1
Q
End of bed assessment
A
- Do they appear confused?- is this new?
- Distressed?/ SOB/PAIN?
- Size and shape- pigeon or barrel chest?
- Abdominal mass- is it pulsating?
- Stomas?- how long have they had it?
- JACCOL- Jaundice, Anaemia, Clubbing, Cyanosis, Oedema, Lymphadenopathy
2
Q
HX taking:
A
- JAM THREADS
- WHATS SACRED
Associated symptoms: - GI- nausea, D&V, Constipation, bleeding
- Gu- poly/oliguria, frequency, haematuria, pain
- Reproductive- menstrual cycle, pain, N&V, sexual hx, pregnancy
3
Q
Difference in adults & paeds abdomens
A
- newborn bladder is right below the symphysis pubis
- Children have weaker abdominal muscles, easier to palpate but be cautious!
- In pregnancy, it’s hard to palpate as the organs move
- Older adults may have decreased bowel sounds due to aging, bowel obstruction & opiates. Less likely to produce saliva and stomach acid, putting teeth at risk. Liver size decreases making OD more dangerous.
4
Q
IPPA VS IAPP
A
- IPPA in adults
- IAPP in paeds due to decreased musculature, so palpation must be last. As peristalsis may be stimulated!
5
Q
General inspection:
A
-Note down anything unusual
- Abdominal distension- may suggest the presence of ascites/underlying bowel obstruction
- Pallor- underlying anaemia?
- Jaundice- acute hepatitis, liver cirrhosis, pancreatic CA
-Oedema- limbs, is it bi/unilateral?
- Hyperpigmentation of the flanks, think Addisons!
- Cachexia- muscle wastage, commonly associated with underlying malignancy & advanced liver failure.
- Hernias- may be visible from the end of bed, get them to cough
6
Q
Hands
A
- nicoteine staining
- Splinter haemorrhages
- Cyanosis
- Leukonychia- hypoalbuminemia
- Clubbing- schamroths window- Liver/ severe kidney problem
7
Q
Examine the eyes
A
- Coneal arcus
- Xanthalasema- yellow deposits indicating raised cholesterol
8
Q
Mouth
A
Look at pts lips & around the mouth for signs of cyanosis
- Angular stomatitis: Inflammatory condition affecting the corners of the mouth. Iron deficiency?- they can no longer absorb iron!
- Glossitis: Smooth erythematous enlargment of the tounge associated with iron, B12 deficiency.
- Oral candiasis- fungal infection associated with immunosuppression- white slough
9
Q
Neck- Lymph nodes
A
- Left supraclavicular lymph node receives drainage from the abdominal cavity.
. Enlargment is known as Virchow/ Trosier node. This node has been established as the spread of gastric CA. - Right supraclavicular lymph node receives lymphatic drainage from the thorax and therefore lymphadenopathy in this region may be associated with oesophageal CA!
10
Q
Inspection
A
- Cullens sign (bruising of the tissue surrounding the umbilicous) - late sign of pancreatitis
- Grey turners sign (bruising in the flanks) is a late sign of haemorrhaging pancreatitis
- Caput medusae- Engorged paraumbilical vein associated with portal hypertension
*Hair loss- may indicate a drop in testosterone and increased circulating oestrogen.
- Brusing may suggest underlying clotting abnormalities
- Spider navi- little burst veins that have bleed, caused by increased oestrogen
11
Q
What are the 6F’S of abdominal distension?
A
- Fat
- Faeces
- Fluid
- Foetus
- Flatulence
- Fulminant mass- rapid developing mass
12
Q
Auscultation
A
- Listen in each quadrant for 2-15mins
- Listen for hypo/hyperactive bowel sounds- caused by peristalsis.
- Normal is between 5-30 per min
- Hyperactive- Diarrhoea, post eating
- Hypoactive- Asleep, constipated, medication use
- Absent- Ileus (when the bowel is paralysed/not doing it’s job) , constipation, rupture of bowel
13
Q
Arterial bruitis?
A
- A swishing sound can be heard on auscultation
- This is where there is stenosis (narrowing of blood vessels) at the site of auscultation.
14
Q
Sites for abdominal auscultation:
A
- Aorta midline a few cm above the umbilicus
- Renal- left & right- a few cm lateral of the aorta
- Iliac- left & right, a few cm inferior to the umbilicus
- Femoral- left & right, on the inguinal lines
15
Q
Percussion
A
- If we find the spleen on percussion, assume that it is enlarged. A normal finding is to not find the spleen!
- Liver should be between 6-12cm
16
Q
What could a dull sound heard on percussion of abdo indicate?
A
- Fluid
- Ascites
- Blood
17
Q
Where are tympanic sounds usually heard over?
A
- The stomach
18
Q
Percussion: Liver
A
- Normally 6-12cm
- Location: Right midclavicular line
- Get pt to hold their breath otherwise, the diaphragm will move the liver about.
- Liver should be quite dull, listen for a change in sound!
19
Q
Percussion: Spleen
A
- Should be below the mid axillary line (left side)
- If spleen has moved, assume it has enlarged- splenomegaly
- Normal = oval area of dullness between the 9th and 11th ribs
20
Q
Percussion: Spleen
A
- Should be below the mid axillary line (left side)
- If spleen has moved, assume it has enlarged- splenomegaly
- Normal = oval area of dullness between the 9th and 11th ribs
21
Q
Percussion: Spleen
A
- Should be below the mid axillary line (left side)
- If spleen has moved, assume it has enlarged- splenomegaly
- Normal = oval area of dullness between the 9th and 11th ribs
22
Q
What is the pinch test?
A
- McBurney’s point (right side, below umbilicous 2/3 away)
- Pinch fold of abdominal skin over McBurney’s point, elevate skin away from peritoneum
- If pt experiences pain when the skin fold strikes the peritoneum, the test is + and peritonitis is present.
23
Q
Rebound tenderness
A
- Apply pressure to an area of the lower abdomen using hand, quickly remove and if this ilicits pain when skin & tissue that was pushed down moves back into place , positive for peritonitis
24
Q
Murphys sign
A
- Tests for Cholecystitis (inflammation of the gall bladder)
- Place hand below right costal margin and get pt to take a deep breath in, if they experience pain at peak inspiration, likely cholecystitis!
25
Kidneys
- Kidney should be relatively easy to palpate.
- Place left hand on the pts back under the 12th rib and push upwards
- Place right hand down just below the anterior costal margin and ask pt to take a deep breath to help descend the kidney, to trap it between the fingers.
- Balloting the kidneys
* If kidneys are easily palpable or tender= hydronephrosis or pyelonephritis
26
Costovertebral angle tenderness
- Place non dominant hand underneath the 12th rib and form a fist with dominant hand and punch slightly
- Ask pt if they experience tenderness/pain if yes, likely pyelonephritis
27
Appendicitis test: Roversing
- Palpate LLQ, if pt experiences pain in RLQ, suggest peritoneal irritation!
28
Appendicitis: Psoas sign
- RLQ pain with extension/flexion of the right hip against resistance
29
Appendicitis: Obturators sign
- Get pt lying on their left side and if they experience RLQ when you flex their right leg and internally/externally rotate it, positive for appendicitis!
30
UTI
- Combination of clinical features & presence of bacteria in the urine.
* Adult males should not be getting UTIs as they have a longer urethra than women.
UTI’s can result in:
- Acute/ chronic pylenonephritis
- Cystitis
- Urethritis
- Prostatitis
* Infection may spread to surrounding tissue or the bloodstream- urosepsis!
31
What checks should you do on pts you’re suspecting UTI?
- CVA tenderness- kidney stone/pylenonephritis
- Kidney balloting
32
What is cystitis?
- Infection of the bladder rather than the ureter. There is colonisation of bacteria in the bladder, this may be from not going to the toilet or fully void the bladder, the colonisation had been there long enough to start penetrating the tissue.
33
Common UTI symptoms:
- Foul smelling urine
- Burning sensation whilst urinating
- Dark urine
- Passing urine frequently
- Pain in lower abdomen
34
Testing for UTI
- Urine dipstick, fairly reliable, however it doesn’t say which type of bacteria is causing it, so it is harder to know which antibiotic will work best to treat it!
- Lab cultures, not performed on everyone as it is more expensive and can take up to 48hrs for results. However, it confirms the type of bacteria present, identifies antibiotic- resistant bacteria.
35
Bacterial biofilm
- Acute infection are assumed to involve planktonic bacteria.
- They are generally treatable with Abx!
HOWEVER,
When the bacteria succeeds in forming a biofilm in the host, the infection can become untreatable://
36
Asymptomatic pts
- Common in 65+
- Makes UTI diagnosis difficult
- If they are asymptomatic, we do not treat UTI’s unless they are pregnant!!!
- Very common in catheterised pts
37
NICE UTI GUIDELINES
- 65 + to recieve a full assessment before UTI diagnosis
- Dipstick testing not to be used in diagnosis for pts with catheters
- Adults with UTI who aren’t responding to treatment to have a urine culture.
-Abx not to be prescribed to treated asymptomatic UTI’s in non pregnant women & adults with catheters.
38
Paediatric
- Children in nappies are at a greater risk of developing a UTI as when their bottom is wiped after a bowel movement, it comes into contact with their genitals.
- Presenting symptoms- fever, irritability, vomiting
39
Paed UTI risk factor:
- <1 year
- Females- as they have short urethras
- Previous UTI
- Voiding dysfunction that has not been diagnosed
* Vesicoureteral reflux (VUR)- When after voiding, some of the urine goes back up the bladder!
- No hx of breastfeeding makes babies more prone to UTI’s!!
40
Gestational UTI
- In pregnancy, the kidneys can dilate by 15cm due to increased progesterone
- Increased kidney capacity due to increased blood volume
- Ureter dilates, increasing the pressure, making voiding fully harder
- Decreased muscular tone
* Increased risk of UTI during pregnancy, that’s why it’s always treated with ABX, even when asymptomatic.
41
Risk factor of UTI in pregnancy
- Anatomical abnormalities of urinary tract
- HX of recurrent UTI
- Diabetes- sugar in the urine helps bacteria grow:/
- Constipation
42
Gestational pyelonephritis
Associated with:
- Fetal growth restriction
- Preterm labour
- Fetus is at a risk of cerebral palsy
- Septicaemia & maternal death
More common in 3rd trimester!
43
Abx consideration in pregnancy
- Trimethoprim- teratogenic (may cause foetal abnormalities ) risk in 1st trimester
- Nitrofurantonin- risk of foetal haemolysis (bleeding) in 3rd trimester!!!
44
Interstitial cystitis
- Feeling of pain/pressure in bladder area- urgency with little frequency
- Antihistamine, immunotherapy can be used
Caused by:
- Defect in bladder tissue, allowing substances to penetrate the bladder
- Inflammatory mast cells- release histamines & other irritating chemicals
45
Acute pyelonephritis
- Kidney infection
- Need a lab culture
- Common in women aged 15-29, infants & elderly- loss of tone in elderly ureter making it harder for the bacteria to get out there.
- Rapid onset, common s&s: Fever and flank pain!
- Costovertebral angle tenderness
46
Chronic pyelonephritis
- May cause AKI, kidney injury/disease if left untreated
Commonly caused by:
- Vesicoureteral reflux
- Recurrent renal infection
- BP is often high
47
Costovertebral angle tenderness
- Under the 12th rib, place non dominant hand flat and form a fist with the dominant hand and lightly punch, test is + if pt exhibits pain.
* Balloting the kidneys also tests for pylenonephritis
48
Costovertebral angle tenderness
- Under the 12th rib, place non dominant hand flat and form a fist with the dominant hand and lightly punch, test is + if pt exhibits pain.
* Balloting the kidneys also tests for pylenonephritis
49
AKI
- A spectrum of injury to the kidneys resulting from a number of causes.
- Decline in renal excretory function over hrs or days and failure to maintain fluid electrolyte.
Clinically recognised by:
- Oliguria or Anura and rise in serum creatinine!
- Rise in creatinine of 26umol or > within 48hrs.
- 50% or > rise in serum creatinine preceding 7 days
- A fall in urine output for > 6hrs
50
Causes of AKI
- Sepsis
- Medication (long term use of ace inhibitors, NSAIDS)
- Toxins and drugs (antibiotics, chemo)
- Hypovolaemia
- Reduced cardiac output
- Obstruction- kidney stones, BPH
51
AKI symptoms
- Decreased urine output
- Fluid retention
- SOB
- Chest pain/pressure
- Confusion
- Nausea, weakness
52
Bladder cancer
- 10th most common
- Common in >65, rare in <40
-Haematuria
- Oliguria, Dysuria, Polyuria
- Weight loss
- Pain in back, lower abdomen/bones- metastasis or renal pain
- Malaise, tiredness
53
Benign Prostate hyperplasia
- Relationship to oestrogen & testosterone has an effect, as men age, they produce less testosterone so have have higher oestrogen
Can lead to:
- UTI, Urinary retention
Common symptoms:
*Difficulty starting urination is a common symptom, with incomplete voiding, they’re more at risk of UTI.
* Weak urine flow
* Difficulty initialising urination
* Interrupted urinary flow
54
Acute urinary retention s&s:
- Inability to urinate
- Painful urgent need to urinate
Pain/discomfort in lower abdomen
- Bloating of lower abdomen
* All these s&s within the last few hrs or days!
55
Chronic urinary retention s&s:
- Urinary frequency - urination 8> times a day
- Trouble beginning a urine stream
- Weak/interrupted stream
- Urgent need to urinate with little success
Mild/ constant discomfort in lower abdomen & urinary tract.
56
Causes of urinary retention
- Stricture- tightening of the urethra, no longer have a wider lumen
- Scar tissue from surgery- may have had prostrate cancer
- Urinary stones- V painful
- Nerve damage
- Medications- NSAIDS, antidepressants, opiod analgesic
57
Cystocele & Rectocele
- Urinary bladder is pressing into the vagina, It’s not fully empty
- previous pressure has allowed things like feces to go where it shouldn’t.
S&s:
- Pressing on lower abdomen to allow bowel movement.
58
Nephrolithiasis
- Kidney bladder stones
- May be related to frequent uTIS
- Urea, which gets released by bacteria gets broken down into ammonia and co2, ammonia increases urinary PH, allowing more urinary salts to precipitate.
S&S:
- Acute/ severe flank pain
- Nausea & vomiting
- Urinary frequency & urgency
- Blood in urine
59
Ectopic pregnancy
- Very common- especially in
- Anywhere that’s not the uterus, not jst in fallopian tube
- Not a viable pregnancy, higher risk of rupture, significant bleeding
- Shoulder pain- due to irritation of the phrenic nerve.
60
Ovarian torsion
- When the ovary twists around the ligamnet
- Usually secondary to an ovarian cyst, when ovulation occurs, the egg can develop into a cyst.
- If the cyst doesn’t resolve, the ovaries get heavy and there’s pulling which causes a torsion
- Risk of rupture of the cyst
- May lose ovaries
- IVF is a risk as they are given lots of drugs to stimulate the growth of follicles and eggs.
61
Symptoms of ovarian torsion:
- Pelvic bleeding
- Nausea and vomiting
- Fever
- Abnormal bleeding
- Unexplainable mass
* Symptoms are common to kidney stones, appendicitis, gastroenteritis
62
Testicular torsion
- May occur in newborn
- Due to trauma or spontaneous
S&S:
- Severe localised pain
- Symtpoms visible, N& V
- Swelling & reddening of scrotal skin
- If one testes becomes larger than the other
* If blood supply is not restored in 6hrs, the testicle will die and be removed and replaced with a new one.
63
Which organ do you think is affected when there is pain caused by eating?
The stomach & duodenum
64
What may cause retroperitoneal pain?
- Leaning forward, think retroperitoneal structures like the back, think Pancreatitis.
65
What are causes of abdominal pain?
- Inflammation of a viscus (organ)
- Perforation
- Haemorrhage
- Obstruction
- Infarction
66
Common UPPER GI symptoms
1. Jaundice: High level of bilirubin causing yellowing of the skin & sclera and dark urine.
- The liver (hepatitis) , gall bladder may be obstructed
- May be pancreatic cancer or gall stones
2. Aphthous (mouth) ulceration- round ulcers occurring on the mucous membrane, typically benign; due to stress, mechanical trauma
3. Vomiting- look out for green bile
4. Haematemesis- blood vomit, may be coffee ground indicating gastric or duodenal ulcer
67
What’s gastro- oesophageal reflux?
- Backflow of stomach contents
- Burning pain, worse lying down, better sitting up
- May be caused by additional pressure- common in 3rd trimester pregnancy
68
Dysphagia?
- Difficulty swallowing
- What do they struggle swallowing?
- People with a neurological dysphagia struggle swallowing fluid rather than food.
- May be mechanical if they struggle swallowing solid foods
* Odynophagia- pain whilst swallowing
- Due to oesophageal obstruction?, stricture, infection?
69
Mallory Weiss tear
- Tear/laceration of the mucous membrane, commonly at the point where the oesophagus and stomach meet
- Tear may result in severe bleeding from GI tract
S&S:
- Abdominal pain, hx of severe vomiting, haematemesis
- Strong involuntary effort to vomit (retching)
- Blood often clotted and has the appearance of COFFEE GROUNDS!
- Stools may be dark, tary (MELANA)
- In cases with substantial blood loss, they may be SHOCK & COLLAPSE :?
70
Common causes of Mallory- Weiss tear:
- Chronic alcohol & hiccups
- Cancer pts
- Severe chest/abdominal TRAUMA (may be due to CPR)
- Severe vomiting- most common!!
71
Common LOWER GI symptoms:
- Abdominal pain
- Distension- ascites, bowel obstruction, enlarged organs, tumours
- Constipation
- Diarrhoea
- Streatorrhoea- floaty, beige bowel movements- excess fats, may be due to pancreases, gall bladder, coeliac disease
- Malena- Dark, tar like sticky stools- peptic ulcer
- Haematochezia- Frank, red blood, think haemorrhoids as with this, it can’t have travelled far!
72
Ascites
- Build up fluid in the abdomen due to an imbalance
- Fluid may move due to position, going to the lowest point
- Strongly associated with alcohol abuse,
CAUSES:
- Liver cirrhosis
- Cancer- stomach/bowel
- HF, inflammation of pancreas, kidney issues
TREATMENT:
- Avoid alcohol, no salt diet, lifestyle changes, may be on diuretics
73
Ascites S&S:
- Weight gain, reduced mobility
- Reduced appetite, constipation
- N&V
- Increased pressure in the lungs, causing SOB especially when lying flat.
* COMPLICATIONS:
- Infection within fluid
74
GI systemic s&s:
- Anorexia
- Weight loss
- N&V
- Fever
- Pruitus- itchiness
- Confusion
75
Acute abdo
- Rapid onset of severe abdominal symptoms indicating life threatening pathology requiring surgical intervention.
76
Acute appendicitis
- Blockage in the appendix, feces is blocking the whole, bacteria gets trapped proliferating in a small space, building up pressure causing inflammation!
- May close off blood vessels
- Abdominal pain in umbilical region travelling to RLQ, N&V, pyrexia,
* Appendicitis as a surgical emergency occurs in 500-600 pregnancies per annum in uk during 2nd trimester.
* Appendix function- Resets gut micro biome flora
77
Mesenteric adenitis
- Common in <20
-HX of viral/bacterial infection, their response to this infection causes swelling in the lymphatic tissue in the mesentery.
PRESENTATION:
- Severe LRQ pain- appendicitis mimic
- Will NOT present with deep green bile vomiting
- Feel rubbish
- If viral, no treatment. HOWEVER, if bacterial, treated with antibiotics
78
Diverticulitis
- Holes in the bowel, gives bacteria the opportunity to bacteria to get caught, causing inflammation, causing pain
- Affects women more than men
- Advice them to increase fibre intake
S&S:
- Fever, tachycardia, Malaise
- Usually presents in the L iliac fossa
- Abdominal distension
- Palpable masss
79
CROHNS VS ULCERATIVE COLITIS:
CROHNS:
- Can be anywhere in the gastrointestinal tract from mouth to the anus
- Affects full thickness of bowel wall
- Patchy/ cobblestone
ULCERATIVE COLITIS:
- Occurs only in the colon
- Consistent inflammation along the colon
80
AAA
- Tearing pain, severe pain that resolves or no pain
- Ruptured aneurysm s&s: Abdominal/back pain, pulsation abdominal mass, hypotension
- Palpation only occurs in AAA>5CM
RISK FACTORS:
* Connective tissue disorders, Hypertension, stress from pregnancy
81
Acute cholecystitis
- Inflammation of the gall bladder, usually caused by gall stones.
- Stones get trapped in the neck of the gall bladder, don’t allow passage of bile causing build up of pressure:/
- Murphys test: Get pt to breath in once you’ve placed your hand under their rib on RUQ, then get them to breath out.
* As the diaphragm expands with that breath, it shoves the liver down on top of th gall bladder pinching it.
- Surgery is the treatment. Complications is PERITONITIS
82
Peritonitis
- Rebound tenderness or the pinch test; McBurney’s point
- Guarding, rigidity often present
- May be due to a perforated organ, releasing contents which irritates the peritoneum
- Absent bowel sounds may be heard
- Elderly, immunosuppressed (cancer & steroid use) pts are at greater risk.
- PTS are usually septic!
83
Merkels diverticulum
- Congenital, affects 2% of population
- A pouch develops, this is tissue that’s grown in the wrong place, usually pancreatic or stomach tissue.
* Extra pancreatic tissue affects insulin production
* Stomach tissue in the wrong place results in excess acid
CAN LEAD TO:
- Hypochloric acid release
- Volvulus
84
Volvulus- bowel obstruction
- When the intestine twists around itself causing reduced blood supply and infarction
- Any hollow viscera (organ) can become obstructed
- If obstruction is suspected, inquire about previous surgery or gastrointestinal intestinal malignancy
- Assess for abdominal tenderness
PMMH
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