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74 Cards in this Set

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viseral pain

hollow organs contract


difficult to localize


cramping, aching, burning gnawing


n/v, sweating, pallor, restlessnes


Visceral periumblical pain early may signify

acute appendicitis


gradually will change to parietal pain in RLQ

Parietal pain

Inflammed parietal parietal peritoneum


Steady aching pain


More severe than visceral pain


Located precisely over involved structure


Aggravated by coughing moving

If pt prefers to lie still think

Parietal pain

Melena

black sticky, shiny, tarry stool


Upper GI-esophagus, stomach, duodenum


may occur with as little as 100cc

Hematochezia

Red or maroon colored


Lower GI bleed-colon, rectum, or anus

Blood on toilet paper

hemorrhoids

Black nonsticky stools

Injestion of iron, bismuth salts, licorice, or chocolate cookies.

Reddish but nonbloody stools

ingestion of beers

2 causes of obstructed bile ducts

gallstones


pancreatic carcinoma

Dark urine indicates

obstructed or impaired excretion of bilirubin into GI tract.

Itching over liver may indicate

Obstructive jaundice


cholestatic jaundice

Stress incontinence

weak urethral sphincter


causes: childbirth, surgery, prostatic surgery


leakage w/ coughing, laughing, sneezing


bladder not detected on exam



Urge incontinence-bladder small

Detrusor contractions stronger and overcome urethral resistance.


-stroke, brain tumor, lesions of spinal cord


-hyperexcitability of sensory pathways-bladder infections, tumors and fecal impaction


-deconditioning of voiding reflexes as in freq vol voiding at low bladder volumes

Urge incontinence

Invol volume loss preceded by urge to void.


Volume-moderate.


Urgency, freq and nocturne with small to moderate volume.


Possibly "pseudo-stress incontinece"-voiding 10-20 secs after stress-coughing/sneezing or change in position.


Bladder not detectable on exam.

Functional incontinence

Inablility to get to the toilet because of weakness, poor vision or other conditions.


On way to toilet or early in am.


Bladder not detectable.

Overflow incontinence-bladder large

Detrusor contractions are insufficient to overcome urethral resistance.Obstruction of bladder outlet, impaired bladder sensation that interrupts the reflex arc.


Continuous dribbling, decreased force of urinary flow.


***Enlarged bladder found on exam may be tender.



Psoas Sign

Access for possible appendicitis


Place your hand able the pt.'s R knee, ask pt to turn raise that thigh against your hand.Then ask pt to turn on L side and extend the pt.'s R leg at the hip. Flexion of the leg-psoas m contracts, extension stretches it.


**Increased pain=+Psoas sign=irritation of the psoas m by an inflamed appendix.

Rovsing's sign

Appendicitis test


Press deeply and evenly into the LLQ. Then w/draw fingers.


Pain in RLQ during left sided pressure is + Rosvings sign.

Murphy's Sign

Assess acute cholecysitits


Hook you L thumb/fingers under the costal margin where the lateral border of the rectus m intersects with the costal margin. If liver is enlarged, hook thumb/fingers under the liver edge. Ask the pt to take a deep breath. Watch the pt breathing and note the degree of tenderness

+ Murphys Sign

A sharp increase in tenderness with a sudden stop in inspiratory effect = a + Murphy's sign of acute cholecystitis. Hepatic tenderness may also increase with this maneuver but is usually less well localized.

Oburator's Sign

Flex the pt R thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This stretches the internal oburator muscle.




Right hypogastric pain = a + obturator's sign from irritation of the oburator m by an inflamed appendix.

Gray Turner's Sign

Bruising of the flanks- last rib and the top of the hip. Sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum. May takes 24–48 hours to develop, and can predict a severe attack of acute pancreatitis. May be accompanied by Cullen's sign. Indicative of pancreatic necrosis with retroperitoneal or intraabdominal bleeding.

Ascites

Seeks the lowest pt in the abdomen.


Dull percussion


Umb may protrude


Turn pt onto one side to detect shift in position of the fluid level

Ascites assessment-Turn pt to one side

In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top.

Test for fluid wave

Ask pt to press edges hands down midline


Tap one flank sharply with fingertips


Feel the opposite flanks for an impulse transmitted through the fluid.


**Sign is negative until ascots is obvious and can be positive in people w/out ascites


***An easily payable impulse suggests ascots

appendicitis

Peaks 10-12


Begins as dull, steady pain in periumblical area


Progresses over 4-6 hrs and localizes to RLQ


Nausea, low grade fever, anorexia, cough hurts


Sudden pain relief may be appendix rupture.


Rebound tenderness at McBurney's point.


Early voluntary guarding replaces involuntary muscular rigidity.

Cholecystitis

Fever and leukocystosis


jaundice, N/V, Anorexia, jarring deep breathing aggravate, fat intolerance.


Abdominal distention/fullness


Abdomina pain-RUQ or epigastric-steady, aching


May radiate to back


Increase pain with deep breath

Pancreatitis

Eprgastic pain that may radiate to back.


Lying supine or alcohol or heavy meals my aggravate. Leaning forward may relieve.


Fatty stools, Anorexia n/v, wt loss, jaundice, depression.


Rebound tenderness


Pancreatic enzyme insufficiency, diarrhea with fatty stools (steatorrhea) and DM

Mcburney point

Just below the middle of a line joining the umb and the anterior superior iliac spine

AAA s/s

A pulsating feeling near the navel.


Deep, constant pain in your abdomen or on the side of your abdomen


Back pain

AAA risk factors

>65


hx of smoking


male


1st degree relative with hx of AAA repair

AAA

Normal aorta 3cm wide


>3cm suggest AAA


Pain may signal rupture

Assess AA

Press deep in the upper abdomen, slightly left of midline and identify aortic pulsations.

Cancer stomach

Pain variable-persistent, slowly progressive


Not relieved by food, antacids may


Anorexia, nausea,early satiety, wt loss and sometimes bleeding.




Most common 50-70

Cancer pancreas

Steady deep epigastric pain may radiate to back.


Relentlessly progressive illness.


Leaning forward with trunk flexed.


A/N/V, wt loss and jaundice, depression.


Liver enlargement-


Downward displacement of the liver by a


diaphragm.



Seen in COPD


Percussion reveals low upper edge and liver span is normal.


Liver palpable below costal margin.

Liver enlargement-


Normal variation in the liver shape

Some people have an elongated liver and the lobe is easily palpable as it projects downward toward the iliac crest. Such elongation is called Riedel's lobe.




Just a variation in shape not size.

Liver enlargement-


Smooth large liver

Cirrhosis may produce a enlarged liver with a firm, nontender edge. The cirrhotic liver may be scarred and contracted.


An enlarged liver with a smooth tender edge suggests inflammation as in hepatitis, venous congestion-right sided heart failure.

Liver enlargement-


Irregular large liver

An enlarged liver that is firm orchard and has an irregular edge or surface suggest hepatocelluar carcinoma. There may be one or more nodules.




The liver may be tender or nontender.

Urinary frequency-mechanims

Decreased capacity of the bladder


-increased bladder sensitivity to stretch because of inflammation.


-dec elasticity of the bladder wall


-dec cortical inhibition of bladder contraction.


Impaired emptying of the bladder with residual urine in the bladder


-from obstruction or loss of nerve supply

Urinary frequency-Causes

Infections, stones, tumors, foreign bodies,


Scar tissue, motor disorders of the CNS-stroke,


beign prostatic hyperplasia, diabetic neuropathy

Urinary frequency-symptoms

Burning on urination, urinary urgency, gross hematuria,




Hesitancy in starting stream, straining to void, reduced size and force of stream and dribbling

Nocturia with high volume-mechanism

Most types of polyuria


Decreased concentrating ability of the kidney


Excess fluid intake before bedtime


Fluid retaining-dep edema accumulates during the day and is excreted at night.

Nocturia with high volume-cause

Chronic renal insuff d/t disease


Alcohol/coffee


heart failure, nephrotic syndrome, hepatic cirrhosis with ascites, chronic venous insuff



Nocturia with high volume-symptoms

Edema and other symptoms of the underlying disorder

Nocturia with low volumes

Voiding up at night w/out real urge "pseudofreqency.


Cause-insomina



Polyuria-mechanism

Def of antidiuretic hormone (diabetes insipidus)


Renal unresponsiveness to antidiuretic hormone


Solute diuresis


-electrolytes such as sodium/salt


-nonelectrolytes such as glucose


Excess water intake

Polyuria-cause

disorders of the post pituitary and hypothalmus.


kidney dz


uncontrolled DM


Large saline infusions, potent diuretics



Polyuria-symptoms

Thrist, polydipsia, nocturia

Constipation

-present for at least 12 weeks of the prior 6 months with at least 2 of the following conditions


-fewer than 3 BM's week


-25% or more defecations with either straining or sensation of incomplete evacuations


-lumpy, hard stools


-manual facilitation.

consider mediations such as anticholinergic agents, calcium channel blockers, iron supplements and opiates

meds that cause constipation

Obstipation

No passage of feces or gas

Constipation-life activities that cause

-inadquate time for the defecation reflex


-diet deficient in fiber


-false expectation of bowel habits

Constipation causes

Irritable bowel syndrome-constipation/diarrhea


Cancer of rectum


fecal impaction


lesions


drugs


depression


neurologic disorders


metabolic conditions

dysphagia

difficultly swallowing from impaired passage of solid food or liquids. Foods seem to stick

Dysphagia causes-oropharyngeal

Due to motor disorders affecting the pharyngeal muscles.


Acute or gradual.


Aspiration into lungs


From stroke or other neuromuscular conditions

Dysphagia causes-esophageal

Stricture, cancer or ring/web


Factors that relieve-regurggitaion of the food


Factors that aggravate-solid foods

Dysphagia causes-Motor disorders

esophageal spasm


scleroderma


achalasia


Factors that aggregate solids/liquids


Factors that relieve-repeated swallowing movements such as straightening the back, raising the arm or a valsalva maneuver.

diarrhea

stool volume > than 200g in 24 hours


loose watery stools


acute lasts up to 2 weeks


chronic-4 or more weeks

Acute diarrhea

infections

Chronic diarrhea

Chron's


ulcerative colitis

High volume, frequent watery stools

usually are from the small intestine

Small volume stools with tenesmus or diarrhea with mucous, pus, or blood occur in...

rectal inflammatory conditions

Noctural diarrhea

usually pathological

Steatorrhea or fatty diarrheal stools from malabsorption occur in

celiac sprue, pancreatic insufficiency

Diarrhea

common with meds

Bowel sounds increased

diarrhea, or early intestinal obstruction

Bowel sounds decreased or absent

adynamic ileus or peritonitis




before decided BS are absent listen for 2 minutes or longer.

high pitched BS

suggest intestinal fluid and air under tension in a dilated bowel.

Rushes of high pitched sound with abdominal cramping

indicate intestinal obstruction

Bruits


hepatic


arterial

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 the renal artery may explain HTN.

Venous Hum

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

Friction Rubs

Friction rubs are rare. They are grating sounds with respiratory variation. They indicate inflammation of the peritoneal surface of an organ as in liver cancer.




When a systolic bruit accompanies a hepatic friction rub, suspect carcinoma of the liver.