Advanced Physical Assessment
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| Etoh and the abdomen | use the CAGE questionnaire- cirrhosis
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| 1 Standard etoh Drink | 2 oz of regular beer, or wine cooler, 8 oz of malt liquor, 5 oz of wine, 1.5 oz of 80-proof spirits
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| Hepatitis A: | Transmission is fecal-oral- food poisoning- Advise hand wash after bathroom-vaccine @age of 1 year, chronic liver disease, travelers to endemic areasep B
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| Hep C | no vaccine- post exposure
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| Screening for colorectal CA | age 50-75, easisest-High-sensitivity fecal occult (FOBT) annually, Sigmoidoscopy q5 years with FOBT every 3 years,BEST- colonoscopy every 10, Adults age 76 to 85 years – do NOT screen routinely (individual), Adults older the age 85 – do NOT screen at all
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| Visceral abdominal pain | deep organ, hollow organ (intestine), distended, stretched- pt cannot localize, Varies in quality; may be gnawing, burning, cramping, aching, severe associated w/sweating, pallor, n/v. RUQ from liver distension against its capsule in alcoholic hepatitis
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| Parietal Pain in abdomen | superficial- localized-inflammation, Steady, aching, more severe, more nerve endings- periumbilical pain in early appendicitis from distension-gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum
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| Classic condition that has both visceral and parietal pain | appendicitis
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| Referred Pain in abdomen | Pain of duodenal or pancreatic referred to the back; pain from biliary tree rt shoulder or rt posterior chest, also the chest, spine, or pelvis abdomen, and pleurisy or MI epigastric
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| Pain d/t Stretching of encapsulated organs | (liver, spleen, kidney)- swelling/ inflammation of organ itself- constant, dull or moderate-RUQ pain secondary to liver congestion (CHF), LUQ d/t splenic enlargement- flank pain (pyelonephritis).
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| Pain due to Irritation of the mucosal lining | stomach-h.pylori (gastritis or peptic ulcer) or NSAIDS, esophagus (esophagitis), stomach or duodenum (duodenitis or peptic ulcer)
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| Pain in abdomen d/t Smooth muscle spasm | viral gastroenteritis or irritable bowel syndrome- is one of the most common causes for abdominal pain-crampy or colicky
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| Peritoneal irritation causes severe abdominal discomfort that usually | sharp stabbing pain associated with marked tenderness on palpation. Examples include acute appendicitis, diverticulitis, and acute cholecystitis.
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| Direct splanchnic nerve stimulation causes | compresses over the nerve- pain of moderate severity. Retroperitoneal processes such as pancreatic cancer or an expanding aortic aneurysm may compress adjacent splanchnic nerves
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| Gall bladder | RUQ/ epigastric pain; radiates to R shoulder, colicky (gas or obstruction) in nature
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| Pancreas | mid-epigastric, radiates straight through to the back WORSE WHEN PT LYING DOWN
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| Esophagus | retrosternal/ mid-epigastric. r/t swallowing and reflux of gastric acid
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| Small intestine | crampy peri-umbilical discomfort d/t spasm of the smooth ms
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| Appendix | initially, nausea and peri-umbilical, poorly localized visceral pain that peaks in intensity in 4-6 hrs and then may subside, only later to reappear in the RLQ at McBurney’s point.
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| Colon | usually in the LLQ and RLQ. May be constant or occur in spasms. r/t defecation (diverticulitis on the left mostly) sigmoid is the widest
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| Rectum | deep within the pelvis, very poorly localized. Can be intense, associated with the need to defecate
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| Kidney | RUQ, LUQ, left flank, right flank, or either costovertebral angle. It is constant and moderately severe when due to pyelonephritis with systemic signs (fever, chills, and malaise)
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| Ureter | RLQ/LLQ, radiates to testicles or labia. It is excruciatingly severe when due to passing a stone.
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| Stomach | epigastric, may radiate to the left shoulder. Gets worse w eating if due to gastric ulcer
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| Duodenum | epigastric. Occurs due to peptic ulcer, the pain develops during fasting & is relieved with eating
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| RUQ (Liver, kidney, gall bladder) | Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia
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| RLQ (ascending, colon, appendix, ovary, fallopian tube) | Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion
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| LUQ- pancreas, spleen and kidney | Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia
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| LLQ (sigmoid and descending colon, ovary, fallopian tube) | Diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion, constipation
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| Midline or periumbilical | Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial, ischemia or infarction, pancreatitis
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| Flank pain | Abdominal aortic aneurysm, renal colic, pyelonephritis
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| Front to back pan | acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecal appendicitis, posterior duodenal ulcer
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| Suprapubic or lower abdominal | Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic, inflammatory disease, endometriosis, urinary tract infection
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| Referred- Diaphragmatic | goes to supraclavicular area-kehrs sign
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| Referred- ureter | Hypogastrium, groin, inner thigh
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| Referred- cardiac pain | Epigastrium, jaw, shoulder
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| Referred pain from appendix | Periumbilical via T10 nerve
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| Referred pain from duodenum | Umbilical region via greater thoracic splanchnic nerve
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| Referred pain from hiatal hernia | epigastrium via T7 and T8 nerves
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| Referred pain from gallbladder | epigastrium
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| Referred pain from gallbladder and duct | Epigastric pain that wraps around to the scapula
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| The term acute abdomen is used to describe the sudden onset of severe abdominal pain and an acute abdomen indicates | urgent surgical intervention. 1. Peritonitis (infx peritoneal cavity) 2. Bowel infarction 3. Perforation hollow organ (perforated ulcer, appendix) 4. Ruptured AAA
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| Signs of an acute abdomen (peritonitis) | 1. Abdominal distention (protuberance) with tympany on percussion 2. Tenderness 3. Rebound tenderness 4.↑↓ bowel sounds 5. Cutaneous hypersensitivity
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| Rigidity | involuntary spasm of abdominal wall musculature
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| Abdominal fullness | diabetic gastroparesis
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| Belching, bloating, abdominal distention | lactose intolerance
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| RLQ | PID, ectopic, appendicitis
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| LLQ | diverticulitis
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| Irritable bowel syndrome | not d/t d/c but a pain syndrome
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| n/v. loss of appetite | Pregnancy, DKA, adrenal insufficiency, hypercalcemia, uremia, liver disease, Induced vomiting w/out nausea in anorexia/ bulimia
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| coffee ground emesis/ hematemesis | Esophageal or gastric varices, Mallory-Weiss tears w/frequent vomitting, peptic ulcer disease
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| Dysphagia is | difficulty swallowing- with liquids, solids or both- structural abnormalities or motility d/o
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| Odynophagia | pain with swallowing- ulcerations of the esophagus, caustic agents, infections, herpes simplex and candidiasis of the esophagus.
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| Diarrhea is defined as | stool in excess of 200 grams per day- an increase in frequency of stools (usually >3 per day), and increased liquid content of stools*.Acute is < two weeks. Chronic is > four weeks.
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| Constipation | CCB and iron can cause this
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| Constipation is defined as | fewer than three bowel movements per week
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| * Black tarry stools (melena) points to | GI bleed need antibiotic because organism is now inside the cell
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| Inflammatory bowel vs inflammatory bowel | inflammatory has blood in stool- abdominal discomfort and diarrhea for both- but inflammatory has blood- alarming
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| When cause of jaundice is intrahepatic (not hemolytic) or extra hepatic | damaged for the extra hepatic hepatocytes,damaged biliary ducts- viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis within the liver- or extrahepatic- bile ducts, cystic& common bile ducts.
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| To differentiate between intra and extra hepatic jaundice- ask about | urine and the stool- Dark urine and clay color stool
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| Pencil-like stool or blood in stool in | colon cancer
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| Dark tarry stool: | in polyps, carcinoma, GI bleeding
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| Mucus in the stool: | villous adenoma, IBD, IBS
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| Pain with defecation, rectal bleeding or tenderness | Hemorrhoids, Proctitis from STIs
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| BPH s/s | Hesitancy, straining to void, reduced stream, dribbling, irritated bladder, nocturia
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| A scaphoid abdomen presents as a | concavity to the horizontal plane-malnourished individuals.
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| TestGrey Turner’s sign | ecchymosis in one or both flanks-described 1st in pancreatitis, retroperitoneal intraperitoneal bleeding includes ovarian cyst hemorrhage, hemorrhagic ascites secondary to metastatic cancer, bilateral salpingitis, and strangulated bowel w/hemorrhage.
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| Test Cullen’s sign | is periumbilical ecchymosis 1st described for ruptured ectopic pregnancy but indicates retroperitoneal or intraperitoneal bleeding.Blood travels to the periumbilical area
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| Test- venous pattern is normally up and down, what is SVC obstruction | the normal direction of flow is reversed, such that blood flow in the upper abdomen is downward.
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| Test- venous pattern is normally up and down, what is IVC obstruction | blood flow in the lower abdomen is upward with collaterals being especially prominent in the flanks.
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| Test- venous pattern is normally up and down, what is intrahepatic portal vein obstruction | (as seen in cirrhosis) the veins appear to radiate outward from the umbilicus. This prominent venous pattern is called a caput medusa. Flow above the umbilicus is cephalad↑, while flow below the umbilicus is caudad↓
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| Portal vein thrombosis, the blood direction goes which way | towards the belly button- press it and it fills (towards it) more- in portal hypertension, you press it and it empties away from (same direction it’s going)
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| Visible peristalsis occurs early in | mechanical bowel obstruction
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| A Spigelian hernia presents as a | tender mass in the abdominal wall 3 - 5 cm above the inguinal ligaments.
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| Small bowel mechanical obstruction (centrally) may occur because of | scar tissue (adhesions), hernia,, volvulus (twisting of the small bowel onitself), intussusception (small bowel invaginating or telescoping on itself) or gallstone ileus (gallstone impacted in the ileum
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| Large bowel (laterally) mechanical obstruction can be caused by | tumor (colon cancer), volvulus (twisting of the large bowel on itself, usually the sigmoid), hernias, diverticulitis or intussusception.
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| Absence of bowel sounds could be caused by | hypokalemia
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| Arterial bruits most commonly come from | celiac artery
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| Epigastric systolic bruits | midline between the xiphoid and umbilicus- found in those with abdominal aortic aneurysms.
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| Renal artery bruits | anterior abdomen 2 inches up from the umbilicus, often radiating into the flank-The finding of an abdominal bruit having both systolic and diastolic components is virtually diagnostic of renal artery stenosis(which is an important cause of secondary HTN)
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| Peritoneal friction rubs most often originate from the | spleen or liver when their capsules rub against the peritoneum Splenic infarction, liver metastasis, hepatoma
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| Tympany | air- normally occurs over the gastric air bubble in the LUQ.
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| Generalized tympany however is a consistent finding in | mechanical and paralytic ileus, and in the presence of a perforated hollow organ (intestine, stomach etc.).
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| Dullness to percussion occurs over | solid organs, fecal-filled bowel, and laterally over the flanks in abdominal distention due to ascites fluid shifts to more dependent area (not the organ)
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| Light palpation is used to assess the abdominal wall for | intramural (muscle) masses- about 1 cm with palm-having the pt raise his/her head- if mass becomes more, then it is intramural (such as hernias or diastasis recti), if less= intra-abdominal
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| Boas' sign, | cutaneous hypersensitivity over the posterior right lower ribs, inflammation of the gallbladder (acute cholecystitis).
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| Kehr’s sign describes | cutaneous hypersensitivity over the left shoulder secondary to diaphragmatic irritation from splenic rupture.
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| Guarding and rigidity | voluntary and involuntary both seen in peritoneal irritation
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| Test Direct tenderness is | appreciated on deep palpation just beneath the examining hand- appendicitis- hurts when you press over a single point over the RLQ
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| Test Indirect tenderness develops at | a location distant to the site of underlying pathology as a result of peritoneal irritation you have appendicitis but press over the LLQ and hurts over the right side Rovsing’s sign
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| Rebound tenderness (Blumberg's sign) is a | transient, sharp, knife-like pain that results when pressure is suddenly released during deep palpation- d/t peritoneal irritation and inflammation.
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| The cough test (coughing produces a sharp pain in the abdomen) | appears to be a more compassionate way of establishing peritoneal inflammation and is probably of equal or more value (+LR 2.4) than rebound tenderness (+LR 2.1) for detecting peritoneal irritation.
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| When taken together, a positive cough test (+LR 2.4), rigidity (+LR 5.1) and guarding (+LR 2.4) argue strongly for the presence of | peritonitis- inflammation of the peritoneum
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| Murphy's sign | hooking the fingers under the right costal margin and asking the patient to inspire deeply- a "catch" in inspiration is found when there is acute cholecystitis.
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| Costovertebral angle tenderness | pyelonephritis
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| Percuss of the liver dullness in the MCL will tell you it is | displaced- COPD- dullness- lower- pushed down by lungs (9-12 cm) is normal, if 15-20 it is enlarged- DO U/S
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| Palpation of the spleen can be contraindicated with | infectious mononucleosis- can burst- barely palpable is 2x normal- palpate with them on their right side
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| Test- Splenomegaly with jaundice | points to hepatic disease with portal hypertension (such as cirrhosis).
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| Test- Splenomegaly and pallor | points to leukemia and lymphoma.
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| Test | Splenomegaly with lymphadenopathy
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| Spleen or kidney | spleen is coming down from above- has notch, extends beyond midline- dull to percussion-cannot probe between the mass and costal margin w/the spleen- and the kidney is growing upward- so you can put your fingers beneath costal margin
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| Pain with pressure or fist percussion over the costovertebral angle (CVA) supports the diagnosis of | pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal
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| RLQ masses | feces in the right colon, right colon or cecal carcinoma, ovarian cysts, appendiceal abscess, thickened ileum of Crohn's disease, and ectopic pregnancy
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| LLQ mass | feces in the left colon, colon carcinoma, diverticular abscess, ovarian cysts, or ectopic pregnancy.
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| RUQ | hepatomegaly, an enlarged right kidney, an enlarged gallbladder, or an enlarged or inflamed pancreas.
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| LUQ | an enlarged spleen, enlarged left kidney, an inflamed or enlarged pancreas or stool in the splenic flexure of the colon
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| Epigastric masses | an enlarged left lobe of the liver, pancreatic enlargement, masses of the stomach, and aortic aneurysms.
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| Hypogastric mass | increased uterine size (pregnancy, fibroids), abdominal hernias, an enlarged bladder, ovarian cysts, and aortic aneurysms.
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| AAA risk | age ≥65 years, smoking, male gender, 1st degree relative with Hx of AAA repair. A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA.
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| Ascites | centrally you feel tympanny but laterally feel dullness- fluid goes to the dependent sides- go to the right and it shifts to the rt. A protuberant abdomen with bulging flanks suggests ascites
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| Test Differentiation between ascites and a large ovarian cyst | same s/s BUT percussion of the abdomen yields dullness and lateral tympany. The large ovarian cyst forces air-filled bowel laterally toward the flanks.
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| Iliopsoas sign and obturator sign | did in lab- straight leg and leg flex to check for appendicitis
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| Distended bladder | 400-600 ml
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| TEST Rosving sign | Press deeply evenly in the LLQ, then quickly withdraw your fingers- pain will be at RLQ- pain will always be at sign of inflammation
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| Test Murphy sign | cholesistitis- hook your thumb under the right costal margin at edge of rectal muscle, take a deep breath- Sharp tenderness and a sudden stop in inspiratory effort
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| Test- Intussusception | red color jelly appearance- blood and mucous in stool- acute intermittent abdominal pain with distention/onstruction, absent bowel sounds- sausage shaped mass- younger than 6 yrs- more in females-
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| Test- Pyloric stenosis | Hypertrophy (narrowing) of the circular muscle of the pylorus leading to obstruction of the pyloric sphincter- males- olive shaped mass- projectile vomiting- failure to thrive-
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| Biliary atresia | Congenital obstruction or absence of some or all of the bile duct system (mostly the extrahepatic bile ducts) resulting in bile flow obstruction- jaundice, clay-colored stool- dark urine- failure to thrive- full term infant- progressive- abdominal u/s
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| Test Meckel Diverticulum | Outpouching of the ileum (s. interstine) that varies in size- most common congenital anomaly- asymptomatic- inflamed- discovered same time as appendicitis
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| Wilms Tumor (Nephroblastoma): | Most common intraabdominal tumor of childhood (2-3 yrs old)- painless abdominal tumor- abdominal pain, vomiting, and hematuria, htn
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| Hirschsprung Disease | Primary absence of parasympathetic ganglion cells in a segment of the colon, which interrupts intestinal motility- gut not moving- failure to thrive- severe constipation
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| Hemolytic Uremic Syndrome (HUS) | Triad of microangiopathic hemolytic anemia, thrombocytopenia, and uremia-common causes of acute renal failure in children, generally occurring in those younger than 4 years- shiga-like toxin E-coli
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| Acute Salpingitis | bilateral, the tenderness (inflammation of the fallopian tubes) is usually maximal just above the inguinal ligaments-Rebound tenderness and rigidity may be present- motion of the cervix
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| Acute Pleurisy | Abdominal from acute pleural inflammation- mimic acute cholecystitis or acute appendicitis-Rebound tenderness and rigidity are less common-Chest signs present
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| Variation in liver shape | elongation, sometimes called Riedel lobe, represents a variation in shape, not an increase in liver volume or size
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| Irregular large liver | An enlarged liver that is firm or hard with an irregular edge or surface suggests hepatocellular carcinoma
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| Smooth large liver | Cirrhosis (firm, nontender edge- scarred and contracted), hemochromatosis, amyloidosis, and lymphoma- smooth, tender edge= inflammation (hepatitis, or venous congestion in right-sided heart)
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