NR 509 Final week 5 Abdomen and GU

Painful urination accompanies

cystitis (bladder infection), urethritis, and urinary tract infections, bladder stones, tumors, and, in men, acute prostatitis. Women report internal burning in urethritis, and external burning in vulvovaginitis.

1.Where do the Kidneys lie in the abdomen 2. What is costal vertrebral angel of Tenderness

1. The kidneys lie posteriorly in the abdominal cavity behind the peritoneum (retroperitoneal). 2. defines where to elicit for kidney tenderness, called costovertebral angle tenderness.

McBurney's Point

1. To test McBurney's point, with the client in a supine position, 2. slowly apply pressure over McBurney's point and quickly release. 3. If the client experiences severe pain when the pressure is released, it can indicate acute appendicitis.

Urinary tract disorders can often cause flank pain, which is__________. ________caused by distension of the________________

1. Viseral Pain 2. Kidney

Dysuria

- Pain or burning sensation with urination - Often associated with bladder infections, urinary tract infections, or bladder stones

What causes Referred Pain

-Pain caused at sites that are innervated at the same level, but distant, from the primary problem -Palpation does not result in tenderness

Suprapubic Pain

-Pain is often dull and pressure-like -Often associated with a bladder disorder

Normal Abdominal Examination

1. Abdomen is soft, symmetric, and non-tender without distention. 2. Bowel sounds are present and active in all four quadrants 3. No masses, hepatomegaly, or splenomegaly. 4. No visible lesions or scars 5. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. 6. Spleen and kidneys not felt. 7. No costovertebral angle (CVA) tenderness 8. Umbilicus is midline without herniation.

Techniques for Examination of the ABDOMEN

1. Ensure the client is in a comfortable and supine position with arms to their sides 2. has an empty bladder 3. Ask the client to point to any areas of pain and examine those areas last 4. first inspect, then auscultate, palpate, and percuss. 5. When assessing the abdomen, the liver, spleen, kidney, and bladder should also be percussed

Things about Hepatitis B

1. Hepatitis B is transmitted through contact with infectious blood or body fluids through sex, puncture through the skin (i.e., needles), or an infant can contract it during birth. 2. All infants, unvaccinated children, and people who are at elevated risk for exposure are recommended to receive the vaccination

Things about Hepatitis A

1. a highly contagious short-term liver infection spread from person to person or by consuming contaminated food or drinks 2. The best prevention is the hepatitis A vaccine, recommended for all children, people at increased risk for hepatitis A, and people at increased risk for severe disease from hepatitis A

Sudden distension of the ureter and renal pelvis from stones can cause__________ ________which is a ________ ________ that comes and goes and radiates around the trunk into the lower abdomen.

1. ureteral colic 2. sharp pain

Murphy's Sign

1.Patient is lying Suppine 2. Ask the Patient to Exhale while palpating the gall bladder are medial to the midclavical LINE 3. Next Now ask the pateint to take a deep breath so the gall bladder is pushed down against the examiner 4. If Cholecystitis is present patient will experience a SHARP and SUDDEN pain causing them to abruptly seize inhalation. - A positive Murphy sign can indicate acute cholecystitis.

Polyuria refers to a significant increase in

24-hour urine volume, roughly defined as exceeding 3 L.

Dominique, a 36-year-old female, presents to the NP with a chief complaint of painful urination. The client reports having frequent, urgent, and painful urination that began two days ago. Since yesterday, the client has had a fever of up to 102F. The client rates flank pain 7/10. Current vital signs: temperature 101F, pulse 110, respiratory rate 16, and blood pressure 120/80. Which finding should the NP identify as the most significant active problem? A-dysuria, frequency, urgency B-fever C-flank pain D-tachycardia

A-dysuria, frequency, urgency Rationale: The most significant active problem is dysuria, frequency, and urgency. The flank pain, fever, and tachycardia are findings that are likely related to dysuria, frequency, and urgency.

Mateo, a 29-year-old male, presents to the NP with a complaint of blood in his urine (hematuria). Which are priority assessment questions the nurse practitioner (NP) should ask? Select all that apply. A. "Have you recently had a sore throat?" B. "Have you been exposed to any toxic substances at work or home?" C. "Do you have to frequently urinate?" D. "Do you have any pain?" E. "When did you first see blood in your urine?" F "Have you recently had any injuries that impacted your kidneys?" G "How much blood is in your urine?"

A. "Have you recently had a sore throat?" B. "Have you been exposed to any toxic substances at work or home?" C. "Do you have to frequently urinate?" D. "Do you have any pain?" E. "When did you first see blood in your urine?" F "Have you recently had any injuries that impacted your kidneys?" G "How much blood is in your urine?" Rationale: These are all relevant questions related to hematuria. Causes of blood in the urine range from infection, kidney stones, trauma, disease, or ingested substances. Strep throat, if not treated, can also result in kidney problems.

Painless loose or watery stools that last less than 14 days' duration: a. persistent diarrhea b. acute diarrhea c. chronic diarrhea

ACUTE DIARRHEA-

Flank pain, fever, and chills signal

Acute pyelonephritis

medication-induced constipation

Anticholinergic agents, antidepressants, calcium-channel blockers, calcium and iron supplements, and opioids

Mateo, a 29-year-old male, presents to the NP with a complaint of blood in his urine (hematuria). The NP prepares to complete a focused assessment. Which are essential for the NP to assess? Select all that apply. A) central nervous system B)throat C)lungs D)abdomen E) Neck

B)throat D)abdomen E) Neck Rationale: The NP must assess the throat, neck, and abdomen to rule out any redness or exudate in the throat, any swollen lymph nodes in the neck, and any tenderness or masses in the abdomen.

Right Lower Quadrant "The Ape Acknowledged Right Consequences"

Cecum Appendix Ascending colon Terminal ileum Right ovary

Victor, a 55-year-old male, presents with a chief complaint of abdominal pain. The NP diagnoses the client with acute pancreatitis. Which ICD-10-CM Diagnosis Code should the NP select? A. K85 acute pancreatitis B. K85.2 alcohol-induced acute pancreatitis C. K85.9 acute pancreatitis, unspecified D. K85.20 alcohol-induced acute pancreatitis without necrosis or infection

D. K85.20 alcohol-induced acute pancreatitis without necrosis or infection

1. Victor, a 55-year-old male, presents with a chief complaint of abdominal pain. 2. The client reports having progressively worsening nausea, vomiting, and epigastric abdominal pain rated 7/10 that started 3 days ago. The NP assesses that the client has mild abdominal distension and hypoactive bowel sounds. The client also has a history of alcohol abuse. Which finding should the NP identify as the most significant active problem? A. hypoactive bowel sounds B. mild abdominal distension C. nausea and vomiting D. epigastric abdominal pain

D. epigastric abdominal pain Rationale: The most significant active problem is epigastric abdominal pain. The abdominal distension, nausea and vomiting, and hypoactive bowel sounds are all findings related to the epigastric abdominal pain.

Regurgitation is a common symptom of

GERD

obstruct the common bile duct cause

Gallstones or pancreatic, cholangio-, or duodenal carcinoma

An overweight 26-year-old public servant presents to the Emergency Department with 12 hours of intense abdominal pain, light-headedness, and a fainting episode that finally prompted her to seek medical attention. She has a strong family history of gallstones and is concerned about this possibility. She has not had any vomiting or diarrhea. She had a normal bowel movement this morning. Her β-human chorionic gonadotropin (β-hCG) is positive at triage. She reports that her last period was 10 weeks ago. Her vital signs at triage are pulse, 118; blood pressure, 86/68; respiratory rate, 20/min; oxygen saturation, 99%; and temperature, 37.3ºC orally. The clinician performs an abdominal exam prior to her pelvic exam and, on palpation of her abdomen, finds involuntary rigidity and rebound tenderness. What is the most likely diagnosis? a. Ruptured tubal (or ectopic) pregnancy b. Acute cholecystitis c. Ruptured appendix d. Perforated bowel wall e. Ruptured ovarian cyst

Good! a. Ruptured tubal (or ectopic) pregnancy Rationale: The constellation of abdominal pain, syncope, tachycardia, hypotension, positive β-hCG, and findings suggestive of peritoneal inflammation/irritation strongly suggest a ruptured ectopic pregnancy with significant intra-abdominal bleeding leading to peritoneal signs. This case is emergent and requires immediate treatment of her hypotension and presumed blood loss as well as gynecological consult for emergent surgery. Ruptured ectopic pregnancies can lead to life-threatening intra-abdominal bleeding. Although acute cholecystitis, ruptured appendix, bowel wall perforation, and ruptured ovarian cyst are all possibilities, the positive β-hCG testing and her unstable vital signs make ruptured ectopic pregnancy more likely.

Polyuria

High volume of urine Often associated with diabetes

Rebound Tenderness

If the client experiences pain during palpation of the abdomen, ask if the pain occurs when pressure is exerted downward or released. Rebound tenderness causes pain when the pressure is released and can indicate peritoneal inflammation.

Urgency

Intense desire to void; sometimes resulting in incontinence Often associated with a urinary tract infection

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

LIVER DISEASE

Right Upper Quadrant "Lovely Gorilla Decided to Have Hairy Pickles"

Liver Gallbladder Duodenum Pylorus Hepatic flexure of colon Head of pancreas

49-year-old male with well-controlled HIV undergoes a proctoscopic examination as routine screening for anal cancer. The patient is asymptomatic and specifically denies complaints of frequent urination (frequency), large volume of urination (polyuria), or repeated urination at night (nocturia). Under direct visualization, the clinician observes a clear, circumferential demarcation of proximal versus distal tissue. This demarcation was not palpable on digital rectal examination (DRE) prior to proctoscopy. What is the most likely origin of this finding? a. Pathological constriction of the anal canal b. Normal anatomy of the mucosal surface c. Carcinoma d. Valve of Houston e. External anal sphincter

Normal anatomy of the mucosal surface Rationale: The circumferential border between the anal canal and rectum is visible on proctoscopic examination but is not palpable on DRE. This demarcation is known as the dentate or pectinate line. Pathological constriction of the anal canal is incorrect because the patient has no complaints regarding defecation, and this change in tissue between the anal canal and rectum is a normal finding. Carcinoma is incorrect because neoplastic tissue is unlikely to present as a regular, circumferential demarcation between tissues. Valve of Houston is incorrect because the valves of Houston are three inward foldings of the rectal wall; although they are palpable on deep DRE, they do not appear as distinct types of tissue on proctoscopic examination. External anal sphincter is incorrect because the internal and external anal sphincters are distal to the pectinate line and are not superficially visible on internal examination of the anal canal and rectum.

What causes Somatic Pain

Pain caused by inflammation of the peritoneum Pain may be localized or widespread Pain is steady, achy, and aggravated by movement

What Cause Viseral Pain

Pain caused by stretched or distended hollow organs Pain is difficult to localize Pain may be gnawing, cramping, or aching

severe diffuse abdominal pain with guarding and rigidity on examination. Patients may or may not have accompanying abdominal distention.

Peritonitis

Left Lower Quadrant "Lower Diarhhea Started"

Sigmoid colon Descending colon Left ovary

Left Upper Quadrant "Soon after Body Spasms Started"

Spleen Splenic flexure of colon Stomach Body and tail of pancreas

What is commonly present in older adult men and women ≥70 years can give rise to the sensation of difficulty swallowing food.

Xerostomia (insufficient saliva)

A 54-year-old male with a strong family history of breast and prostate cancer presents to his primary care provider to discuss prostate screening. His father died at age 73 years from prostate cancer that was not detected on routine digital rectal examinations (DREs), and he would like to minimize his chance of a similar occurrence. Which of the following is true regarding the anatomy and screening of the prostate by DRE? a. All three lobes of the prostate are palpable on DRE. b. The seminal vesicles are palpable distal to the prostate on DRE. c. The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE. d. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE. e. A prostate of 5 cm diameter without palpable nodes or masses represents a normal prostate examination.

The median lobe of the prostate is located anterior to the urethra and is not palpable on DRE. Rationale: Due to its location at the anterior aspect of the urethra, the median lobe of the prostate is not palpable on DRE, nor are small tumors in this area. All three lobes of the prostate are palpable on DRE is incorrect because the median lobe of the prostate is not palpable on DRE, although the two lateral lobes are palpable. The seminal vesicles are palpable distal to the prostate on DRE is incorrect because the seminal vesicles are proximal (not distal) to the prostate. They are generally not palpable on DRE. The median sulcus divides the lateral lobes from the median lobe and is palpable on DRE is incorrect because the median sulcus divides the lateral lobes from each other; it is palpable on examination. A prostate of 5 cm diameter without palpable nodes or masses represents a normal prostate examination is incorrect because, although a lack of nodes and masses is normal, a 5-cm prostate is larger than normal (which is closer to 2.5 cm diameter).

A 23-year-old woman comes to the respirology clinic for follow-up of her chronic sinusitis and bronchiectasis that is associated with a rare congenital condition called Kartagener syndrome. The preceptor notes that she has situs inversus and asks for a physical exam. Which of the following descriptions best fits with findings on the abdominal exam? a. Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant b. Protuberant abdomen that has scattered areas of tympany and dullness; stool is felt on palpation c. Liver dullness in the right upper quadrant that is displaced downward by the low diaphragm due to chronic obstructive pulmonary disease d. Dullness to percussion of the left lower anterior chest wall roughly at the anterior axillary line e. A change in percussion from tympany to dullness in the left lower anterior chest wall on inspiration

Tympany to percussion in the right upper quadrant, dullness to percussion of the left upper quadrant Rationale: Situs inversus is a rare condition in which organs are reversed and is associated with Kartagener syndrome. Thus, the stomach and gastric air bubble are on the right and liver dullness is on the left. A protuberant abdomen with scattered areas of dullness and tympany and stool on palpation is likely constipation. None of these findings suggest organ reversal. Liver dullness will occur in the left upper quadrant with organ reversal. Findings given in the remaining answer choices are both associated with splenomegaly with the spleen located in the left upper quadrant, which would not be the case for sinus inversus totalis.

Vomiting and nausea with constipation or obstipation (severe constipation with inability to pass both stool and gas) is indicative of

a bowel obstruction and warrants further imaging workup.

Diagnostic criteria for IBS is

a diagnosis of exclusion and requires intermittent pain for 12 weeks of the preceding 12 months with relief from defecation, change in frequency of bowel movements, or change in form of stool (loose, watery, pellet-like), linked to luminal and mucosal irritants that alter motility, secretion, and pain sensitivity.

A 76-year-old retired man with a history of prostate cancer and hypertension has been screened annually for colon cancer using high sensitivity fecal occult blood testing (FOBT). He presents for follow-up of his hypertension, during which the clinician scans his chart to ensure he is up to date with his preventive health care. He has a positive FOBT on one occasion at age 66 years and subsequently went for a colonoscopy. Internal hemorrhoids and sigmoid diverticuli were found on colonoscopy. He has no first-degree relatives with a history of colorectal cancer or adenomatous polyps. What are the U.S. Preventive Services Task Force (USPSTF) screening recommendations for this patient? a. Do not screen routinely b. Continue annual FOBT screening until age 80 years c. Continue annual FOBT screening until age 85 years d. Repeat colonoscopy this year e. Sigmoidoscopy every 5 years with FOBT every 3 years

a. Do not screen routinely Rationale: The USPSTF recommends not screening routinely. For most adults ages 76-85 years, the gain in life years is small compared to colonoscopy risks. It is advised to discuss individualized risks and benefits with the patient. Annual FOBT screening may continue until age 80-85 years if benefits to doing so outweigh risks for the individual patient; however, screening should not be routinely continued. In general, a life expectancy >7 years is necessary for screening to be potentially beneficial. There is no indication to repeat a colonoscopy given the absence of any cancerous or precancerous findings on his colonoscopy 10 years ago. Sigmoidoscopy every 5 years with FOBT every 3 years is a valid screening option, but again screening is not routinely recommended for patients age >75 years.

A 34-year-old female reports anal pain with defecation. She notes incidentally to this complaint that she has developed episodic abdominal discomfort and sores in her mouth. Anoscopic examination reveals anal fissures that appear to be her source of pain. Which of the following underlying conditions is the clinician most likely to find? a. Inflammatory bowel disease (IBD) b. Lymphogranuloma venereum c. Human papillomavirus (HPV) d. Gonorrhea cervicitis e. Primary syphilis

a. Inflammatory bowel disease (IBD) Rationale: Anal fissures are associated with the underlying condition of Crohn disease, which is one of the two IBDs (the other is ulcerative colitis). Anal fissures may have no underlying cause, although constipation is a common and benign condition that may lead to this problem. Lymphogranuloma venereum is incorrect because it is a sexually transmitted infection (STI) that may cause proctitis, but rarely anal fissures. HPV is incorrect because HPV strains contribute to cervical cancer, genital warts, and papillomatosus (an overabundance of genital warts in the anogenital area). Gonorrhea cervicitis is incorrect because although this STI may cause vaginal discharge, itching, and ascending infections in the uterus, it is unlikely to cause anal fissures. Primary syphilis is incorrect because the chancre of primary syphilis may cause proctitis, but it is unlikely to cause anal fissures.

Risk factors for AAA are

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

A 66-year-old client presents to the urgent care center with abdominal pain for three (3) days. What information collected during the health history is relevant to the client's chief complaint? B)recent travel to another state C)tonsillectomy at age 4 D)appendectomy at age 25 E)type 2 diabetes mellitus (DM) F)loratadine 10 mg daily for seasonal allergies G)three (3) vaginal deliveries H)osteoarthritis I)father - colon cancer

appendectomy at age 25 type 2 DM father- colon cancer Rational The NP must gather a clear health history and identify pertinent data to help direct the physical assessment. Pertinent health history related to abdominal complaints includes past abdominal surgeries or Cesarean deliveries, medical history including digestive system disease or type 2 diabetes, family history of digestive disease, travel history outside of the United States, recent hospitalizations, and medication use, particularly the use of antibiotics, laxatives, and opioids

RLQ pain or pain that migrates from the periumbilical region, combined with nausea, vomiting, and loss of appetite is suspicious for

appendicitis. In women, consider pelvic inflammatory disease (PID), ruptured ovarian follicle, and ectopic pregnancy.

3. A 63-year-old underweight administrative clerk with a 50-pack-year smoking history presents with a several month history of recurrent epigastric abdominal discomfort. She feels fairly well otherwise and denies any nausea, vomiting, diarrhea, or constipation. She reports that a first cousin died from a ruptured aneurysm at age 68 years. Her vital signs are pulse, 86; blood pressure, 148/92; respiratory rate, 16; oxygen saturation, 95%; and temperature, 36.2ºC. Her body mass index is 17.6. On exam, her abdominal aorta is prominent, which is concerning for an abdominal aortic aneurysm (AAA). Which of the following is her most significant risk factor for an AAA? a. Female gender b. History of smoking c. Underweight d. Family history of ruptured aneurysm e. Hypertension

b. History of smoking Rationale: History of smoking is her most significant risk factor for an AAA. Male gender, not female gender, is considered as risk factor. Underweight is not a risk factor for AAA. Family history of ruptured aneurysm is vague and could be a cerebral aneurysm. Further, her family history is in a first-degree cousin not a first-degree relative (biologic parents, siblings, and children). Hypertension could contribute to atherosclerosis, which is a risk factor. Further, a diagnosis of hypertension is not based on one elevated blood pressure reading.

An otherwise healthy 28-year-old lawyer presents to the Emergency Department with a 1-day history of severe abdominal pain. The emergency physician suspects appendicitis and general surgery is consulted. The resident believes the patient has signs of peritonitis on exam. Which of the following physical exam findings supports peritonitis? a. Voluntary contraction of the abdominal wall that persists over several examinations b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain c. Abdominal pain that increases with hip flexion d. Localized pain over McBurney point, which lies 2 inches from the anterior superior iliac spinous process on a line drawn from the umbilicus e. Pain with internal rotation of the right hip

b. Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly produces pain Rationale: Pressing down onto the abdomen firmly and slowly and withdrawing the hand quickly producing pain describes rebound tenderness, which, along with guarding and rigidity, is suggestive of peritonitis. Involuntary contraction rather than voluntary contraction of the abdominal wall that persists over several examinations describes rigidity. Abdominal pain that increases with hip flexion is not suggestive of peritonitis. In fact, patients with peritonitis tend to keep hips flexed to reduce stretch and irritation of the parietal peritoneum. They often walk bent forward at the hips for this reason. Localized pain over McBurney point is certainly suggestive of appendicitis, but not suggestive of peritonitis. Similarly pain with internal rotation of the right hip, or a positive obturator sign, suggests irritation of the psoas muscle due to an inflamed appendix, but not peritonitis.

A 49-year-old male nurse experiences fecal incontinence after a motor vehicle accident that left him paralyzed below the waist. He asks his rehabilitation physician about the control of this function in a person without his injuries. Which of the following is true regarding the muscle control of the anal sphincter? a. The internal anal sphincter is under voluntary control, whereas the external anal sphincter is under involuntary control. b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. c. Both internal and external anal sphincter are under voluntary control. d. Both internal and external anal sphincter are under involuntary control. e. Control of the anal sphincters is variable between individuals.

b. The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Rationale: The internal anal sphincter is under involuntary control, whereas the external anal sphincter is under voluntary control. Together, these two muscles hold the anal sphincter closed until the individual is ready to defecate.

A 49-year-old customer service representative presents to his gastroenterologist for follow-up of his long-standing inflammatory bowel disease (IBD). He was diagnosed with ulcerative colitis (UC) at age 37 years and has had irregular care for this condition since then. His sole colonoscopy was done at the time of diagnosis 12 years ago. His only relevant family history is of prostate cancer in his father; his mother and sisters are healthy. Which of the following is true about recommended screening for colon cancer in this patient? a. The patient should begin screening for colon cancer 10 years prior to the age of onset of his father's prostate cancer. b. The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer. c. The patient is due for routine age-based colon cancer screening by colonoscopy regardless of his risk factors. d. The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years. e. The patient's condition puts him at a high risk of bowel perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely.

b. The patient should undergo colonoscopy for his bowel condition, which confers risk of colon cancer. Rationale: The two forms of IBD (UC and Crohn disease) increase the risk of colon cancer and do warrant increased screening at shortened intervals. The patient should begin screening for colon cancer 10 years prior to the age of onset of his father's prostate cancer is incorrect because family history of breast, ovarian, or colon cancer increases an individual's risk of colon cancer, whereas family history of prostate cancer alone does not increase an individual's risk of colon cancer and thus does not indicate increased screening. (Of note, prostate cancer may rarely be a manifestation of the BRCA genetic mutation that would put this patient at higher risk for many types cancer, but this would usually be accompanied by a family history of many cancers, especially breast and ovarian cancer in the female line.) The patient is due for routine age-based colon cancer screening by colonoscopy regardless of his risk factors is incorrect because routine age-based screening by colonoscopy begins at age 50 years. Younger patients may require colonoscopy for diagnosis of symptomatic disease or for screening due to high-risk histories. The patient has a reassuring family history and thus needs no colon cancer screening until at least age 60 years is incorrect because even with a benign family history, routine colon cancer screening by colonoscopy, sigmoidoscopy, and/or fecal occult blood testing is recommended at age 50 years, not at age 60 years. The patient's condition puts him at a high risk of bowel perforation during colonoscopy, thus colon cancer screening should be deferred indefinitely is incorrect. Although risks and benefits should always be considered before any procedure, this patient's risks for colon cancer (and thus benefit from screening) outweigh his risks of a major adverse event from colonoscopy.

Nonspecific diffuse abdominal pain with abdominal distention, nausea, emesis, and lack of flatus and/or bowel movements is symptomatic of a

bowel obstruction

An otherwise healthy 31-year-old accountant presents to an outpatient clinic with a 3-year history of recurrent crampy abdominal pain that lasts for about 1-2 weeks each episode and is associated with onset of constipation. She describes infrequent, small hard stool that she finds very difficult to pass. She has tried to increase dietary fiber and water intake, but usually this is not sufficient and she resorts to over-the-counter laxatives, which she finds upset her stomach but do resolve the constipation. Symptoms typically gradually resolve with bowel movements. Which of the following is the most likely physiological mechanism for her constipation? a. A large, firm fecal mass in the rectum b. Decreased fecal bulk c. Functional change in bowel movement d. Spasm of the external sphincter e. Impairment of autonomic innervations

c. Functional change in bowel movement Rationale: Functional change in bowel movement is characteristic of irritable bowel syndrome (IBS). IBS is characterized by three patterns: diarrhea predominant, constipation-predominant, or mixed. Other functional causes for her constipation should be excluded prior to making this diagnosis. A large firm fecal mass in the rectum is characteristic of fecal impaction, which is common in debilitated, bedridden individuals. Decreased fecal bulk is characteristic of a diet low in fiber. This patient had not found that increasing fiber helps her constipation. Spasm of the external sphincter is associated with painful anal lesions, which this patient does not report. Impairment of autonomic innervations is characteristic of patients with multiple sclerosis, spinal cord injuries, and Hirschsprung disease. She has no known diagnosis that would increase suspicion of neurological impairment.

A 53-year-old African American advertising agent presents for discussion of his prostate cancer risk and possible screening for this disease. His father was diagnosed at age 82 years with prostate cancer but died recently at age 87 years from a myocardial infarction before the disease progressed. Family history also reveals that his mother died of ovarian cancer when he was age 10 years, and two of his maternal aunts had breast cancer. Which of the following is true about risk and screening for prostate cancer? a. The incidence of prostate cancer does not rise until age >65 years, thus this patient needs no screening at this time. b. Prostate cancer is always an aggressive neoplasm, thus the risks of overdiagnosis with screening is outweighed by the benefits of early case-finding. c. This patient is at an elevated risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider. d. This patient's race is a protective factor for prostate cancer, thus reassurance is the only intervention necessary. e. The patient's family history in the female line is irrelevant to his own risks and can be safely ignored in discussion of his risk for prostate cancer.

c. This patient is at an elevated risk of prostate cancer due to his family history, thus screening modalities should be discussed between the patient and provider. Rationale: This patient has a number of obvious risks: family history of prostate cancer (a first-degree relative with prostate cancer doubles or triples the risk of this disease in an individual), African American race, and an unusual family history of cancers that may be associated with the BRCA genetic mutation. Although prostate cancer screening techniques are controversial due to limited sensitivity and specificity, in this case, the risk of over- or underdiagnosis may be outweighed by the benefits of screening. The incidence of prostate cancer does not rise until age >65 years, thus this patient needs no screening at this time is incorrect. The incidence of prostate cancer rises sharply with each decade after age 50 years. Prostate cancer is always an aggressive neoplasm, thus the risks of overdiagnosis with screening is outweighed by the benefits of early case-finding is incorrect. Prostate cancer is very often an indolent disease, with many men dying of other age-related disorders before prostate cancer can evolve far enough to cause mortality. This patient's race is a protective factor for prostate cancer, thus reassurance is the only intervention necessary is incorrect. This patient's race (African American) puts him at increased (rather than decreased) risk for prostate cancer. As such, screening should be discussed, although the risks and benefits of screening for prostate are somewhat ambiguous as discussed above. The patient's family history in the female line is irrelevant to his own risks and can be safely ignored in discussion of his risk for prostate cancer is incorrect. Although prostate cancer alone in the family history is not a red flag for a serious genetic variation, this patient's family history in the female line is suspicious for the BRCA gene that is associated with a variety of cancers. Although the BRCA gene is not all that common in African American populations, this issue should still be addressed with appropriate screening recommended for both prostate cancer and the BRCA gene itself.

Involuntary voiding or lack of awareness suggests

cognitive/neurosensory deficits

Older adults, especially those with dementia, may exhibit _________ When they have a urinary tract infection.

confusion

A 64-year-old retired architect presents to his primary care provider with a magazine article about prostate cancer screening that states, "You should talk to your doctor about the ups and downs of prostate cancer screening." The patient hands this to the clinician and states, "Tell me about the ups and down of prostate screening." Which of the following is true about prostate cancer screening? a. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease. b. The prostate-specific antigen (PSA) effectively differentiates aggressively malignant prostate tumors from indolent cases. c. The prostate-specific antigen (PSA) cut-off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer. d. Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis. e. Most prostate cancers are palpable and symptomatic by the time they are biopsied, reducing the need for screening as patients can report symptoms.

d. Setting normal cut-offs for prostate-specific antigen (PSA) testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis. Rationale: Setting normal cut-offs for PSA testing relies on balancing the risk of overdiagnosis with the risk of underdiagnosis is a very common theme among screening tests: If the norms of a given test are set too tightly, chances are that true cases of the disease will be missed (loss of sensitivity). Conversely, setting looser norms captures more true positives but also captures more patients with normal variant results near the ends of the bell curve (loss of specificity). This problem is increased in screening tests in which there are numerous normal conditions that cause the target result; PSA testing for prostate cancer is notorious for this complication, as is the CA-125 tumor marker for ovarian cancer. Screening tests without clear norms are very problematic in the interpretation of results—a particularly frustrating factor in ovarian cancer screening in which most patients with the disease present at an advanced stage and the need for a good early screening test is clear. Regardless of sensitivity and specificity of testing modalities, screening for prostate cancer should always be ordered due to the malignant nature of the disease is incorrect because the decision to screen should be undertaken on a case-by-case basis with each individual patient. The PSA effectively differentiates aggressively malignant prostate tumors from indolent cases is incorrect because PSA has almost no role in differentiating indolent from aggressive prostate tumors—in fact, PSA can be elevated in conditions that are not cancerous at all, such as benign prostatic hyperplasia, urinary retention, and recent ejaculation. The PSA cut-off of 4.0 ng/ml is virtually 100% specific for aggressive prostate cancer is incorrect because, as above, the PSA is neither particularly sensitive nor specific for prostate cancer of any kind. Most prostate cancers are palpable and symptomatic by the time they are biopsied, reducing the need for screening as patients can report symptoms is incorrect because most prostate cancers identified via biopsy are nonpalpable and asymptomatic. Of note, screening for diseases that are symptomatic in early stages is rarely necessary, as patients can easily report symptoms before the disease becomes dangerous. Unfortunately, a large number of malignant diseases are asymptomatic until local spread or distant metastases have occurred—making effective screening techniques for asymptomatic patients important to long-term survival rates. In the case of prostate cancer, a test that effectively separates indolent from aggressive lesions is ideal but not yet forthcoming.

A 62-year-old male who is undergoing evaluation for possible prostate cancer strongly declines a rectal examination, stating that, "Some trainee once did that and it hurt badly." Which of the following is true about the innervation of the anus and rectum that may explain this patient's experience of discomfort? a. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the rectum the most likely source of this patient's discomfort. b. The rectum contains primarily somatic nerves, whereas the anal canal contains primarily visceral nerves, making the anus the most likely source of this patient's discomfort. c. Proximal to the dentate line, the lower gastrointestinal tract is innervated primarily by somatosensory nerves, making the proximal reach of the examination the most likely site of this patient's pain. d. The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area. e. The dentate or pectinate line does not differentiate any neurological input, making the area either proximal or distal to the line equally responsible for this patient's discomfort.

d. The anal canal has a rich somatosensory innervation, making poorly directed examinations painful in this area. Rationale: The anal canal is characterized by somatosensory innervation, whereas the rectum has little such nerve supply. Thus, the patient's discomfort likely occurred due to the stretch of the anal canal rather than disruption of the more proximal rectal mucosa.

Medical diseases that causes constipation

diabetes, hypothyroidism, hypercalcemia, hypomagnesemia, multiple sclerosis, Parkinson disease, and systemic sclerosis

if fullness or early satiety, consider....

diabetic gastroparesis, anticholinergic medications, gastric outlet obstruction, gastric cancer

Thin pencil like stool occurs in an obstructing apple core lesion of the ....

distal colon.

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

diverticulitis.

In bladder infection, pain in the lower abdomen is typically

dull and pressure-like 1. chronic bladder distention is usually painless.

A 46-year-old executive who is obese and otherwise healthy presents to a family medicine clinic with a 3-month course of recurrent severe abdominal pain that usually resolves on its own after a few hours. Her last episode was prolonged lasting 6 hours, and she is frustrated that she has had to leave or miss work on three separate occasions. She would like a diagnosis and the problem fixed. Which symptoms or signs would be most suggestive of a diagnosis of biliary colic? a. Exacerbating factor includes alcohol intake b. Positive McBurney point tenderness c. Poorly localized periumbilical pain d. Vomiting of bile e. Associated right shoulder pain

e. Associated right shoulder pain Rationale: Pain with biliary colic can produced referred pain to the right shoulder or scapula due to irritation of the right hemidiaphragm. Alcohol is not an exacerbating factor for biliary colic. Positive McBurney point tenderness is associated with acute appendicitis. The Murphy sign is associated with acute cholecystitis. Poorly localized periumbilical pain is associated with early stages of acute appendicitis. Vomiting bile is associated with small bowel obstruction.

A third-year medical student rotating on the internal medicine service performs a digital rectal examination (DRE) on a 56-year-old female patient. The patient has been admitted for suspicion of a myocardial infarction, and confirmation that there is no blood in the stool is required before anticoagulation can be started. The student reports that the fecal occult blood test was negative but notes that he palpated a structure through the anterior rectum that he could not identify. The attending physician confirms normal anatomy and reviews with the student that the most likely identity of the structure palpable is which of the following? a. Sacrum b. Pectinate line c. Uterine fundus d. Prostate e. Cervix

e. Cervix Rationale: The cervix is often palpable through the anterior rectal wall on DRE of female patients. Sacrum is incorrect because it lies posterior (not anterior) to the rectum. Pectinate line is incorrect because it lies circumferentially in the rectum. It is visible on proctoscopic examination but is not palpable on digital rectal examination. Uterine fundus is incorrect because, although the cervix is palpable through the anterior rectal wall on digital examination, the fundus of the uterus is generally too proximal to palpable. Prostate is incorrect because this patient is female, making the presence of a prostate notably unlikely.

A 58-year-old man with a history of diabetes and alcohol addiction has been sober for the last 10 months. He presents with a 4-month history of increasing weakness, recurrent epigastric pain radiating to his back, chronic diarrhea with stools 6-8 times daily, and weight loss of 18 lb over 4 months. What is the mechanism of his most likely diagnosis? a. Helicobacter pylori infection b. Inflammation of the gallbladder c. Inflammation of colonic diverticulum d. Reduced blood supply to the bowel e. Fibrosis of the pancreas

e. Fibrosis of the pancreas Rationale: Fibrosis of the pancreas is associated with chronic pancreatitis. Chronic pancreatitis leads to fibrosis and decreased pancreatic function, which causes diarrhea from pancreatic enzyme insufficiency and diabetes mellitus. H. pylori infection may cause peptic ulcer disease and dyspepsia, which is not usually associated with diarrhea. Inflammation of the colonic diverticulum is diverticulitis and typically causes left-lower-quadrant pain, fever, constipation, and sometimes diarrhea. It is typically an acute disease. Reduced blood supply to the bowel characterizes mesenteric ischemia. It can be acute or chronic in presentation and causes diffuse abdominal pain, vomiting, diarrhea, or constipation. It is associated with older age and vascular risk factors such as coronary artery disease.

2. A 63-year-old janitor with a history of adenomatous colonic polyps presents for a well visit. Basic labs are performed to screen for diabetes mellitus and dyslipidemia. Electrolytes and liver enzymes were also measured. His labs are all normal expect for moderate elevations of aspartate aminotransferase, alanine aminotransferase, γ-glutamyl transferase, and alkaline phosphatase as well as a mildly elevated total bilirubin. He presents for a follow-up appointment and the clinician performs an abdominal exam to assess his liver. Which of the following findings would be most consistent with hepatomegaly? a. Liver span of 11 cm at the midclavicular line b. Liver span of 8 cm at the midsternal line c. Dullness to percussion over a span of 11 cm at the midclavicular line d. Dullness to percussion over a span of 8 cm at the midsternal line e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration

e. Liver palpable 3 cm below the right costal margin, mid clavicular line, on expiration Rationale: The liver being palpable 3 cm below the right costal margin, midclavicular line, would be considered normal on inspiration when the liver is pushed down into the abdominal cavity on inspiration, but is abnormal on expiration. Findings to support hepatomegaly would be more convincing if, by percussion, the liver span was >12 cm at the midclavicular line. For patients with obstructive lung disease, air trapping in the lungs may displace the liver downwards into the abdominal cavity. The liver span and dullness to percussion refer to the same measurement. Measurements of 6-12 cm at the mid-clavicular line and 4-8 cm at the midsternal line are considered normal.

A 45-year-old female executive reports to her primary care provider that she has recently experienced a change in the patterns of her bowel movements. She expresses a great concern as her family history includes a maternal aunt who died of colon cancer at age 49 years; her mother has had colonoscopies every 3 years with numerous adenomatous polyps removed. Which of the following historical elements would be the most concerning for colon cancer in this patient? a. Long-term history of hemorrhoids b. Recent history of black, tarry stools c. Remote history of anal pruritus d. New-onset anal fissures e. Recent onset of small-caliber stools

e. Recent onset of small-caliber stools Rationale: Small-caliber stools may be caused by narrowing of the colon due to a mass. Colonoscopy should be performed to rule out such pathology, especially in a patient with such a notable family history. Long-term history of hemorrhoids is incorrect because hemorrhoids are not directly associated with colon cancer. However, bleeding from hemorrhoids should be evaluated carefully in high-risk patients, as bleeding attributed to hemorrhoids is virtually indistinguishable from fresh blood from the lower gastrointestinal (GI) tract. A low threshold for ordering colonoscopy should be maintained in patients with risk factors for colon cancer, including age >50 years and strong family history. Recent history of black, tarry stools is incorrect because black, tarry stools ("melena") generally represent blood in the GI tract, whereas melanotic stools usually have a source in the upper tract, not the colon. Although this should be thoroughly investigated, it is not likely to have colon cancer as a source. Remote history of anal pruritus is incorrect because it may be due to hemorrhoids, proctitis, receptive anal intercourse, pinworms, and a variety of other sources. Anal pruritus is not typically associated with colon cancer. New-onset anal fissures is incorrect because anal fissures may be associated with constipation and Crohn disease, but they are not generally indicative of colon cancer.

Visceral periumbilical pain can be suggestive

early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum

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

esophageal stricture, Zenker diverticulum, or esophageal or gastric malignancy.

Hematemesis may accompany

esophageal/gastric varices gastritis peptic ulcer disease

An obstructed distended gallbladder may merge with the liver, forming a

firm oval mass below the liver edge and an area that is dull to percussion

Infants may exhibit generalized symptoms such as? when they have a urinary tract infection

fussiness, poor appetite, and fever

Dark urine indicates

impaired excretion of bilirubin into the GI tract

Stress incontinence arises from decreased. CAUSE

intraurethral pressure. CAUSE 1. if sudden coughing, sneezing, or laughing causes loss of urine usually in women after they have a baby 2. These problems are common in men with partial bladder outlet obstruction from benign prostatic hyperplasia or urethral stricture.

Change in bowel habits with a palpable mass warns of

late-stage colon cancer

Visceral pain in the RUQ

liver distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis or biliary pathology.

Painless jaundice points to

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

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

nephrolithiasis (renal stone

Causes of bladder distention

outlet obstruction from a urethral stricture or prostatic hyperplasia, medication side effects, and neurologic disorders such as stroke or multiple sclerosis

What is charistics of RENAL STONES

patients with colicky pain from a renal stone move around frequently trying to find a comfortable position

Diarrhea is common with use of which medications?

penicillins and macrolides, magnesium based antacids, metformin, and herbal or alternative meds

flank or back pain suggests

pyelonephritis

Flank pain, along with fever and chills, may indicate which 2 things

pyelonephritis or urinary tract infection

small-volume stools with tenesmus or diarrhea with mucus, pus, or blood occur in

rectal inflammatory conditions.

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

regurgitation

Some patients may not actually vomit but raise esophageal or gastric contents without nausea or retching, called

regurgitation

High-volume frequent watery stools are usually from the

small intestine

Visceral pain is often described as....

steady, achy, or dull pain

Oily residue, sometimes frothy or floating, occurs with

steatorrhea (fatty diarrheal stools) from malabsorption in celiac sprue, pancreatic insufficiency, and small bowel bacterial overgrowth.

Which Organs are not Palpable

stomach and much of the liver and spleen,

Nosocomial diarrhea is a

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

Renal or ureteral colic is caused by

sudden obstruction of a ureter, for example, from renal or urinary stones or blood clots

Extrahepatic jaundice arises from obstruction of

the extrahepatic bile ducts, most commonly the common bile ducts

Causes of polyuria include

the high fluid intake of psychogenic polydipsia and poorly controlled diabetes, the decreased secretion of antidiuretic hormone (ADH) of central diabetes insipidus, and the decreased renal sensitivity to ADH of nephrogenic diabetes insipidus.

Myoglobin from rhabdomyolysis can cause

tinge the urine pink in the absence of red cells. Flank

In men, painful urination without frequency or urgency suggests

urethritis

Urgency suggests

urinary tract infection (UTI) or irritation from possible urinary calculi. Frequency is common in UTI and bladder neck obstruction.

What is the characteristics of Somatic/parietal pain? Somatic or parietal pain originates from inflammation of the parietal peritoneum, called peritonitis,.

which can be localized or diffuse. It is a steady, aching pain that is usually more severe than visceral pain and more precisely localized over the involved structure. It is typically aggravated by movement or coughing. Patients with parietal pain usually prefer to lie still.

Carotenemia

yellow-orange color in light-skinned persons from large amounts of foods containing carotene,especially palms and soles, but not the sclera or mucous membranes