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GI complaintsGI complaintsCommon signs & symptomsCommon signs & symptoms
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Abdominal PainAbdominal Pain
CommonCommon
What is causing it?What is causing it?
LifeLife--threatening?threatening?
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Acute AbdomenAcute Abdomen
Sudden onset of abdominal painSudden onset of abdominal pain
Indicates peritoneal irritationIndicates peritoneal irritation
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AnatomyAnatomy
Gastrointestinal SystemGastrointestinal System Look it Up!Look it Up!
Renal or Urinary SystemRenal or Urinary System
Reproductive SystemReproductive System
MaleMale FemaleFemale
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The AbdomenThe Abdomen (2 of 2)(2 of 2)
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Description ofAbdominal PainDescription ofAbdominal Pain
LocalLocal
General ordiffuseGeneral ordiffuse
ReferredReferred
ColicColic
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UlcerUlcer
Erosion of the stomach or intestinal lining.Erosion of the stomach or intestinal lining.
Epigastric or abdominal painEpigastric or abdominal pain HematemesisHematemesis blood in emesisblood in emesis
Bright redBright red
Coffe groundCoffe ground
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HerniaHernia
Protrusion of tissue through body wallProtrusion of tissue through body wall
painpain red orblue skin discolorationred orblue skin discoloration
incarceratedincarcerated
can be serious medical emergencycan be serious medical emergency
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Esophageal VaricesEsophageal Varices
enlargedblood vessels in the esophagusenlargedblood vessels in the esophagus
that can rupturethat can rupture
massive bright redbleeding (oral)massive bright redbleeding (oral)
ShockShock
Hx of liverdisease or ETOH abuseHx of liverdisease or ETOH abuse
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Bowel ObstructionBowel Obstruction
Ablockage of the bowel lumen prohibitingAblockage of the bowel lumen prohibitingthe passage of materialthe passage of material
Hx of recent abdominal surgeryHx of recent abdominal surgery
constipationconstipation
colicky abdominal paincolicky abdominal pain
abdominal distentionabdominal distentionNausea/VomitingNausea/Vomiting
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AppendicitisAppendicitis
Inflammation of the appendixInflammation of the appendix
feverfeveranorexiaanorexia
N/VN/V
RLQ painRLQ pain
Rebound tendernessRebound tenderness
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CholecystitisCholecystitis
Inflammation of the gallbladderInflammation of the gallbladder
Gallstones?Gallstones?recent ingestion of fatty food?recent ingestion of fatty food?
RUQ painRUQ pain
gradual onsetgradual onsetnot colicky painnot colicky pain
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Kidney StonesKidney Stones
Calculi in the kidneyCalculi in the kidney
severe flank painsevere flank painmaybe colickymaybe colicky
restlessnessrestlessness
nausea & vomitingnausea & vomiting
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Urinary Tract Infection (UTI)Urinary Tract Infection (UTI)
Bacterial infection in the urinary tractBacterial infection in the urinary tract
Lower abdominal painLower abdominal painPain and/orburning with urinationPain and/orburning with urination
HematuriaHematuria
Urgency and frequencyUrgency and frequency
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PyelonephritisPyelonephritis
Inflammation of the kidneyInflammation of the kidney
Flank painFlank painPain and/orburning with urinationPain and/orburning with urination
HematuriaHematuria
FeverFever
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Pelvic Inflammatory DiseasePelvic Inflammatory Disease
The inflammation of the female pelvicThe inflammation of the female pelvic
organs (STD)organs (STD)
Dull RLQ or LLQ painDull RLQ or LLQ pain
abnormal vaginal dischargeabnormal vaginal discharge
nausea & vomitingnausea & vomiting
feverfever
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Ectopic PregnancyEctopic Pregnancy
Embryo gestation outside uterus (usuallyEmbryo gestation outside uterus (usually
fallopian tube)fallopian tube)
RLQ or LLQ painRLQ or LLQ pain
late LMPlate LMP
may have vaginal bleedingmay have vaginal bleeding
shockshock
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PeritonitisPeritonitis
Inflammation of the peritoneumInflammation of the peritoneum
Generalized abdominal painGeneralized abdominal painFeverFever
Rigid abdomenRigid abdomen
Nausea and/or vomitingNausea and/or vomitingDistentionDistention
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Dissecting Abdominal AorticDissecting Abdominal Aortic
AneurysmAneurysmAneurysm develops between arterialAneurysm develops between arterial
layerslayers
shearing/tearing abdominal painshearing/tearing abdominal pain
sudden onsetsudden onset
shockshockunequal femoral pulsesunequal femoral pulses
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AssessmentAssessment
OPQRSTOPQRST -- all pain isall pain is notnot the samethe same
SAMPLE or HAMSAMPLE or HAM
nausea, vomiting, diarrheanausea, vomiting, diarrhea
anorexiaanorexia
feverfever weakness or syncopeweakness or syncope
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The physical examThe physical exam
observe fordistentionobserve fordistention
palpate forTRPGRpalpate forTRPGR
check all 4 quadrantscheck all 4 quadrants start away from painstart away from pain
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FemalesFemales
Always consider a gynecological problemAlways consider a gynecological problem
with women having abdominal painwith women having abdominal pain
Pregnant?Pregnant?
LMPLMP
Normal?Normal?
Prior gynecological problemsPrior gynecological problems
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NotesNotes
nasogastric tubes (NG tubes)nasogastric tubes (NG tubes)
gastrointestinal tube (GI tubes)gastrointestinal tube (GI tubes) colostomy / illeostomycolostomy / illeostomy
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GI BleedingGI Bleeding PainPain
heartburnheartburn
Signs of shockSigns of shock
And the following types ofbleedingAnd the following types ofbleeding
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Bright red rectal bleedingBright red rectal bleeding
indicates bleed close to anus.indicates bleed close to anus.
obvious sign ( not subtle )obvious sign ( not subtle ) minorbleeds usually hemorrhoidminorbleeds usually hemorrhoid
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MelenaMelena
Dark, tarDark, tar--like stoolslike stools
Lower GI bleedLower GI bleed
Can be only indication of GI bleedCan be only indication of GI bleed
can represent significant blood losscan represent significant blood loss
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Coffee ground emesisCoffee ground emesis
Partially digestedbloodPartially digestedblood
chronicchronic stomach orduodenumstomach orduodenum
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Bright red emesisBright red emesis
upper Gi bleedupper Gi bleed
above stomachabove stomach
Think Esophageal varicesThink Esophageal varices
Can be severeCan be severe
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HemorrhoidHemorrhoid
Enlargedblood vessels near the anus.Enlargedblood vessels near the anus.
Rectal painRectal pain
bleedingbleeding
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Examination of Abdomen
Position of the patient: the patient should lie flat, with one pillow under the head in
order to relax the muscles of abdominal wall.
Exposure: abdomen shouldbe exposed from xiphisternum to the pubis.
1. Inspection:
Shape of abdomen:
Normally full
Scaphoid: a sunken abdomen due to starvation or wasting disease
Protuberant:due to fat (gross obesity), fetus (pregnancy), flatus (gaseous
distension due to intestinal obstruction), fluid (ascites).Symmetry:
Normally symmetrical
Asymmetry due to visible bulge due to hepatic, splenic and kidney enlargement
or a tumour. Bulging may be central due to uterus, bladder or ovary enlargement.
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Movements:
Normally moving equally with respiration
Respiratory movement of the abdomen usually cease in the presence of acute
peritonitis.
Umbilicus:
normally central and inverted
Placed upwarddue to pregnancy and huge ovarian cyst
Flat or everteddue to ascites.
Prominent veins:Collateral veins visible due to IVC obstruction due to tumour or thrombosis, the
direction of flow is upwards towards heart.
Collateral veins due to cirrhosis radiate from umbilicus forming Caput Medusa,
the direction of flow is downwards towards the leg below the umbilicus.
Skin:
Look for previous surgical scars, striae and pigmentationsStriae may be due to pregnancy, ascites, recent weight loss and Cushings
syndrome.
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Pulsations:
Usually transmitted from the abdominal aorta
Less frequently causedby right ventricle, the liver or an abdominal aneurysm.
Peristalsis:Prominent in small intestinal obstruction
May be visible as slow way of movement passing across the upper abdomen
from left to right in pyloric stenosis
They may be present normally.
Hernias:Look for incisional, epigastric, umbilical, femoral and inguinal hernias.
Inspection of abdomen at eye level:
Squat down beside the bed so that the patients abdomen is at eye level, ask himto take slow anddeep breaths through mouth and watch for any evidence of
asymmetrical movement, indicating the presence of mass such as enlarged liver
and spleen.
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2. Palpation:
General principles:
Ensure that the examining hands are warm.
If patient is in a low bed, sit on, or kneel beside, the bed. Ask the patient if any particular area is tender and examine this area last.
Encourage the patient to breath gently through the mouth.
If necessary, ask the patient to bend the knees to relax the abdominal
muscles.
Palpation can be divided into three phases:1. Light
2. Deep andduring
3. Inspiration
Light palpation:
Object: to note tenderness, guarding, rigidity and lump.
Method:
Place the examining hand on the abdomen and thereafter maintain
continuous contact with the patients abdominal wall.
Note the tenderness and lumps in each region.
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Deep palpation:
Object: to detect deeper masses and to define those already discovered.
Method: palpate the abdomen with the flat of the hand. If a mass is discovered
describe its characteristics such as,
Site, size, tenderness.
Surface which may be regular or irregular.
Edges: regular/irregular
Consistency: hard/soft. Mobility and movement with inspiration.
Pulsatile or not.
Whether one can get above the mass.
Palpation during inspiration:
The liver, spleen, kidney and gall bladder shouldbe examinedduring inspiration.
The key success in visceral palpation is to keep the examining hand still and wait
for the organs edge to descend and strike during inspiration.
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How to palpate liver?
Place the hand flat on the abdomen with the fingers pointing upwards and
position the sensing fingers (middle and index) lateral to the rectus muscle.
Press the hand firmly inward and upward and keep steady while the patient
takes a breath through the mouth.
If the liver edge is palpable describe its character such as sharp or round, hard
or soft, regular or irregular and non-tender or tender.
Causes of tender hepatomegaly are hepatitis, liver abscess andcongestion due
to right heart failure.
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Measuring Liver Span
Percuss from the fourth intercostal space downward and mark
the upperborder of liver identified when percussion note
becomes dull from resonant, usually at the level of sixth rib.
Now percuss from right iliac fossa upwards and mark the level
where the lowerborder of liver is palpable. Measure this spanthat is usually less than 12.5cm. Span increases in
hepatomegaly anddecreases in cirrhosis.
Liver may be palpable without hepatomegaly due to
downwarddescent due to hyperinflation of lung in asthma andCOPD.
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How to measure spleen?
Place the examining hand on the anterior abdominal wall with the fingertips
well below the left costal margin, pressing inwards and upwards.
Ask the patient to take deep breath, if spleen is enlarged it will hit the fingers
during inspiration.
If the spleen is not palpable, the patient must be rolled on the right side
towards the examiner with left hip and knee flexed and palpation is repeatedwith the right hand while the left hand of examiner compressing left lower
costal margin downwards.
If spleen is still not palpable examine the patient from the left side, curling the
fingers of the examining hand under the left costal margin as the patient
breathes in deeply.
Spleen can be palpatedby hooking method while standing on the left side of
the patient.
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How to measure kidney?
Use a bimanual technique to palpate the kidneys.
Place one hand posteriorly below the lower rib cage and the other over the
upper quadrant anteriorly.
Push both hands together firmly and feel the lower pole moving down between
hands as the patient breathes in deeply.
Push kidney back and forwards between the two hands- this is known as
balloting.
Assess the size, surface and consistency of palpable kidney.
Examine the left kidney.
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3. Percussion:
Object:
To differentiate between abdominal distension due to ascites, gas, cystic or
solid tumour. To define the size and nature of organs and masses.
General principles:
Percuss from resonant to dull area.
Percuss the upperborder of liver, and then measure the liver span.
Thrill:
To detect the thrill, place a detecting hand on the patients flank; flick the skin of the
abdominal wall over the other flank using the forefinger.
Shifting dullness:
Percussion shouldbe started in the midline (with the fingers pointing towardsthe feet) then continue percussion towards the flanks until a dull note is
obtained.
Keep the finger in place as the patient rolls to the other side.
Pause for about 10seconds and percuss again.Ascites is suggested if the note
becomes resonant and confirmedby obtaining a dull note while percussing
back towards the umbilicus.
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4.Auscultation:
Place the diaphragm of stethoscopejust below the umbilicus and ascultate for
peristalsis bowel sounds for at least 3 minutes before deciding that they are
absent (i.e. paralytic ileus)
Auscultate liver forbruit present in hepatoma.
Auscultate for renal bruit on either side of midline above the umbilicus, it may
be present in renal artery stenosis.
Auscultate over the aorta forbruit.
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