Internal Dx II

AMPLE
A – allergies
• Medication allergies
• Hay fever
M – medication
• Which medications
• why
P – Past medical history
L – Last meal
• what they ate
• what time they ate
• how they reacted to the meal
• any nausea or vomiting
• Last menstrual period?
o Was it regular, abnormal bleeding, severe dysmenorrhea, day of onset?
E – Events of present illness
• Chief complaint
o Which of those is the main concern for you?
o Interrupts your normal activities?
 Chief complaint usually becomes secondary to the actually problem
you will be working on.

OPPQRST
O – Onset
• How it happened
• When it happened
o How long ago before you came to see me did it happen?
• What circumstances brought on the pain
P – Provocative
• What makes it worse?
o Spicy foods o Not eating
o Caffeine o Positional
o Smoking o Bowel movement
o Medications
• GU Pain
o Urinating o Exercise
o Sexual activity
• Painless blood in stool? Malignancy
• Painless blood in urine? Malignancy
• Painless blood in breast lesion? malignancy
P – Palliative
o What makes it better?
o eating
Q – Quality
o c-clamp feeling at kidneys (renal colic) o burning
 o aching o sharp
o cramping o dull
R – Radiation
o Does the pain travel?
o Referred pain
o Distant to area of lesion that does not follow a generally predictable pattern
o Due to somites (embryology)
o Prostate – low back
o Pancreas – mid back (comfort position is fetal)
S – Setting
o When does it happen?
o What are you doing when this happens?
T – Timing
o What time of the day?
o How long does it happen when it comes on?

HISTORY
H – Hospitalization
• How long were you there?
• What for?
• When?
• Any negative reactions?
o Do you still have your appendix?
o Do you still have your gallbladder?
 Small metal clamps on lumbar views (RUQ)
o Do you still have your spleen?
 Small metal clamps on LUQ
I – Injuries
• What happened?
• When?
• What did they do for you?
• What was the outcome?
o Current blunt trauma
 MVA’s
 Focal area of adynamic ileus
o Small loops of dilated small bowel (d/t MVA)
 Sports injuries
o Football
o hockey
S – Sugar diabetes
o small vessel disease
o peripheral neuropathy
o mesenteric infarct
o higher incidence of cystitis (bladder infections)
o most common co-morbid disease you will see in patients
o Have you and your family been tested for diabetes?
o Does it run in the family?
o Polyruria
 o Polyphagia
o Polydipsia
o Do your wounds take longer than normal to heal?
o Sores for no reason?
o Hands and feet feel abnormally cold?
T – tumors
o Have you or anyone in your family been diagnosed with tumors?
o Including skin cancer
o Basal Cell Carcinoma
o Squamous Cell carcinoma
o Melanoma
o Can metastasize to the GI tract
o When?
o What type?
o What did they do about it?
o What was the outcome?
o Most common malignancy
1. Skin
2. Prostate
3. Lung
4. breast
O – Operations
o appendectomy
o hysterectomy
o tonsillectomy
R – Review of Systems
o General overview of their health
o Review check list that is filled out with patient information
Y – Youth diseases
o Measles
o Mumps
o Rubella
o Tetanus
o Pertussis
o Diphtheria
o Chicken pox

Rigidity – involuntary contraction of the abdominal wall muscles

Peritonitis
• Bacterial (septic)
• Penetrating trauma
• Hemorrhagic

Peritoneum
• Sack that keeps all the organs in the abdomen
• Visceral and parietal
• Kidneys – retroperitoneal
• Sigmoid, cecum, and parts of transverse are retroperitoneal
If patient is ticklish – put your hand on top of theirs to palpate
(be firm when palpate to combat ticklish)

Palpate abdominal wall then move to deep

Roll

Superficial palpation
• Find mass
o Contract abdominal musculature by flexing neck
 If mass stays – in front of abdominal wall
 If moves – behind abdominal wall
• Normal kidney is not usually palpable unless it is in a very very thin patient
o Enlargement of the kidney is nephromegaly
• Hepatomegaly
o m/c cause – hepatitis
o m/c type of hepatitis – alcoholic hepatitis
o m/c infectious hep – hepatitis C

• rebound tenderness
o push down deeply in non tender area
o quickly release
o pt feels pain in region not palpated
o late appendicitis due to peritonitis (Rovsing’s sign)
 appendicitis
• most common organic cause of an acute abdomen
• Murphy’s punch test
o Costervertebral abdomen tenderness
o Kidney disease
o Murphy’s punch test
 12th rib
• shifting dullness
o when abdomen is full of fluid – ascites
o m/c cause of ascites – liver disease (cirrhosis)
o percuss fluid – very dull
o roll on left side, percuss from bottom and percuss to fluid level
o roll on right side, wait five minutes, percuss again, fluid should have moved
• Psoas sign
o Pain in RLQ
 Appendicitis
o Resisted hip flexion (supine)
• Obturator sign
o Resisted internal right hip rotation
 Appendicitis

• Abdominal distension
o Def:
 Abnormal enlargement of the abdomen
 o 3 things that can cause enlargement
 gas
• most common
• due to some type of obstruction
 fluid
 mass
o Neoplasm
 Intraluminal
• Obstructs from inside
 Extraluminal
• Obstructs from outside bowel
o Ovarian cyst
 Physical exam of mechanical obstruction
• Increased bowel sounds – early
• Decreased bowel sounds – late obstruction
• In a thin person you can possibly see peristalsis
• Feels like bloating or gas
• No contour or shape
• Bounces back when you press on it (gas)
• Hear tympany on percussion
o Post-operative adhesions
 Fibrous band connecting two pieces of small bowel
 Can cause kinking in the bowel
• will cause partial obstruction
o abscess
 chronic walled off infection
 causes
• diverticulitis
• ulcerative colitis
• crohn’s
• appendicitis
 extraluminal
 can cause extraluminal bowel obstruction
o pregnancy
o hernia
 ischemia
 strangulation of a hernia
o volvulus
 mesenteric portion of bowel twists on itself
 most common locations
• sigmoid
• cecal
o intusseception
 telescoping of the bowel
 fixed part of bowel telescopes into another portion of the bowel
 usually in infants and kids
• Non-mechanical
 o Ascites
 Fluid accumulation in peritoneal cavity
• Pus
• Blood
• Protein
• Serum/water
 Most common cause
• Liver disease (cirrhosis)
 Portal venous hypertension
 Fluid wave
 Small amounts of ascites can be found with
• Puddle sign
o Put patient on all fours
o Percuss around umbilicus
o Re-purcuss after five minutes
o Dull area around umbilicus
o Excess gas
 Big fats
o Trauma
 Ascites might be hemorrhagic
o Infection
o Peritonitis
 Inflammation of the peritoneum
 Infections or non-infectious
• Due to gut perforation
o Adynamic ileus
 Peristalsis shuts down

• Abdominal pain patterns

o Diffused
 Visceral pain
• organ involvement
• appendicitis
• hepatitis
o Focal
 Parietal pain
 Organ distension
 peritonitis
o Slide
 Diastasis recti
• Separation of the rectus abdominus muscle
o Linea alba opens up
o Traumatic
o Post-surgical
o Idiopathic
• Bowel is pouching out
• Pregnancy can cause this as well
• Abdominal pain
o Burning
 PUD
• Peptic ulcer disease
 GERD
• can cause pain in the chest of a burning nature
o Cramping
 Feeling like you have to go poop
 Usually from organ distension
 Biliary colic
 IBD
• Inflammatory bowel diseases
 IBS
 Mesenteric ischemia

o Colicky
 Waxes and wanes
 Renal stones
 Biliary colic
 Appendicitis
o Achy
 Constipation
• Most common
 Appendicitis
 AAA(saccular)
o Knife-like (very serious)
 AAA (dissecting/saccular rupture)
 Pancreatitis
o Sudden onset
 Perforation
 Obstruction
 Pancreatitis
 Ruptured ectopic
o Location
 Diffuse
• Early appendicitis
• AAA
• IBD
• Peritonitis
o widespread
• Trauma
• Obstruction
 Epigastric (middle third, xiphoid process)
• PUD
• GB dz
 • Hepatic ez
• Cardiac dz
• Pancreatitis
 RUQ
• Biliary tree dz
o Liver and gallbladder
• PUD
o Peptic ulcer disease
• Pancreatitis
• Renal dz
• Cardiopulmonary dz
 LUQ
• PUD
• Pancreatitis
• Splenic dz
• Renal dz
• Cardiopulmonary dz
 RLQ
• Late appendicitis
• Crohn’s dz
o Chronic inflammatory
o Granulomatis
o Full thickness of bowel wall is affected
o Distal ileum
o Proximal large bowel
o Affects
 From mouth to anus
 “tunghole to bunghole”
• Obstruction
• Reproductive dz
o salpingitis
• AAA
o Thinning of vessel wall that results in ballooning
o Dissected
 The wall splits apart
 LLQ
• Diverticulosis/itis
o Diverticulum
 Outpouching through the wall of a hallow viscus
 Can fill with stuff - “la poop”
• Obstruction
• UC
o Ulcerative colitis
o Left colon (most common)
• Reproductive dz
• AAA
 Periumbilical
 • Obstruction
• Early appendicitis
• AAA
• Mesenteric thrombosis/ischemia
o Thrombus in mesenteric vessels that supply small bowel
and colon
• Pancreatitis
o Auto-digestion of the pancreas
• Abdominal Aortic Aneurysm
o Focal widening > 3.5 cm
o >60 years; M:F = 5:1
o infrarenal (90%)
o extension into