cause kidney pain, often reported as flank pain at or below the posterior costal margin near the costovertebral angle. -It may radiate anteriorly toward the umbilicus. -Kidney pain is a visceral pain usually produced by distention of the renal capsule and typically dull, aching, and steady. -Ureteral pain is dramatically different. -It is usually severe and colicky, originating at the costovertebral angle and radiating around the trunk into the lower quadrant of the abdomen, or possibly into the upper thigh and testicle or labium. -Ureteral pain results from sudden distention of the ureter and associated distention of the renal pelvis. -Ask about any associated fever, chills, or hematuria. -Kidney pain, fever, and chills occur in acute pyelonephritis. -Renal or ureteral colic is caused by sudden obstruction of a ureter, for example, from renal or urinary stones or blood clots.

Chronic Pancreatitis (Book)

Book: -Fibrosis of the pancreas secondary to recurrent inflammation -Epigastric, radiating through to the back -Steady, deep -Chronic or recurrent course -Aggrevates: Alcohol, heavy or fatty meals -Relieves: Possibly leaning forward with trunk flexed; often intractable -Pancreatic enzyme insufficiency, diarrhea with fatty stools (steatorrhea) and diabetes mellitus.

Chronic Lower Abdominal Pain (Book)

Book: -If there is chronic pain in the quadrants of the lower abdomen, ask about change in bowel habits and alternating diarrhea and constipation. -Change in bowel habits with mass lesion indicates colon cancer. -Intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), without structural or biochemical abnormalities are symptoms of irritable bowel syndrome.17,18

Acute Cholecystitis (Book)

Book: -Inflammation of the gallbladder, usually from obstruction of the cystic duct by gallstone -Right upper quadrant or upper abdominal; may radiate to the right scapular area -Steady, aching -Gradual onset; course longer than in biliary colic -Aggrevate: Jarring, deep breathing -Anorexia, nausea, vomiting, fever

Stomach Cancer (Book)

Book: -Predominantly adenocarcinoma (90%-95%) -Increasingly in "cardia" and GE junction; also in distal stomach -The history of pain is typically shorter than in peptic ulcer. -Pain is persistent, slowly progressive. -Aggrevates: Often food -Not relieved by food or antacids -Anorexia, nausea, early satiety, weight loss, and sometimes bleeding. Most common in ages 50-70 Although the incidence of gastric cancer is lower than in the past, it has remainedrelatively steady for several years. It was estimated that approximately 21,000 adultswould be diagnosed in the United States in 2012, with 10,540 deaths (AmericanCancer Society, 2012). Suspected contributing factors, including excess salt intakeand chronic gastritis, as is seen with H. pylori, can lead to gastric cancer. The earlystage of the disease is asymptomatic, and diagnosis is made usually only after significant advancement. The 5-year survival rate is 20.6%. igns and SymptomsCancers of the stomach are rarely symptomatic until the disease has pro-gressed. Symptoms may be mild and consistent with heartburn or includemore definite abdominal pain. Other symptoms include nausea and vomiting,diarrhea, constipation, fullness, anorexia, fatigue, and weight loss. Althoughthe abdominal examination may be negative, tenderness and/or a palpablemass may be present.Diagnostic StudiesThe patient should be referred for endoscopy. A CBC should be ordered, anemiaassessed, and stool guaiac performed.

Cancer of the Pancreas (Book)

Book: -Predominantly adenocarcinoma (95%) -Epigastric and in either upper quadrant; often radiates to the back -Steady, deep -Persistent pain; relentlessly progressive illness -Relieves: Possibly leaning forward with trunk flexed; often intractable -Anorexia, nausea, vomiting, weight loss, and jaundice; depression

Aorta (book)

Book: -Press firmly deep in the upper abdomen, slightly to the left of the midline, and identify the aortic pulsations. -In people older than age 50, assess the width of the aorta by pressing deeply in the upper abdomen with one hand on each side of the aorta, as illustrated. In this age group, a normal aorta is not more than 3 cm wide (average, 2.5 cm). -This measurement does not include the thickness of the abdominal wall. -The ease of feeling aortic pulsations varies greatly with the thickness of the abdominal wall and with the anteroposterior diameter of the abdomen. -Risk factors for abdominal aortic aneurysm (AAA) are age 65 years or older, history of smoking, male gender, and a first-degree relative with a history of AAA repair.57,58 -A periumbilical or upper abdominal mass with expansile pulsations that is 3 cm or more wide suggests an AAA. -Sensitivity of palpation increases as AAAs enlarge: for widths of 3.0-3.9 cm, 29%; 4.0-4.9 cm, 50%; ≥5.0 cm, 76%.59,60 -Screening by palpation followed by ultrasound decreases mortality, especially in male smokers 65 years or older. -Pain may signal rupture. -Rupture is 15 times more likely in AAAs >4 cm than in smaller aneurysms.60

Gastroesophageal reflux disease (GERD) (Book)

Book: -Prolonged exposure of esophagus to gastric acid due to impaired esophageal motility or lower esophageal sphincter action. ' -Helicobacter pylori may be present. -Chest or epigastric -Burning (heartburn) Also regurgitation -After meals, specifically fatty foods -Aggrevate: Lying down, bending over. Physical activity -Relieve: Antacids; avoiding alcohol, fatty meals, chocolate, selected drugs such as theophylline, calcium channel blockers -Wheezing, chronic cough, shortness of breath, hoarseness, choking sensation, halitosis, sore throat. -Increases risk of Barrett's esophagus and esophageal cancer. GERD is the most common organic cause of heartburn. Lower esophagealsphincter (LES) control can be decreased by several medications (e.g., theo-phylline, dopamine, diazepam, calcium-channel blockers), foods and beverages(e.g., caffeine, alcohol, chocolate, fatty foods), and tobacco use. When LES toneis lower than normal, secretions are allowed to reflux into the esophagus, causingdiscomfort. Reflux is also promoted by weight gain and other variables causinggreater pressure against the LES.Signs and SymptomsThe most common symptom of GERD is heartburn, which typically occursafter meals and is often relieved by antacids. Other symptoms include belch-ing, regurgitation, and/or water brash. Respiratory and ear, nose, and throatsymptoms may develop, including cough, wheeze, aspiration, hoarseness, andglobus sensation (fullness in the throat). Symptoms may occur primarily atnight, when patients recline following a meal. See Box 10.1 for common trig-gers of GERD.Diagnostic StudiesDiagnosis can often be made by the history, although the degree of symptomsmay not be consistent with the degree of esophageal injury. When GERD is themost likely cause of acute epigastric discomfort, empiric treatment may includeavoiding any triggers and prescribing antacids and/or antisecretory agents, par-ticularly for a young, otherwise healthy patient without known risk factors for260Advanced Assessment|Advanced Assessment and Differential Diagnosis by Body Regions Box 10.1Common Triggers for GERD• Tomato products• Citrus• Spicy foods• Coffee• Fatty foods• Peppermint• Chocolate• Alcohol• Smoking more serious disorders. However, the risk of delaying the definitive diagnosis andtreatment must be weighed when considering this route. Endoscopy provides direct visualization of the esophagus and evidence to rule out other disorders.Ambulatory esophageal pH monitoring may help to identify association betweensymptoms and reflux. Barium swallows and upper GI x-ray have a high potentialof missing esophageal damage.

Screening for Problem Drinking (book)

Book: -Standard Drink Equivalents: 1 standard drink is equivalent to 12 ounces of regular beer or wine cooler, 8 ounces of malt liquor, 5 ounces of wine, or 1.5 ounces of 80-proof spirits -Initial Screening Question: "How many times in the past year have you had 4 or more drinks a day (women), or 5 or more drinks a day (men)?" -Cut Points for Drinks per Day -Women Men -Drinks per day -Moderate drinking ≤1 ≤2 -Maximum drinking ≤3 ≤4 if < 65 years (and ≤14 drinks in a week) ≤3 if > 65 years (and ≤7 drinks in a week) -Binge drinking* ≥4 ≥5 * Brings blood alcohol level to 0.08 g %, usually within 2 hours.

Biliary Colic (Book)

Book: -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 -Steady, aching; not colicky -Rapid onset over a few minutes, lasts one to several hours and subsides gradually. -Often recurrent -Anorexia, nausea, vomiting, restlessness

Bladder (book)

Book: -The bladder normally cannot be examined unless it is distended above the symphysis pubis. -On palpation, the dome of the distended bladder feels smooth and round. -Check for tenderness. -Use percussion to check for dullness and to determine how high the bladder rises above the symphysis pubis. -Bladder volume must be 400 to 600 mL before dullness appears.[53] -Bladder distention from outlet obstruction may be due to urethral stricture, prostatic hyperplasia; or from medications and neurologic disorders such as stroke or multiple sclerosis. -Suprapubic tenderness is common in bladder infection.

Risk factors for Hep A, B, and C (book)

Book: -The mainstay for protecting adults against viral hepatitis is adherence to vaccination guidelines for hepatitis A and hepatitis B, the most effective method for preventing infection and transmission. -Educating patients about how the hepatitis viruses spread and the benefits of vaccination for groups at risk is also important.

Stress Incontience (Book)

Book: -The urethral sphincter is weakened so that transient increases in intra-abdominal pressure raise the bladder pressure to levels that exceed urethral resistance. -In women, often a weakness of the pelvic floor with inadequate muscular support of the bladder and proximal urethra and a change in the angle between the bladder and the urethra (see Chapter 14). -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. -Momentary leakage of small amounts of urine with coughing, laughing, and sneezing while the person is in an upright position. -A desire to urinate is not associated with pure stress incontinence. - The bladder is not detected on abdominal examination. -Stress incontinence may be demonstrable, especially if the patient is examined before voiding and in a standing position. -Atrophic vaginitis may be evident. -In men, stress incontinence may follow prostatic surgery. -when increased abdominal pressure causes bladder pressure to exceed urethral resistance due to poor urethral sphincter tone or poor support of bladder neck; urge incontinence—when urgency is followed by immediate involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance; overflow incontinence—when neurologic disorder or anatomic obstruction from pelvic organs or the prostate limits bladder emptying until the bladder is overdistended -As described earlier, bladder control involves complex neuroregulatory and motor mechanisms (see p. 435). -Several central or peripheral nerve lesions may affect normal voiding. -Can the patient sense when the bladder is full? And when voiding occurs? -Although there are four broad categories of incontinence, a patient may have a combination of causes. In addition, the patient's functional status may significantly affect voiding behaviors even when the urinary tract is intact. Is the patient mobile? Alert? Able to respond to voiding cues and reach the bathroom? Is alertness or voiding affected by medications? Functional incontinence may arise from impaired cognition, musculoskeletal problems, or immobility.

bladder (book)

Book: -distended may be palpable above the symphysis pubis. -accommodates roughly 300 mL of urine filtered by the kidneys into the renal pelvis and the ureters. - expansion stimulates contraction of smooth muscle, the detrusor muscle, at relatively low pressures. -Rising pressure triggers the conscious urge to void. -Increased intraurethral pressure can overcome rising pressures and prevent incontinence. -Intraurethral pressure is related to smooth muscle tone in the internal urethral sphincter, the thickness of the urethral mucosa, and, in women, sufficient support to the bladder and proximal urethra from pelvic muscles and ligaments to maintain proper anatomical relationships. -Striated muscle around the urethra can also contract voluntarily to interrupt voiding. -Neuroregulatory control functions at several levels. - In infants, empties by reflex mechanisms in the sacral spinal cord. -Voluntary control depends on higher centers in the brain and on motor and sensory pathways between the brain and the reflex arcs of the sacral spinal cord. -When voiding is inconvenient, higher centers in the brain can inhibit detrusor contractions until the capacity , approximately 400 to 500 mL, is exceeded. -The integrity of the sacral nerves that innervate the bladder can be tested by assessing perirectal and perineal sensation in the S2, S3, and S4 dermatomes (see p. 731).

Jaundice (Book)

Book: -icterus, the yellowish discoloration of the skin and sclerae from increased levels of bilirubin, a bile pigment derived chiefly from the breakdown of hemoglobin. -Normally the hepatocytes conjugate, or combine unconjugated bilirubin with other substances, making the bile water soluble, and then excrete it into the bile. -The bile passes through the cystic duct into the common bile duct, which also drains the extrahepatic ducts from the liver. - More distally, the common bile duct and the pancreatic ducts empty into the duodenum at the ampulla of Vater. -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. -Predominantly unconjugated bilirubin occurs from the first three mechanisms, as in hemolytic anemia (increased production) and Gilbert's syndrome. -Impaired excretion of conjugated bilirubin is seen in viral hepatitis, cirrhosis, primary biliary cirrhosis, and drug-induced cholestasis, as from oral contraceptives, methyl testosterone, and chlorpromazine. -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. -Extrahepatic jaundice arises from obstruction of the extrahepatic bile ducts, most commonly the cystic and common bile ducts. -Gallstones or pancreatic carcinoma may obstruct the common bile duct. -As you assess the patient with jaundice, pay special attention to the associated symptoms and the setting in which the illness occurred. -What was the color of the urine as the patient became ill? When the level of conjugated bilirubin increases in the blood, it may be excreted into the urine, turning the urine a dark yellowish brown or tea color. -Unconjugated bilirubin is not water-soluble, so it is not excreted into urine. -Dark urine from bilirubin indicates impaired excretion of bilirubin into the gastrointestinal tract. -Ask also about the color of the stools. When excretion of bile into the intestine is completely obstructed, the stools become gray or light colored, or acholic, without bile. -Acholic stools may occur briefly in viral hepatitis; they are common in obstructive jaundice. -Does the skin itch without other obvious explanation? Is there associated pain? What is its pattern? Has it been recurrent in the past? -Itching occurs in cholestatic or obstructive jaundice; pain may signify a distended liver capsule, biliary colic, or pancreatic cancer.

Nausea (Book)

Book: -often described as "feeling sick to my stomach," may progress to retching and vomiting. -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. -Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching, called regurgitation. -Regurgitation occurs in GERD, esophageal stricture, and esophageal cancer. -Ask about any vomitus or regurgitated material and inspect it if possible. What color is it? What does the vomitus smell like? How much has there been? You may have to help the patient with the amount: a teaspoon? Two teaspoons? A cupful? -Vomiting and pain indicate small bowel obstruction. Fecal odor occurs with small bowel obstruction or gastrocolic fistula. -Ask specifically if the vomitus contains any blood, and quantify the amount. -Gastric juice is clear and mucoid. - -Small amounts of yellowish or greenish bile are common and have no special significance. -Brownish or blackish vomitus with a "coffee grounds" appearance suggests blood altered by gastric acid. -Coffee-grounds emesis or red blood is termed hematemesis. -Hematemesis may accompany esophageal or gastric varices, gastritis, or peptic ulcer disease. -Is there any dehydration or electrolyte imbalance from prolonged vomiting or significant blood loss? Do the patient's symptoms suggest any complications of vomiting, such as aspiration into the lungs, seen in debilitated, obtunded, or elderly patients? -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. Nausea and vomiting usually stem from GI infections but may reflect many cat-egories of problems, including other infections, actual or functional GI obstruc-tion, metabolic disorders, central nervous system disorders, drugs, pain,pregnancy, and psychiatric disorders. A detailed list of potential causes is providedin Table 10.11. This section describes the basic approach to nausea and vomitingto differentiate among major potential causes. Table 10.11 summarizes common 270 Advanced Assessment|Advanced Assessment and Differential Diagnosis by Body Regions Table 10.11C 270 Advanced Assessment|Advanced Assessment and Differential Diagnosis by Body Regions Table 10.11C

Dysphagia (Book)

Book: -patients may report difficulty swallowing from impaired passage of solid foods or liquids from the mouth to the stomach, or dysphagia. -Food seems to stick, hesitate, or "not go down right," suggesting motility disorders or structural anomalies. -The sensation of a lump in the throat or the retrosternal area unassociated with swallowing is not true dysphagia. -Oropharyngeal Dysphagia, due to motor disorders affecting the pharyngeal muscles -Acute or gradual onset and a variable course, depending on the underlying disorder -Attempts to start the swallowing process -Aspiration into the lungs or regurgitation into the nose with attempts to swallow. -From stroke, bulbar palsy, or other neuromuscular conditions -Esophageal Dysphagia -Mechanical Narrowing -Mucosal rings and webs: Intermittent Solid foods Regurgitation of the bolus of food Usually none -Esophageal stricture Intermittent; may become slowly progressive Solid foods Regurgitation of the bolus of food A long history of heartburn and regurgitation -Esophageal cancer May be intermittent at first; progressive over months Solid foods, with progression to liquids Regurgitation of the bolus of food Pain in the chest and back and weight loss, especially late in the course of illness -Motor Disorders -Diffuse esophageal spasm Intermittent Solids or liquids Maneuvers described below; sometimes nitroglycerin Chest pain that mimics angina pectoris or myocardial infarction and lasts minutes to hours; possibly heartburn -Scleroderma Intermittent; may progress slowly Solids or liquids Repeated swallowing; movements such as straightening the back, raising the arms, or a Valsalva maneuver (straining down against a closed glottis) Heartburn; other manifestations of scleroderma Regurgitation, often at night when lying down, with nocturnal cough; possibly chest pain precipitated by eating -Achalasia Intermittent; may progress Solids or liquids -Indicators of oropharyngeal dysphagia include drooling, nasopharyngeal regurgitation, and cough from aspiration in neuromuscular disorders affecting motility such as stroke or Parkinson's disease; gurgling or regurgitation of undigested food occur in structural conditions like Zenker's diverticulum. -Ask the patient to point to where the dysphagia occurs. -Pointing to below the sternoclavicular notch indicates esophageal dysphagia. -Pursue which types of foods provoke symptoms: solid foods, or solids and liquids? Establish the timing. When does the dysphagia start? Is it intermittent or persistent? Is it progressing? If so, over what time period? Are there associated symptoms and medical conditions? -If solid foods, consider structural esophageal conditions like esophageal stricture, web or Schatzki's ring, neoplasm; if solids and liquids, a motility disorder is more likely. -Is there odynophagia, or pain on swallowing? -Consider esophageal ulceration from radiation, caustic ingestion, or infection from Candida, cytomegalovirus, herpes simplex, or HIV. -Odynophagia can be pill-induced from aspirin or non-steroidal anti-inflammatory agents.

kidneys (book)

Book: -posterior organs. -The ribs protect their upper poles. -The costovertebral angle, formed by the lower border of the 12th rib and the transverse processes of the upper lumbar vertebrae, defines where to examine for tenderness, termed costovertebral angle tenderness, or CVAT.

Hep C (book)

Book: -transmitted by repeated percutaneous exposure to infected blood and is the most common bloodborne pathogen in the United States, found in approximately 2% of the population.[35]-[37] -However, prevalence reaches 50% to 90% of groups at high risk, namely injection drug users and patients transfused with clotting factors before 1987. - highly persistent and causes chronic liver disease in 75% of those infected. - It accounts for roughly 50% of cirrhosis, end-stage liver disease, and liver cancer. -Additional risk factors include history of injection drug use even one time, blood transfusion or organ transplant before 1992, blood transfusion or organ transplant before 1992, hemodialysis, known exposure to the hepatitis C virus from needlesticks or an infected blood or transplant donor, HIV infection, and birth from a hepatitis C-positive mother. -Sexual transmission is rare . -There is no vaccine, so prevention depends on screening and counseling to avoid risk factors. -Response to antiviral therapy is 40% to 80% depending on the viral genotype.

Tender Abdomens (book) a. Abdominal Wall Tenderness b. Visceral Tenderness c. Tenderness From Disease in the Chest and Pelvis d. Acute Pleurisy e. Acute Salpingitis f. Tenderness of Peritoneal Inflammation g. Acute Cholecystitis h. Acute Appendicitis i. Acute Diverticulitis

Book: a. Tenderness may originate in the abdominal wall. When the patient raises the head and shoulders, this tenderness persists, whereas tenderness from a deeper lesion (protected by the tightened muscles) decreases. b. 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 quite helpful. c. d. Abdominal pain and tenderness may result from acute pleural inflammation. When unilateral, it may mimic acute cholecystitis or appendicitis. Rebound tenderness and rigidity are less common; chest signs are usually present. d. Pleurisy may result from (1) an underlying lung process, (2) an infection orirritation in the pleural space, (3) the transport of an infectious or other diseaseagent or neoplastic metastases to the pleura, and (4) trauma, especially ribtrauma. Basilar pleurisy may produce referred pain to the abdomen.Signs and SymptomsPleurisy is differentiated from abdominal disease by chest x-ray or evidence of arespiratory origin, such as increased pain with deep breathing and coughing, shallow or rapid breathing, the absence of nausea or vomiting, or a tendencytoward relief of pain with pressure on the chest wall or abdomen. A pleural friction rub is pathognomonic.Diagnostic StudiesPleurisy may not be evident on any thoracic imaging, and diagnosis may be madeby history and physical examination. A chest x-ray or CT of the chest showinginflammation or pleural thickening is helpful in some cases.257Chapter 10|AbdomenDecision RuleEbell (2001) reports a prediction rule developed by Balthazar, Robinson, Megibow,and Ranson (1990) to determine the severity of acute pancreatitis. The Ranson ruleis based on 88 patients and was not validated on a second group. The rule uses ascore determined by MRI results, with an index possible range of 0 to 10. A catego-rization of patients indicates the risk of both mortality and complication from thedisease. Patients at the low end of the index (1-3) are predicted to have a low risk ofmortality (3%) and complications (8%), whereas patients scoring at the high end(7-10) of the index are predicted to have a higher incidence of mortality (17%)and/or complications (92%). e. 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 uterus causes pain. f. Tenderness associated with peritoneal inflammation 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 boardlike muscular rigidity. These signs on palpation, especially abdominal rigidity, double the likelihood of peritonitis.53 Local causes of peritoneal inflammation include: g. Signs are maximal in the right upper quadrant. Check for Murphy's sign (see p. 468). Acute Pancreatitis In acute pancreatitis, epigastric tenderness and rebound tenderness are usually present, but the abdominal wall may be soft. h. Right lower quadrant signs are typical of acute appendicitis but may be absent early in the course (McBurney's point). The typical area of tenderness is illustrated. Explore other portions of the right lower quadrant as well as the right flank. i. Acute diverticulitis most often involves the sigmoid colon and then resembles a left-sided appendicitis. Diverticular disease is prevalent in patients over 60 years of age. It is seen morecommonly in Western countries and is thought to be due to raised intraluminalcolonic pressures. Since the sigmoid colon has the smallest diameter of any por-tion of the colon, it is the most common site for the development of diverticula.Patients with connective tissue disease, such as scleroderma, Marfan's syndrome,and Ehlers-Danlos syndrome, are at increased risk. Chronic constipation can bean aggravating factor due to straining, which increases intraluminal pressures.Signs and SymptomsAlthough the pain can be generalized, it is typically localized to the left lower abdomen and is accompanied by tenderness, fever, and leukocytosis. These symp-toms in a person with a known history of diverticulosis make the diagnosis almostcertain for diverticulitis. Other symptoms can include constipation or loosestools, nausea, vomiting, and positive stool occult blood. With diverticulitis, there is an increased risk of perforation, which presents with a more dramatic clinicalpicture as a result of peritonitis. Look for signs of peritonitis, such as a positiveheel strike test and/or rebound tenderness.Diagnostic StudiesA CBC will show mildly elevated white blood cells. Plain abdominal films shouldbe obtained to look for an ileus, a small or large bowel obstruction, and free airin the abdomen, indicating perforation. Acute medical management is indicated,and after 7 to 10 days, a flexible sigmoidoscopy and/or barium enema with water-soluble contrast is recommended. These should not be done in the acute stagebecause the risk of perforation increases during the procedure. A CT withoutcontrast may also be helpful.

Black and Bloody Stools (Book) a. melena b. Black, Nonsticky Stools c. Red Blood in the Stools (hematochezia) d. Reddish but Nonbloody Stools

Book: a.-Refers to passage of black, tarry (sticky and shiny) stools. -Occult blood tests are positive. -Involves loss of at least 60 mL of blood into the gastrointestinal tract (less in children), usually from the esophagus, stomach, or duodenum and transit time of 7-14 hours. -Less commonly, when transit is slow, blood loss originates in the jejunum, ileum, or ascending colon. -In infants, melena may result from swallowing blood during the birth. -Gastritis, GERD, peptic ulcer (gastric or duodenal) -Usually epigastric discomfort from heartburn, dysmotility; if peptic ulcer, pain after meals (delayed, 2-3 hours if duodenal ulcer). -May be silent. -Gastritis or stress ulcers -Recent ingestion of alcohol, aspirin, or other anti-inflammatory drugs; recent bodily trauma, severe burns, surgery, or increased intracranial pressure -Esophageal or gastric varices -Cirrhosis of the liver or other causes of portal hypertension -Reflux esophagitis Mallory-Weiss tear in esophageal mucosa due to retching and vomiting -Retching, vomiting, often recent ingestion of alcohol b. -May result from other causes, with negative occult blood tests. -These stools have no pathologic significance. -Ingestion of iron, bismuth salts, licorice, or even chocolate cookies -Asymptomatic c. -Usually originates in the colon, rectum, or anus; much less frequently from the jejunum or ileum. -Upper gastrointestinal hemorrhage may also cause red stools; blood loss is then usually large (more than a liter). -Rapid transit through the intestinal tract leaves insufficient time for the blood to turn black from oxidation of iron in hemoglobin. -Colon cancer -Often a change in bowel habits, weight loss -Hyperplasia or adenomatous polyps -Often no other symptoms -Diverticula of the colon -Often no symptoms unless inflammation causes diverticulitis -Inflammatory conditions of the colon and rectum •Ulcerative colitis, Crohn's disease •Infectious diarrhea •Proctitis (various causes including frequent anal intercourse) -Rectal urgency, tenesmus -Ischemic colitis -Lower abdominal pain, sometimes fever or shock in older adults. -Abdomen typically soft to palpation -Hemorrhoids Blood on the toilet paper, on the surface of the stool, or dripping into the toilet -Anal fissure Blood on the toilet paper or on the surface of the stool; anal pain d. -Ingestion of beets -Pink urine, which usually precedes the reddish stool; from poor metabolism of betacyanin -Melena may appear with as little as 100 mL of blood from upper gastrointestinal bleeding; hematochezia if more than 1,000 mL of blood, usually from lower gastrointestinal bleeding. -Is the blood mixed in with stool or on the surface? Does the blood appear as streaks on the toilet paper or is it more copious? -Blood on the surface or toilet paper may occur with hemorrhoids.

GI disorder symptoms (book)

Book: •Abdominal pain, acute and chronic •Indigestion, nausea, vomiting including blood, loss of appetite, early satiety •Dysphagia and/or odynophagia •Change in bowel function •Diarrhea, constipation •Jaundice -rank high among reasons for office and emergency room visits. -abdominal pain, heartburn, nausea and vomiting, difficulty or pain with swallowing, vomiting of stomach contents or blood, loss of appetite, and jaundice. -diarrhea, constipation, change in bowel habits, and blood in the stool, often described as either bright red or dark and tarry.

Risk factors for liver disease (book)

Book: •Hepatitis: Travel or meals in areas of poor sanitation, ingestion of contaminated water or foodstuffs (hepatitis A); parenteral or mucous membrane exposure to infectious body fluids such as blood, serum, semen, and saliva, especially through sexual contact with an infected partner or use of shared needles for injection drug use (hepatitis B); intravenous illicit drug use; or blood transfusion (hepatitis C) •Alcoholic hepatitis or alcoholic cirrhosis (interview the patient carefully about alcohol use) •Toxic liver damage from medications, industrial solvents, environmental toxins, or some anesthetic agents •Gallbladder disease or surgery that may result in extrahepatic biliary obstruction •Hereditary disorders in the Family History

Urinary and Renal disorder symtpoms (book)

Book: •Suprapubic pain •Dysuria, urgency, or frequency •Hesitancy, decreased stream in males •Polyuria or nocturia •Urinary incontinence •Hematuria •Kidney or flank pain •Ureteral colic -difficulty urinating, urgency and frequency, hesitancy and decreased stream in men, high urine volume, urinating at night, incontinence, blood in the urine, and flank pain and colic from renal stones or infection.

Percussion of Spleen

Video: can do same thing as liver, but harder to percuss the borders because its located under the ribs and off to the side, around the 10th inner costal space, anterior auxiliary line -percuss here, see if its dull - take a deep breath in, see if its tympanic -the spleen shifts up so no splenic enlargement Book -Two techniques may help you to detect splenomegaly, an enlarged spleen: -Percuss the left lower anterior chest wall 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's space. -As you percuss along the routes suggested by the arrows in the following figures, note the lateral extent of tympany. Percussion is moderately accurate in detecting splenomegaly (sensitivity, 60%-80%; specificity, 72%-94%).[56] -If percussion dullness is present, palpation correctly detects presence or absence of splenomegaly more than 80% of the time.[56] -If tympany is prominent, especially laterally, splenomegaly is not likely. -The dullness of a normal spleen is usually masked by the dullness of other posterior tissues. -Fluid or solids in the stomach or colon may also cause dullness in Traube's space. -Check for a splenic percussion sign. -Percuss the lowest interspace in the left anterior axillary line, as shown next. -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. -A change in percussion note from tympany to dullness on inspiration suggests splenic enlargement. - This is a positive splenic percussion sign. -If either or both of these tests is positive, pay extra attention to palpation of the spleen. -The splenic percussion sign may also be positive when spleen size is normal.

Rebound Test

Video: for appendicitis, -press deeply into the stomach and suddenly let go and ask the patient which hurt more, -if the the initial pressure hurt more or once you let go of your hands, the rebound hurt more book Rebound tenderness is tested by slowly pressing over the abdomen with yourfingertips, holding the position until pain subsides or the patient adjusts to thediscomfort, and then quickly removing the pressure. Rebound pain, a sign ofperitoneal inflammation, is present if the patient experiences a sharp discomfortover the inflamed site when pressure is released.

Palpation of spleen (book)

book -With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. -With your right hand below the left costal margin, press in toward the spleen. -Begin palpation low enough so that you are below a possibly enlarged spleen. -If your hand is close to the costal margin, it is not sufficiently mobile to reach up under the rib cage. -Ask the patient to take a deep breath. -Try to feel the tip or edge of the spleen as it comes down to meet your fingertips. -Note any tenderness, assess the splenic contour, and measure the distance between the spleen's lowest point and the left costal margin. -In approximately 5% of normal adults, the tip of the spleen is palpable. -Causes include a low, flat diaphragm, as in chronic obstructive pulmonary disease, and a deep inspiratory descent of the diaphragm. -An enlarged spleen may be missed if the examiner starts too high in the abdomen to feel the lower edge. -Splenomegaly is eight times more likely when the spleen is palpable.53 -Causes include portal hypertension, hematologic malignancies, HIV infection, and splenic infarct or hematoma. -The spleen tip, illustrated below, is just palpable deep to the left costal margin. -Repeat with the patient lying on the right side with legs somewhat flexed at the hips and knees. -In this position, gravity may bring the spleen forward and to the right into a palpable location. This enlarged spleen is palpable about 2 cm below the left costal margin on deep inspiration.

general history (book)

book A general history for the abdominal examination should include any reports ofnausea and/or vomiting; current bowel habits, including diarrhea, changes inbowel or bladder habits, or constipation; and pain, weight loss or gain, changein appetite, bloating, excessive gas or belching, dysphagia, heartburn or indiges-tion, rectal bleeding, or black stools. Ask about history of jaundice, liver disease,hepatitis, gallbladder disease, fever, or malaise. As specific complaints are dis-cussed subsequently in the chapter, further symptom analysis is described. A general past medical history should include any history of jaundice, liver dis-ease, hepatitis, gallbladder disease, infectious diseases, peptic ulcer disease (PUD), GERD, bleeding or platelet disorders, trauma, or previous surgeries with the emphasis on abdominal surgeries.nFamily HistoryIdentify any family history of liver or gallbladder disease, hepatitis, or cancer.There is a familial predisposition to certain diseases of the digestive tract, suchas inflammatory bowel disease, polyposis, and cancer of the colon. The risk ofhepatitis is increased among family members in the same household, especiallyhepatitis C.nHabitsHabits may be particularly important for certain abdominal complaints, espe-cially the use of tobacco, caffeine, and alcohol. Also important are a list of allmedications/drugs, activity, exercise, and sleep patterns. Identify usual dietaryintake. Explore sexual habits. Ask about travel patterns and recent exposures.

urinary tract (book)

book: - "Do you have any difficulty passing your urine?" - "How often do you go?" -"Do you have to get up at night? How often?" -"How much urine do you pass at a time?" -"Is there any pain or burning?" -"Do you ever have trouble getting to the toilet in time?" -"Do you ever leak any urine? Or wet yourself involuntarily?" -Does the patient sense when the bladder is full and when voiding occurs? -Involuntary voiding or lack of awareness suggests cognitive or neurosensory deficits. -Ask women if sudden coughing, sneezing, or laughing makes them lose urine. -Roughly half of young women report this experience even before bearing children. -Occasional leakage is not necessarily significant. -Ask older men, "Do you have trouble starting your stream?" "Do you have to stand close 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?" "Is there dribbling when you're through?" -Stress incontinence arises from decreased intraurethral pressure (see Table 11-7). -These problems are common in men with partial bladder outlet obstruction from benign prostatic hyperplasia; also seen with urethral stricture.

Liver Enlargement: Apparent and Real (book) a. Downward Displacement of the Liver by a Low Diaphragm b. Normal Variations in Liver Shape c. Smooth Large Liver d. Irregular Large Liver

book: -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 far from perfect. a. This finding is common when the diaphragm is low (e.g., 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. b. In some people, especially those with a lanky build, the liver tends to be elongated so that its right lobe is easily palpable as it projects downward toward the iliac crest. -Such an elongation, sometimes called Riedel's lobe, represents a variation in shape, not an increase in liver volume or size. -Examiners can only estimate the upper and lower borders of an organ with three dimensions and differing shapes. Some error is unavoidable. c. 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, as in right-sided heart failure. d. An enlarged liver that is firm or hard and has an irregular edge or surface suggests hepatocellular carcinoma. -There may be one or more nodules. -The liver may or may not be tender.

Screening for Alcohol Abuse (book)

book: -Alert clinicians often notice clues of unhealthy alcohol use from social patterns and behavioral problems that emerge during the history. -The patient may report past episodes of pancreatitis, family history of alcoholism, or arrest for intoxicated driving. -Examination of the abdomen may reveal such classic findings as hepatosplenomegaly, ascites, or even caput medusa, a collateral pathway of recanalized umbilical veins radiating up the abdomen that decompresses portal vein hypertension. -Other classic findings include spider angiomas, palmar erythema, and peripheral edema. -Current 12-month prevalence of alcohol abuse or dependence is on the rise, affecting 8.5% of the U.S. population, or 15 to 20 million people.[25] Lifetime prevalence is approximately 30%, and in emergency rooms and trauma admissions, prevalence reaches 30% to 40% and 50%, respectively.[26],[27] Addictions are increasingly viewed as chronic relapsing behavioral disorders with substance-induced rearrangements of brain neurotransmitters resulting in tolerance, physical dependence, sensitization, craving, and relapse. -Alcohol addiction has numerous sequelae and is highly correlated with fatal car accidents, suicide and other mental health disorders, family disruption, violence, hypertension, cirrhosis hemorrhagic stroke, and malignancies of the upper gastrointestinal tract and liver. -Because early detection of at-risk behaviors may be challenging, learn the basic identifiers for problem drinking. -The U.S. Preventive Services Task Force (USPSTF) recommends screening and behavioral counseling for all adults in primary care setting settings, including pregnant women.[28] -If your patient drinks alcoholic beverages, begin screening by asking about heavy drinking, then follow up with the well-validated CAGE questions or the Alcohol Use Disorders Identification Test (AUDIT). -Keep in mind cutoffs for problem drinking listed below -Tailor your recommendations to the severity of the problem, ranging from brief interventions, which are proven to be effective, to long-term rehabilitation. -Take advantage of the helpful "Clinician's Guide for Helping Patients Who Drink Too Much."[

Palpation of Kidneys (book)

book: -Although kidneys are retroperitoneal and not usually palpable, learning the techniques for examination helps you distinguish enlarged kidneys from other enlarged organs and abdominal masses. -A left flank mass may represent marked splenomegaly or an enlarged left kidney. -Suspect splenomegaly if a notch is palpated on medial border, the edge extends beyond the midline, percussion is dull, and your fingers can probe deep to the medial and lateral borders but not between the mass and the costal margin. -Confirm findings with further evaluation.

Liver (book)

book: -Because the rib cage shelters most of the liver, direct assessment is difficult. - Liver size and shape can be estimated by percussion and palpation. -Pressure from your palpating hand helps you to evaluate its surface, consistency, and tenderness.

urinary frequency, urgency, dysuria (book)

book: -Decreased capacity of the bladder •Increased bladder sensitivity to stretch because of inflammation -Infection, stones, tumor, or foreign body in the bladder -Burning on urination, urinary urgency, sometimes gross hematuria •Decreased elasticity of the bladder wall -Infiltration by scar tissue or tumor -Symptoms of associated inflammation (see above) are common. •Decreased cortical inhibition of bladder contractions -Motor disorders of the central nervous system, such as a stroke -Urinary urgency; neurologic symptoms such as weakness and paralysis -Impaired emptying of the bladder, with residual urine in the bladder •Partial mechanical obstruction of the bladder neck or proximal urethra Most commonly, benign prostatic hyperplasia; also urethral stricture and other obstructive lesions of the bladder or prostate - Prior obstructive symptoms: hesitancy in starting the urinary stream, straining to void, reduced size and force of the stream, and dribbling during or at the end of urination •Loss of peripheral nerve supply to the bladder Neurologic disease affecting the sacral nerves or nerve roots, e.g., diabetic neuropathy -Weakness or sensory defects -Infection or irritation of either the bladder or urethra often provokes several symptoms. -Frequently there is pain on urination, usually felt as a burning sensation. -Some clinicians refer to this as dysuria, whereas others reserve the term dysuria for difficulty voiding. -Women may report internal urethral discomfort, sometimes described as a pressure, or an external burning from the flow of urine across irritated or inflamed labia. -Men typically feel a burning sensation proximal to the glans penis. -In contrast, prostatic pain is felt in the perineum and occasionally in the rectum. -Painful urination accompanies cystitis or urethritis, and urinary tract infections.22 -If dysuria, consider bladder stones, foreign bodies, tumors; also acute prostatitis. -In women, internal burning occurs in urethritis, and external burning in vulvovaginitis. -Other associated symptoms are common. -Urinary urgency is an unusually intense and immediate desire to void, sometimes leading to involuntary voiding or urge incontinence. -Urinary frequency, or abnormally frequent voiding, may occur. -Ask about any related fever or chills, blood in the urine, or any pain in the abdomen, flank, or back (see illustration following). -Men with partial obstruction to urinary outflow often report hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urinary stream, or dribbling as voiding is completed. -Urgency suggests bladder infection or irritation. -In men, painful urination without frequency or urgency suggests urethritis.

Overflow incontinence (Book)

book: -Detrusor contractions are insufficient to overcome urethral resistance. -The bladder is typically large, even after an effort to void. -Obstruction of the bladder outlet, as in benign prostatic hyperplasia or tumor -A continuous dripping or dribbling incontinence -An enlarged bladder is often found on abdominal examination and may be tender. -Other signs include prostatic enlargement, motor signs of peripheral nerve disease, a decrease in sensation (including perineal sensation), and diminished to absent reflexes. -Weakness of the detrusor muscle associated with peripheral nerve disease at the sacral level -Decreased force of the urinary stream Impaired bladder sensation that interrupts the reflex arc, as from diabetic neuropathy - Prior symptoms of partial urinary obstruction or other symptoms of peripheral nerve disease may be present.

Urge Incontinence (Book)

book: -Detrusor contractions are stronger than normal and overcome the normal urethral resistance. -The bladder is typically small. -Decreased cortical inhibition of detrusor contractions from stroke, brain tumor, dementia, and lesions of the spinal cord above the sacral level Involuntary urine loss preceded by an urge to void. -The volume tends to be moderate. -The bladder is not detectable on abdominal examination. -Hyperexcitability of sensory pathways, as in bladder infections, tumors, and fecal impaction -Urgency -Frequency and nocturia with small to moderate volumes -If acute inflammation is present, pain on urination -When cortical inhibition is decreased, mental deficits or motor signs of central nervous system disease are often, though not necessarily, present. -Deconditioning of voiding reflexes, as in frequent voluntary voiding at low bladder volumes Possibly "pseudo-stress incontinence"—voiding 10-20 seconds after stresses such as a change of position, going up or down stairs, and possibly coughing, laughing, or sneezing -When sensory pathways are hyperexcitable, signs of local pelvic problems or a fecal impaction may be present.

incontinence secondary to medication (book)

book: -Drugs may contribute to any type of incontinence listed. -Sedatives, tranquilizers, anticholinergics, sympathetic blockers, and potent diuretics -Variable. -A careful history and chart review are important. Variable

Abdominal Bruits and Friction Rubs (book)

book: -If the patient has high blood pressure, listen in the epigastrium and in each upper quadrant for bruits. -Later in the examination, when the patient sits up, listen also in the costovertebral angles. -Epigastric bruits confined to systole are normal. -A bruit in one of these areas that has both systolic and diastolic components strongly suggests renal artery stenosis as the cause of hypertension. -Four percent to 20% of healthy individuals have abdominal bruits.53 -Listen for bruits over the aorta, the iliac arteries, and the femoral arteries, as illustrated. -Bruits with both systolic and diastolic components suggest the turbulent blood flow from atherosclerotic arterial disease. -Listen over the liver and spleen for friction rubs. -Friction rubs are present in hepatoma, gonococcal infection around the liver, splenic infarction, and pancreatic carcinoma.

Assessing Percussion Tenderness of the Kidneys (book)

book: -If you find tenderness when examining the abdomen, also check each costovertebral angle. -Pressure from your fingertips may be enough to elicit tenderness; if not use fist percussion. -Place the ball of one hand in the costovertebral angle and strike it with the ulnar surface of your fist. -Use enough force to cause a perceptible but painless jar or thud. -Pain with pressure or fist percussion suggests pyelonephritis but may also have a musculoskeletal cause. -To save the patient from repositioning, integrate this assessment into your examination of the posterior lungs or back.

Assessing possible peritonitis (book)

book: -Inflammation of the parietal peritoneum, or peritonitis, signals an acute abdomen.[54] -Signs of peritonitis include a positive cough test, guarding, rigidity, rebound tenderness, and percussion tenderness.[53] -Even before palpation, ask the patient to cough and identify where the cough produces pain. -Then palpate gently, starting with one finger then with your hand, to localize the area of pain. -As you palpate, check for guarding, rigidity, and rebound tenderness. -Guarding is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted. -Rigidity is an involuntary reflex contraction of the abdominal wall that persists over several examinations. Assess for 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. -When positive, these signs roughly double the likelihood of peritonitis; rigidity makes peritonitis almost four times more likely.53 -Causes include appendicitis, cholecystitis, and a perforation of the bowel wall.

Localized Bulges in the Abdominal Wall (book) a. Umbilical Hernia b. Diastasis Recti c. Incisional Hernia d. Epigastric Hernia e. Lipoma

book: -Localized bulges in the abdominal wall include ventral hernias (defects in the wall through which tissue protrudes) and subcutaneous tumors such as lipomas. -The more common ventral hernias are umbilical, incisional, and epigastric. -Hernias and a rectus diastasis usually become more evident when the patient raises head and shoulders from a supine position. a. 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 to 2 years. b. Separation of the two rectus abdominis muscles, through which abdominal contents form a midline ridge when the patient raises head and shoulders. Often seen in repeated pregnancies, obesity, and chronic lung disease. It has no clinical consequences. c. 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. d. A small midline protrusion through a defect in the linea alba occurs between the xiphoid process and the umbilicus. With the patient's head and shoulders raised (or with the patient standing), run your fingerpad down the linea alba to feel it. e. 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 it. The tumor typically slips out from under it.

Assessing Percussion Tenderness of a Nonpalpable Liver (book)

book: -Place your left hand flat on the lower right rib cage and gently strike your hand with the ulnar surface of your right fist. -Ask the patient to compare the sensation with that produced by a similar strike on the left side. -Tenderness over the liver suggests inflammation, as in hepatitis, or congestion, as in heart failure.

Functional Incontinence (book)

book: -This is a functional inability to get to the toilet in time because of impaired health or environmental conditions. -Problems in mobility resulting from weakness, arthritis, poor vision, or other conditions. -Environmental factors such as an unfamiliar setting, distant bathroom facilities, bed rails, or physical restraints Incontinence on the way to the toilet or only in the early morning -The bladder is not detectable on physical examination. -Look for physical or environmental clues to the likely cause.

Deep palpation (Book)

book: -This is usually required to delineate abdominal masses. -Again using the palmar surfaces of your fingers, press down in all four quadrants. -Identify any masses; note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or pressure from the examining hand. -Correlate your palpable findings with their percussion notes. -Abdominal masses may be categorized in several ways: physiologic (pregnant uterus), inflammatory (diverticulitis of the colon), vascular (an abdominal aortic aneurysm), neoplastic (colon cancer), or obstructive (a distended bladder or dilated loop of bowel).

Palpation of the Right Kidney (book)

book: -To capture the right kidney, return to the patient's right side. -Use your left hand to lift up from the back, and your right hand to feel deep in the right upper quadrant. -Proceed as before. -A normal right kidney may be palpable, especially when the patient is thin and the abdominal muscles are relaxed. It may be slightly tender. -The patient is usually aware of a capture and release. -Occasionally, a right kidney is located more anteriorly and must be distinguished from the liver. -The edge of the liver, if palpable, tends to be sharper and extend farther medially and laterally. -It cannot be captured. The lower pole of the kidney is rounded. -Causes of kidney enlargement include hydronephrosis, cysts, and tumors. -Bilateral enlargement suggests polycystic kidney disease.

Hep A (book)

book: -Transmission is fecal/oral. - Fecal shedding, followed by poor hand washing, causes contamination of water and foods, leading to infection of household and sexual contacts. -Infected children are often asymptomatic, contributing to spread of infection. -The Centers for Disease Control and Prevention (CDC) recommends vaccination for all children at age 1 year and for groups at increased risk—travelers to endemic areas, male-male partners, injection and illicit drug users, and persons with chronic liver disease including hepatitis B or C. -For immediate protection and prophylaxis for household contacts and travelers, immune serum globulin can be administered within 2 weeks of contact and before travel. -Advise washing hands with soap and water before bathroom use, changing diapers, and preparing and eating food.[31]

Hep B (book)

book: -causes more serious threats to patient health. -Approximately 95% of infections in healthy adults are self-limited, with elimination of the virus and development of immunity. -Risk of chronic infection is highest when the immune system is immature, occurring in 90% of infected infants and 30% of children infected before age 5 years.[32],[33] -Fifteen percent to 25% of adults infected after childhood die prematurely from cirrhosis or liver cancer; over 70% are asymptomatic until liver disease is advanced. -The CDC recommends screening of all pregnant women and universal vaccination for all infants beginning at birth. -For adults, recommendations for vaccination now include high-risk groups, as well as expanded programs in high-risk settings.[34] -Recommendations for Vaccination: High-Risk Groups and Settings -Sexual contacts, including sex partners for those already infected, people with more than one sex partner in the prior 6 months, people seeking evaluation and treatment for sexually transmitted infections, and men having sex with men -People with percutaneous or mucosal exposure to blood, including injection drug users, household contacts of antigen-positive persons, residents and staff of facilities for the developmentally disabled, health care workers, and people on dialysis -Others, including travelers to endemic areas, people with chronic liver disease and HIV infection, and people seeking protection from hepatitis B infection -All adults in high-risk settings, such as STI clinics, HIV testing and treatment programs, drug-abuse treatment programs and programs for injection drug users, correctional facilities, programs for men having sex with men, chronic hemodialysis facilities and end-stage renal disease programs, and facilities for people with developmental disabilities -Adults in primary care and specialty settings, in at-risk groups or requesting the hepatitis B vaccine even without acknowledging a specific risk factor -Adults in occupational exposure settings, in occupations involving exposure to blood or other potentially infectious body fluids

Other interventions for reducing risk of colorectal cancer (book)

book: -diets high in fat and low in calcium, folate, fiber, and fruits and vegetables increase risk for colorectal cancer; -There is stronger evidence that aspirin, nonsteroidal anti-inflammatory drugs, and postmenopausal estrogen-progesterone therapy reduce the incidence of colorectal cancer and adenomas.[50],[51] -However, both the National Cancer Institute and the USPSTF recommend against these interventions due to increased risk of gastrointestinal bleeding and of breast cancer, coronary heart disease, and thromboembolic events, respectively.[52]

Screening for Colorectal Cancer (Book)

book: -the third most common cancer in both men and women, and it causes almost 10% of deaths from cancer.[38] -More than 90% of cases occur after age 50, primarily from neoplastic changes in adenomatous polyps; only about a third of cases have identifiable high-risk factors.[39] -Incidence rates are decreasing, except in adults younger than 50 years who fall outside the current age threshold for screening. -Overall mortality rates are declining, reflecting improvements in early detection and treatment. -However, mortality rates in African Americans are double those of other ethnic groups. -Since population screening rates continue to lag at only 60%, the USPSTF in 2008 conducted a detailed review of newer screening modalities that might expand screening options and availability.[40],[41] -The USPSTF concluded that several high-sensitivity fecal screening tests are reasonable substitutes for Hemoccult testing, but found insufficient evidence to assess fecal DNA testing or radiation exposure and test performance of computed tomography colonography. -The USPSTF established new age cutoffs for screening, summarized below. -Assess risk: Begin screening at age 20 years. -If high risk, refer for more complex management. - If average risk at age 50 (high-risk conditions absent), offer the screening options listed. -Common high-risk conditions (25% of colorectal cancers) -Personal history of colorectal cancer or adenoma -First-degree relative with colorectal cancer or adenomatous polyps -Personal history of breast, ovarian, or endometrial cancer -Personal history of ulcerative or Crohn's colitis -Hereditary high-risk conditions (6% of colorectal cancers) -Familial adenomatous polyposis -Hereditary nonpolyposis colorectal cancer -Screening recommendations—U.S. Preventive Services Task Force 2008 -Adults age 50 to 75 years—options -High-sensitivity fecal occult blood testing (FOBT) annually -Sigmoidoscopy every 5 years with FOBT every 3 years -Screening colonoscopy every 10 years -Adults age 76 to 85 years—do not screen routinely, as gain in life-years is small compared to colonoscopy risks, and screening benefits not seen for 7 years; use individual decision making if screening for the first time -Adults older than age 85—do not screen, as "competing causes of mortality preclude a mortality benefit that outweighs harms" -In 2008, the American Cancer Society Colorectal Cancer Advisory Group, consisting of the American Cancer Society, the U.S. Multi-Society Task Force on Colorectal Cancer, and the American College of Radiology, also issued screening guidelines supporting double-contrast barium enema or computed tomography colonography every 5 years and fecal DNA testing.[42] -When adenomas are detected during screening, screening intervals generally narrow to 3 to 5 years. -For patients who have first-degree relatives with colorectal cancer or adenomatous polyps, screening often begins at age 40 or 10 years before the youngest case in the affected family. -Screening tests vary in sensitivity and specificity. -Colonoscopy, which visualizes the entire colon, is considered the highest standard, with a sensitivity and specificity of 90% and 98% when combined with biopsy.[43] -In individuals with adenomas, colonoscopy is associated with a 76% to 90% risk reduction for colorectal cancer, particularly for cancer in the left colon and rectum.[44] -Colonoscopy misses 10% of adenomas ≥6 mm and 12% of adenomas ≥12 mm. -Risk of perforation is 3.8 per 10,000 procedures.[40],[41] -For flexible sigmoidoscopy with biopsy, sensitivity for large distal adenomas or cancer is 88% to 98% and specificity is over 92%. -FOBT is 50% sensitive as a single test but 90% sensitive when used in annual screening program, with a specificity of 90%. - In a recent study, high-sensitivity FOBT and fecal DNA shared a sensitivity of 20% and similar specificities.[45] For best results, high-sensitivity FOBT should involve at-home collection of two stool samples per card from three consecutive bowel movements, or a total of six specimens over a 2- to 3-day period. - A single specimen is inadequate due to sensitivity of only 5%.[46] -Any positive specimen warrants a follow-up colonoscopy. Colorectal cancer is the second leading cause of death from malignancies in theUnited States. Over half are located in the rectosigmoid region and are typicallyadenocarcinomas. Risk factors include a history of polyps, positive family historyof colon cancer or familial polyposis, ulcerative colitis, granulomatous colitis,and a diet low in fiber and high in animal protein, fat, and refined carbohydrates.Signs and SymptomsThe cancer may be present for several years before symptoms appear. Complaintsinclude fatigue, weakness, weight loss, alternating constipation and diarrhea, a change in the caliber of stool, tenesmus, urgency, and hematochezia. Physicalexamination is usually normal except in advanced disease, when the tumor canbe palpated or if hepatomegaly is present owing to metastatic disease.Diagnostic StudiesStool for occult blood is recommended, and a colonoscopy is diagnostic. Rec-ommended laboratory studies include a CBC and carcinoembryonic antigen(CEA) test. A positron emission tomography (PET) scan may be valuable fortumor origin and metastasis.

a. Bowel Sounds (book) b. bruits c. venous hum d. friction rubs book

book: a. -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 minutes or even longer. -High-pitched tinkling sounds suggest intestinal fluid and air under tension in a dilated bowel. -Rushes of high-pitched sounds coinciding with an abdominal cramp indicate intestinal obstruction. b. A hepatic suggests carcinoma of the liver or alcoholic hepatitis. Arterial with both systolic and diastolic components suggest partial occlusion of the aorta or large arteries. Partial occlusion of a renal artery may explain hypertension. c. rare. It is a soft humming noise with both systolic and diastolic components. It indicates increased collateral circulation between portal and systemic venous systems, as in hepatic cirrhosis. d. rare. They 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.

Nocturia (book)

book: -With High Volumes Most types of polyuria (see p. 445) -Decreased concentrating ability of the kidney with loss of the normal decrease in nocturnal urinary output -Chronic renal insufficiency due to a number of diseases -Possibly other symptoms of renal insufficiency -Excessive fluid intake before bedtime -Habit, especially involving alcohol and coffee -Fluid-retaining, edematous states. -Dependent edema accumulates during the day and is excreted when the patient lies down at night. -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 reaccumulates in the body. -With Low Volumes Frequency -Voiding while up at night without a real urge, a "pseudofrequency" -Insomnia -refers to urinary frequency at night, sometimes defined as awakening the patient more than once; urine volumes may be large or small. -Clarify the patient's daily fluid intake. -Note any change in nocturnal voiding patterns and the number of trips to the bathroom. -Abnormally high renal production of urine suggests polyuria. -Frequency without polyuria during the day or night suggests bladder disorder or impairment to flow at or below the bladder neck.

Palpation of Liver

video: hooking technique - take fingers, hook them under neath costal margins, underneath ribs, take a deep breath, feel liver border as it bumps against my fingers book: -Place your left hand behind the patient, parallel to and supporting the right 11th and 12th ribs and adjacent soft tissues below. -Remind the patient to relax on your hand if necessary. -By pressing your left hand upward, the patient's liver may be felt more easily by your other hand. -Place your right hand on the patient's right abdomen lateral to the rectus muscle, with your fingertips well below the lower border of liver dullness. -Some examiners like to point their fingers up toward the patient's head, whereas others prefer a somewhat more oblique position, as shown on the next page. - In either case, press gently in and up. -Ask the patient to take a deep breath. -Try to feel the liver edge as it comes down to meet your fingertips. -If you feel it, lighten the pressure of your palpating hand slightly so that the liver can slip under your finger pads and you can feel its anterior surface. -Note any tenderness. -If palpable at all, the normal liver edge is soft, sharp, and regular, with a smooth surface. -The normal liver may be slightly tender. -Firmness or hardness of the liver, bluntness or rounding of its edge, and irregularity of its contour suggest an abnormality of the liver. -On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line. -Some people breathe more with the chest than with the diaphragm. -It may be helpful to train such a patient to "breathe with the abdomen," thus bringing the liver, as well as the spleen and kidneys, into a palpable position during inspiration. -An obstructed, distended gallbladder may form an oval mass below the edge of the liver and merge with it. The merged area is dull to percussion. -In order to feel the liver, you may have to alter your pressure according to the thickness and resistance of the abdominal wall. -If you cannot feel it, move your palpating hand closer to the costal margin and try again. -The edge of an enlarged liver may be missed by starting palpation too high in the abdomen, as shown above. -Try to trace the liver edge both laterally and medially. -Palpation through the rectus muscles, however, is especially difficult. -Describe or sketch the liver edge, and measure its distance from the right costal margin in the midclavicular line. -The "hooking technique" may be helpful, especially when the patient is obese. -Stand to the right of the patient's chest. -Place both hands, side by side, on the right abdomen below the border of liver dullness. -Press in with your fingers and up toward the costal margin. -Ask the patient to take a deep breath. -The liver edge shown below is palpable with the fingerpads of both hands.