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67 Cards in this Set
- Front
- Back
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Lower esophageal pain
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usually subxyphoid or substernal; may refer to the back
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Gastric and Duodenal pain
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produces epigastric discomfort; may radiate to back
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Small Bowel pain
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usually periumbilical; likely in the RLQ when terminal ileum involved
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Colonic pain
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felt in the lower abdomen; LLQ
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Retrosigmoid pain
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refer to the sacrum
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Transverse colon
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give upper abdominal or periumbilical pain
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Gallbladder and Common Bile Duct
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epigastric pain, RUQ, radiating to scapula
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Pancreatic pain
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usually epigastric or midline, radiates to back
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Diffuse pain
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generalized peritonitis
metabolic disturbances psychogenic illness |
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Obstruction
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Gastric outlet: Small bowel:
Large bowel: Biliary tract: Urinary tract |
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Peritoneal Irritation
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infection: chemical irritation (bile, blood, gastric acid): spread from a local inflammatory process
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Vascular insufficiency
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embolization: atherosclerotic narrowing, hypotension, AA dissection
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Mucosal ulceration
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PUD, gastric cancer
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Altered motility
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gastroenteritis: inflammatory bowel disease; IBS: diverticular disease
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Metabolic disturbances
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DKA, lead poisoning
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Nerve injury
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hepes zoster; root compression; nerve invasion
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Muscle wall disease
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trauma; myosis; hematoma
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referred pain
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pneumonia; Inferior MI; pulmonary infarction
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Psychopathology
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Depression; anxiety; neurosis
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Acute pain: first priority
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R/o obstruction, peritoneal irritation, vascular compromise, cardiopulmonary disease
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Chronic pain: first priority
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gradual pace, get to know patient and problem before jumping into extensive testing
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OPQRST
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O:onset
P:palliative/provoking Q:quality (describe) R:radiating S:severity T:timing (intermittent/cont.) |
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Nife F;s of distention
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fat, fatal tumor, false pregnancy, fetus, feces, fibroids, flatus,fluid, full bladder
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If a patient is reluctant to change positions, this might be...
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peritoneal irritation
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If a patient is restless it might be due to
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obstruction
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Do orthostatics on a patient because...
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obstruction, peritonitis, bowel infarction can produce large losses in intravascular volume
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Absence of fever rules out serious pathology?
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no, especially in elderly or chronically ill patient
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Examine skin for..
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jaundice, stigmata of chronic liver disease, clubbing or spooning of fingernails, trauma, excoriations, surgical scars, evidence of dehydration, edema, rash
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examine:
eyes... chest... heart... |
eyes: sclera for icterus
chest: splinting, pleural friction rub, signs of LL pneu Heart: murmurs, chamber enlargment, signs of failure |
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Auscultation: describe findings
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absent sounds: paralytic ileus or late obstruction
High pitched rushes: obstruction Bruits |
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Palpation for
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start in quadrant diagonally opposite to point of maximal pain with legs flexed/relaxed: bimanual palpation of flank: rebound tenderness: Hepatomegaly: splenomegaly: masses
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Possible findings include
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hernias: incisional, inguinal, femoral: pulsating masses: CVA tenderness: Bulging flanks: shifting dullness: fluid wave (ascites)
Digital examination of stomas |
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Murphy's sign
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inspiratory arrest with RUQ palpation (cholecystitis)
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Charcot's sign
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RUQ pain, jaundice, fever (gall stones)
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Courvoisier's sign
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palpable, nontender GB with jaundice (pancreatic malignancy)
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McBurney's point tenderness
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located 2/3 of the way between the umbilicus and anterior superior iliac spine (appendicitis)
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Iliopsoas sign
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elevation of the legs against resistance causes pain (retrocecal appendicitis)
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Obturator sign
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flexion of right thigh and external rotation of thigh causes pain in pelvis (appendicitis)
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Rovsing's sign
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manual pressure and release at LLQ colon causes referred pain at McBurney's point
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Cullen's sign
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bluish peri-umbilical discoloration (peritoneal hemorrhage)
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Grey Turner's sign
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flank ecchymosis (retroperitoneal hemorrhage)
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Rectal exam, check for...
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masses and tenderness, fecal occult blood test
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Pelvic exam, check for...
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adnexal tenderness, masses, cervical discharge, uterine size, cervical motion tenderness (CMT)
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When would you do deep palpation with distraction techniques?
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psychogenic pain is suspected
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In the elderly: abdominal pain is out of proportion to tenderness and suggests vascular compromise...
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peritoneal signs may be absent or minimal: only early clues may be unexplained mild fever, tachycardia, vague abd discomforts: Maintain high index of suspicion
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Stigmata of liver disease
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spider angiomata: caput medusae (peri-umbilical collateral veins): Gynecomastia: Ascites: Hepatosplenomegaly: testicular atrophy
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In a CXR...look for
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free air under diaphram: infiltration, effusion-left sided with pancreatitis
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In an abdomen xray...look for
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flank stripe, subdiaphragmatic free air, distended loops of bowel, air fluid levels, calcification, fecaliths, portal vein gas, aortic aneurysm
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Possible causes of nausea
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possibility of pregnancy; exposure to ill contacts; common source of food; DM; migraine; cardiac disease; ulcer; liver disease; CNS disease
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Dx of nausea
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gastroparesis, bacterial, viral, parasitic, gastroenteritis, systemic infection, medications, preg, appy, gallstones, hepatitis, PUD, GERD, obstruction, psychogenic, increased ICP, toxins, bulimia, renal failure, DKA, labyrinthitis, tumors, constipation, AMI, pancreatitis, ileus
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Diagnosis is driven by
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Labs, studies, procedures
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Diarrhea
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almost always related with an infectious process
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viral (diarrhea)
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most common form: 1-2 days, self limiting, changes in small intestine cell morphology
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bacterial (diarrhea)
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suspect if others are sick who patient has shared contaminated food
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Protozoal (diarrhea)
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Giardia is an example: prolonged watery diarrhea that often afflicts travelers returning fron endemic areas where water supply is contaminated: begins 3-7 days after arrival in foreign location: acute
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Diarrhea: examples of parasitic
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Giardia lamblia
Cryptosporidium Entamoeba histolytica |
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Diarrhea: examples of bacterial
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E. coli, Salmonella, Shigella, Campylobacter, Vibro (cholerae)
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Diarrhea: examples of viral
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Rotavirus, Norwalk
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Diarrhea: acute lab/studies include
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CBC: increasd WBC with LEFT shift (indicates infection)
electolytes: elevated Na (dehydration), lowered K (diarrhea), elevated BUN & Creat (dehadration) |
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Stool sample (diarrhea)
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Ova and parasites, culture, leukocyte stain: antigen assays for C. difficile and rotovirus
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Diarrhea diagnosis
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Ulcerative colitis: Fecal impaction: Malabsorption: Crohn's: drugs: pseudomembranous colitis (due to abx use): diverticulitis: spastic colon
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Diarrhea that is chronic...
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passage of loose stools greater than 200gms/day for more than 3 weeks
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types of diarrhea
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inflammatory: osmotic: secretary: intestinal dysmotility: factitious
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Inflammatory type of diarrhea
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due to inflammatory bowel disease (ulcerative colitis, Crohn's): radiation enterocolitis, AIDS, Eosinophilic gastroenteritis
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osmotic type of diarrhea
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pancreatic insufficiency; bacterial overgrowth; celiac disease; lactase deficiency; whipple's disease; abetalipoproteinemia; short bowel syndrome; drugs(neomycin, nondigestible intraluminal solute that exerts an osmotic force)
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Secretory (diarrhea)
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carcinoid syndrome; zollinger-ellison syndrome; vasoactive intestinal peptide-secreting pancreatic adenomas; medullary carcinoma of thyroid; villous adenoma of rectum; microscopic colitis; choleric diarrhea - excessive secretion of electrolytes
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factitious diarrhea
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laxative abuse; self induced - patient may add water to urine or stool
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