Term
| what do pt's biggest complaints relate to? |
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Definition
| work-related, personal/family, or financial |
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Term
| if a pt tells you a complaint started 2 months ago, what should your next question be? |
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Definition
| "what happened 2 months ago?" |
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Term
| what can a indigestion complaint be due to? |
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Definition
| n/v, anorexia, anicteric heptitis (viral, toxin, alcohol, drug), pregnancy, diabetic ketoacidosis, uremia (w/renal failure), and emotional stress |
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Term
| what can lead to belching/aerophagia? |
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Definition
| agitated/nervous pts may gulp down food, cauliflower/asparagus/beans can cause gas, IBS, and lactose intolerance |
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Term
| what can lead to abdominal fullness or early satiety? |
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Definition
| diabetic gastroparesis, acute duodenal ulcer near pylorus - the edema of which may cause early satiety, occult neoplasm (pain-free and losing weight), cicatrix formation (scars from past ulcers), and hepatitis |
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Term
| what may cause hematemesis (blood beginning proximal to the ligamentum treitz - bright red/coffee grounds)? |
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Definition
| could be secondary to retching, mallory-weiss, or boerhaave syndrome |
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Term
| what are important questions to ask about vomiting? |
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Definition
| when, what does it look like. also need to look at hx (possible esophageal web, look for plummer vinson syndrome) |
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Term
| if a pt says they vomit 30-40 min after eating and that it is mixed with bile, what should you be thinking of? |
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Definition
| a problem with the pylorus, such as an ulcer, neoplasm, or cictrix |
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Term
| if a pt says they vomit 2 hrs after eating and it looks/smells terrible, what should you be thinking of? |
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Definition
| obstruction at the ilocecal valve (could be due to a gallstone - gall stone ileus). odor because of succus entericus, the enzymes that are put out by the pancreas, biliary system, liver to digest foods |
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Term
| what are the three types of pain pts will complain of? |
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Definition
| visceral pain (first pain; generalized burning/cramping), parietal pain (pain gravitates toward a specific organ), and referred pain (ex. acute cholecystitis irritates glisson's capsule which is innervated by the phrenic nerve, so it can refer to the shoulder) |
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Term
| what is cholecystocoronary syndrome? |
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Definition
| gallbladder pathology leading to an MI |
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Term
| what is the important differentiation for pts with jaundice? what are other important questions? |
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Definition
| determine if the jaundice is pre, intra, or extra-hepatic. ask if the pt has started any new medication and ask if they have shakes/chills (potential pre-hepatic lysis of cells, can be caused by quinidine) |
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Term
| what can cause intra-hepatic jaundice? |
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Definition
| toxins from work, alcohol, medications (HMG CoA-reductase inhibitors, nitrofurantoins) |
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Term
| what are important questions to ask about diarrhea? |
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Definition
| how many bowel movements per day/per night (bacteria stay up at night/IBS calms down w/sleep), any blood, what does it look like (watery/diarrhea/no odor - IBS, large/greasy/foulsmelling - malabsorption or infection) |
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Term
| what might flank pain be indicative of? |
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Definition
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Term
| when examining the abdomen, what things need to be looked at? |
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Definition
| scars (think of adhesions). the only indication for removing adhesions is if they cause pain. |
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Term
| if a pt complains of epigastric pain, what should you think of? |
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Definition
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Term
| when examining the liver, what things need to be looked at? about how big should the liver be? |
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Definition
| if liver seems large, need to percuss liver to make sure it isn't just being pushed farther below the costal margin b/c of COPD. a normal sized liver for women is about 6-10 cm and for men is about 8-12 cm. a sharp edge with some pain is normal for liver palpation, if it feels nodular/fatty - could indicate alcoholic cirrhosis. if the nodules feel larger - possible post-necrotic viral cirrhosis. if any abnormality - need to scan. |
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Term
| what is courvoisier's law? |
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Definition
1) if patient has a large gall bladder, no jaundice and right upper quadrant pain, most likely have a stone in cystic duct
2) if patient has small gall bladder, jaundice and pain, most likely a stone in common bile duct
3) if patient has a large gall bladder, no pain and jaundice, most likely a carcinoma at the head of the pancreas |
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Term
| what is a positive JB murphy sign? |
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Definition
| have a the pt take a deep breath and hold your fingers at the upper R quandrant as they exhale. if they catch their breath for a second upon contact of your finger w/the gall bladder = postive JB murphy sign |
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Term
| what do light yellow stools mean? what other sign might accompany this? |
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Definition
| improper micelle formation due to lack of bile (due to some impedance) - pts may also belch often w/this condition |
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Term
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Definition
| run fingers gently down the back, about a cm lateral to the spine on each side - if there is excitability/hypersensitivity at T11-L1 = positive boas sign, possible indication of cholecystitis |
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Term
| what kind of pain to pts with pancreas problems often complain of? |
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Definition
| peri-umbilical pain esp in the *supine position (feel better w/leaning forward) |
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Term
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Definition
| bluish discoloration around the umbilicus - predicts a severe attack of acute pancreatitis |
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Term
| what is grey-turner's sign? |
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Definition
| retroperitoneal bleeding coming around the flanks, which may be accompanied by cullen's sign, and if so it may be indicative of pancreatic necrosis with retroperitoneal or intraabdominal bleeding |
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Term
| if you percuss the liver and find it to be within the normal range (8-12 cm for male and 6-10 cm for a female ), can you then say the liver is normal? |
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Definition
| no - if there is cirrhosis, the pt will have portal HTN, which will enlarge the spleen as well |
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Term
| what can stria on the abdomen mean? |
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Definition
| stria can be secondary to portal HTN/cirrhotic liver (inability of the liver to break down estrogens), also cushing's or obesity |
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Term
| what is an anatomic change to the rectus abdominus muscles as pts age? |
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Definition
| they become more moon-shaped |
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Term
| which is better, a large or small epigastric hernia? |
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Definition
| large - b/c it can move freely, whereas smaller hernias can lead to edema |
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Term
| what do distended superficial veins proximal to the umbilicus (caput medusa) tell you? |
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Definition
| there is cirrhosis, and the portal blood is taking an alternate route to drain b/c it can't get through the liver back to the heart |
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Term
| how does appendicitis present? |
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Definition
| pain starts in visceral area and then refers to RLQ. the pt will point to pain emanating from an area 1/3 the distance from the ASIS to the umbilicus - known as mcburney's point |
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Term
| what is the blumberg sign? |
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Definition
| press in the area softly, then let up quickly. if the peritoneal wall contracts or spasms, that is a positive sign for appendicitis |
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Term
| what is the rovsings sign? |
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Definition
| go to the LLQ and press gently, then pull up. when you push in gently, you are pushing the intestinal coils to the R, and when you let up they will experience RLQ pain = positive sign for appendicitis |
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Term
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Definition
| since the appendix lays in contact with the psoas muscles, if you take a leg off to the side and drop it off the table to put compression onf the appendix, pain is a positive sign for appendicitis |
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Term
| what is the obturator sign? |
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Definition
| flex the leg and medially rotate it to stretch the obturator internus over an inflamed appendix, if there is pain, it is a positive sign for appendicitis |
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Term
| how is the rectal exam for appendicitis performed? why is this important to do? |
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Definition
| go up and to the R side and you can touch the inflamed area of the retro-cecal appendix - discomfort/pain = positive sign for appendicitis. 60% of appendices were retro-cecal |
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Term
| how do you test for ascites? |
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Definition
| have the pt lay on one side, and percuss up until the solid sound becomes resonant, then make a mark and do it on the other side. if the level is the same on both sides, that which is producing the solid sound is liquid and the pt likely has ascites |
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Term
| what can you do if you think a pt has ascites, but there is not much fluid? |
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Definition
| have the pt get on their hands and knees and percuss their abdomen - if it is dull, they have some ascitic fluid |
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Term
| what is the SNG gradient? what can it tell you? |
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Definition
| the serum/ascites albumin gradient. if (S/A) it is greater than 1.10 g/dl - most of the albumin is in the serum (less in ascitic fluid), meaning it is transudate - you are probably dealing with a cirrhotic liver, nephrosis or CHF. if it is 1.10 g/dl or less - most of the exudate is in the abdominal cavity, the fluid is exudate and the pt may have a pancreatic neoplasm or TB |
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Term
| what is the SNG gradient? what can it tell you? |
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Definition
| the serum/ascites/albumin gradient. if it is greater than 1.10 g/dl - most of the albumin is in the serum (less in ascitic fluid), meaning it is transudate - you are probably dealing with a cirrhotic liver, nephrosis or CHF. if it is 1.10 g/dl or less - most of the exudate is in the abdominal cavity, the fluid is exudate and the pt may have a pancreatic neoplasm or TB |
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Term
| where is an important place to look if a pt has ascites? |
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Definition
| check the supraclavicular lymph nodes, GI neoplasms will have L supraclavicular adenopathy |
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Term
| where is an important place to look if a pt has ascites? |
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Definition
| check the supraclavicular lymph nodes, GI neoplasms will have L supraclavicular adenopathy |
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Term
| where should be checked for aortic aneurysms? what is the normal diameter for the aorta? |
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Definition
| midway between the xiphoid process and the umbilicus, where the renal arteries are and check them for stenosis or metaplasia. the aorta is in the center and should be around 2.5 cm in diameter. stress the importance of pts getting this checked out if it is larger. |
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