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a clinical sign that a doctor or other health care provider may detect in physical examination of a patient's abdomen.
It refers to pain upon removal of pressure rather than application of pressure to the abdomen. (The latter is referred to simply as abdominal tenderness.)It represents aggravation of the parietal layer of peritoneum by stretching or moving.
Rebound tenderness can be associated with peritonitis, which can occur in diseases like appendicitis, and may occur in ulcerative colitis with rebound tenderness in the right lower quadrant. The others are tenderness and abdominal guarding.
Performed by asking the patient to breathe out and then gently placing the hand below the costal margin on the right side at the mid-clavicular line (the approximate location of the gallbladder). The patient is then instructed to inspire (breathe in). Normally, during inspiration, the abdominal contents are pushed downward as the diaphragm moves down (and lungs expand). If the patient stops breathing in (as the gallbladder is tender and, in moving downward, comes in contact with the examiner's fingers) and winces with a 'catch' in breath, the test is considered positive. A positive test also requires no pain on performing the maneuver on the patient's left hand side.
It is useful for differentiating pain in the right upper quadrant. Typically, it is positive in cholecystitis or choledocholithiasis, but negative inpyelonephritis and ascending cholangitis.
elicited when gently tapping the area of the back overlying the kidney producing pain in people with an infection around the kidney (perinephric abscess) or pyelonephritis or renal stone. Since the kidney lies directly below this area, known as the costovertebral angle, tapping disturbs the inflamed tissue causing pain.
is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by hyperbilirubinemia (increased levels ofbilirubin in the blood). This hyperbilirubinemia subsequently causes increased levels of bilirubin in the extracellular fluid. Typically, the concentration of bilirubin in plasma must exceed 1.5 mg/dL
Steatorrhea (or steatorrhoea) is the presence of excess fat in feces. Stools may also float due to excess lipid, have an oily appearance and be especially foul-smelling. Possible biological causes can be lack of bile acids (due to liver damage, hypolipidemic drugs, or having had the gallbladder removed in a cholecystectomy), defects in pancreatic enzymes, and defective mucosal cells. The absence of bile acids will cause the feces to turn gray or pale. Another cause of steatorrhea is due to the adverse effect of octreotide or lanreotide, which are analogs of somatostatin, used clinically to treat acromegaly.
any event or process that occurs suddenly and quickly, and is intense and severe to the point of lethality
- Fulminant liver failure
- Fulminant colitis
- Fulminant pre-eclampsia
- Fulminant meningitis
- Fulminant hepatic venous thrombosis (Budd-Chiari syndrome)
any medical procedure where access to inner organs or other tissue is done via needle-puncture of the skin, rather than by using an "open" approach where inner organs or tissue are exposed.
percutaneous refers to the access modality of a medical procedure, whereby a medical device is introduced into a patient's blood vessel via a needle stick. This is commonly known as the "Seldinger Technique" Seldinger technique named after Dr. Sven Ivar Seldinger. The technique involves placing a needle through the skin and into a blood vessel, such as an artery or vein, until bleedback is achieved. This is followed by introduction of a flexible "introducer guide wire" to define the pathway through the skin and into the passageway or "lumen" of the blood vessel. The needle is then exchanged for an "introducer sheath" which is a small tube that is advanced over the introducer guide wire and into the blood vessel. The introducer guide wire is removed, and exchanged for a catheter or other medical device to be used to deliver medication or implantation of a medical implant such as a filter or a stent into the blood vessel.
The benefit of a percutaneous access is in the ease of introducing devices into the patient without the use of large cut downs, which can be painful and in some cases can bleed out or become infected. A percutaneous access requires only a very small hole through the skin, which seals easily, and heals very quickly compared to a surgical cut down.
Percutaneous access and procedures almost exclusively refer to catheter procedures such as PTA ballooning, stent delivery, filter delivery, cardiac ablation, and peripheral or neurovascular catheter procedures.
Difference between active and passive immunization
Active immunization entails the introduction of a foreign molecule into the body, which causes the body itself to generate immunity against the target. This immunity comes from the T cells and the B cells with their antibodies.Active immunization can occur naturally when a person comes in contact with, for example, a microbe.
Passive immunization is where pre-synthesized elements of the immune system are transferred to a person so that the body does not need to produce these elements itself. Currently, antibodies can be used for passive immunization. This method of immunization begins to work very quickly, but it is short lasting, because the antibodies are naturally broken down, and if there are no B cells to produce more antibodies, they will disappear.Passive immunization occurs physiologically, when antibodies are transferred from mother to fetus during pregnancy, to protect the fetus before and shortly after birth.
Difference between icteric and ictal
Jaundice (also known as icterus; attributive adjective: icteric) is a yellowish pigmentation of the skin
Ictal refers to a physiologic state or event such as a seizure, stroke or headache.
Difference between edema and ascites
Edema is an abnormal accumulation of fluid beneath the skin or in one or more cavities of the body that produces swelling. Generally, the amount of interstitial fluid is determined by the balance of fluid homeostasis, and increased secretion of fluid into the interstitium or impaired removal of this fluid may cause edema.
Ascites is excess fluid in the space between the tissues lining the abdomen and abdominal organs (the peritoneal cavity).
??? is ascites simply edema when in space btw tissues lining the abdomen and abdominal organs ???
Small Bowel Syndrome
(SBS, also short gut syndrome or simply short gut) is a malabsorption disorder caused by the surgical removal of the small intestine, or rarely due to the complete dysfunction of a large segment of bowel.
- The symptoms of short bowel syndrome can include:
- Abdominal pain
- Diarrhea and steatorrhea (oily or sticky stool, which can be malodorous)
- Fluid retention
- Weight loss and malnutrition
Patients with short bowel syndrome may have complications caused by malabsorption of vitamins and minerals, such as deficiencies in vitamins A, D, E, K, and B12, calcium, magnesium, iron, folic acid, and zinc. These may appear as anemia, hyperkeratosis (scaling of the skin), easy bruising, muscle spasms, poor blood clotting, and bone pain.
- Symptoms of short bowel syndrome are usually addressed by prescription medicine. These include:
- Anti-diarrheal medicine (e.g. loperamide, codeine)
- Vitamin, mineral supplements and L-Glutamine powder mixed with water
- H2 blocker and proton pump inhibitors to reduce stomach acid
- Lactase supplement (to improve the bloating and diarrhoea associated with lactose intolerance)
- Surgery, including intestinal lengthening, tapering, and small bowel transplant.
- Parenteral nutrition (PN or TPN for total parenteral nutrition - nutrition administered via intravenous line).
- Nutrition administered via gastrostomy tube
occurs as a complication of inflammatory bowel disease, such as ulcerative colitis and Crohn’s disease, and infections of the colon. The term "toxic" means that this complication occurs with infection or inflammation.
- may cause the following symptoms:
- Abdominal pain
- Abdominal distention
- Abdominal tenderness
- Rapid heart rate
A premonition. There is often an aura before a migraine or a grand mal seizure. The aura, a symptom of brain malfunction, may consist of flashing lights, a gleam of light, blurred vision, an odor, the feeling of a breeze, numbness, weakness, or difficulty speaking.
Levels of Consciousness
neurological scale that aims to give a reliable, objective way of recording the conscious state of a person for initial as well as subsequent assessment.
- Brain injury is classified as:
- Severe, with GCS ≤ 8
- Moderate, GCS 9 - 12
- Minor, GCS ≥ 13
If ≤ 7, person is in "coma"
"less than eight, intubate"
Ischemia versus Infarction
Ischemia is a restriction in blood supply, generally due to factors in the blood vessels, with resultant damage or dysfunction of tissue; is an absolute or relative shortage of the blood supply to an organ, i.e. a shortage of oxygen, glucose and other blood-borne fuels. A relative shortage means the mismatch of blood supply (oxygen/fuel delivery) and blood request for adequate metabolism of tissue. Ischemia results in tissue damage because of a lack of oxygen and nutrients. Ultimately, this can cause severe damage because of the potential for a build-up of metabolic wastes; as an inadequate flow of blood to a part of the body, caused by constriction or blockage of the blood vessels supplying it
Infarction refers to tissue death (necrosis) that is caused by a local lack of oxygen due to obstruction of the tissue's blood supply. The resulting lesion is referred to as an infarct.
is chest pain or discomfort you get when your heart muscle does not get enough blood. It may feel like pressure or a squeezing pain in your chest. It may feel like indigestion. You may also feel pain in your shoulders, arms, neck, jaw or back.Angina is a symptom of coronary artery disease (CAD), the most common heart disease. CAD happens when a sticky substance called plaque builds up in the arteries that supply blood to the heart, reducing blood flow.
- a disease in which plaque builds up inside your arteries. Plaque is a sticky substance made up of fat, cholesterol, calcium, and other substances found in the blood. Over time, plaque hardens and narrows your arteries. That limits the flow of oxygen-rich blood to your body and can lead to serious problems, including
- Coronary artery disease. These arteries supply blood to your heart. When they are blocked, you can suffer angina or a heart attack.
- Carotid artery disease. These arteries supply blood to your brain. When they are blocked you can suffer a stroke.
- Peripheral arterial disease. These arteries are in your arms, legs and pelvis. When they are blocked, you can suffer from numbness, pain and sometimes infections.
Atherosclerosis usually doesn't cause symptoms until it severely narrows or totally blocks an artery. Many people don't know they have the disease until they have a medical emergency.
to dissolve blood clots in a procedure termed thrombolysis
is used in myocardial infarction (heart attack), thromboembolic strokes, deep vein thrombosis and pulmonary embolism to clear a blocked artery and avoid permanent damage to the perfused tissue (e.g. myocardium, brain, leg) and death. A less frequent use is to clear blocked catheters that are used in long-term medical therapy.
- The thrombolytic drugs include:
- tissue plasminogen activator t-PA:alteplase (Activase)
- reteplase (Retavase)
- tenecteplase (TNKase)
- anistreplase (Eminase)
- streptokinase (Kabikinase, Streptase)
- urokinase (Abbokinase)
technique of mechanically widening a narrowed or obstructed blood vessel, typically as a result of atherosclerosis. An empty and collapsed balloon on a guide wire, known as a balloon catheter, is passed into the narrowed locations and then inflated to a fixed size using water pressures some 75 to 500 times normal blood pressure (6 to 20 atmospheres). The balloon crushes the fatty deposits, opening up the blood vessel for improved flow, and the balloon is then deflated and withdrawn.
is the maximum amount of air a person can expel from the lungs after a maximum inspiration. It is equal to the inspiratory reserve volume plus the tidal volume plus the expiratory reserve volume.
A person's vital capacity can be measured by a spirometer which can be a wet or regular spirometer. In combination with other physiological measurements, the vital capacity can help make a diagnosis of underlying lung disease. The unit that is used to determine this vital capacity is the millilitre (ml).
A normal adult has a vital capacity between 3 and 5 litres. Predicted normal values for VC can be calculated online and depend on age, sex, height, weight and ethnicity as well as the research study that they are based upon.
a sudden constriction of the muscles in the walls of the bronchioles. It is caused by the release (degranulation) of substances from mast cells or basophils under the influence of anaphylatoxins. It causes difficulty in breathing which can be very mild to severe.
Bronchospasms appear as the feature of asthma, chronic bronchitis, anaphylaxis, as a possible side effect of the drug pilocarpine (which is used to treat illness resulting from the ingestion of deadly nightshade as well as other things) and also as a side effect for beta blockers (used to treat hypertension) and other drugs. It can present as a sign of giardiasis.
Some of the things that can cause bronchospasms are consuming foods, taking medicines or getting insect bites or stings when one is allergic to them.
The overactivity of the bronchioles' muscle is a result of exposure to a stimulus which under normal circumstances would cause little or no response. The resulting constriction and inflammation causes a narrowing of the airways and an increase in mucus production; this reduces the amount of oxygen that is available to the individual causing breathlessness, coughing and hypoxia.
The peak expiratory flow (PEF), also called peak expiratory flow rate (PEFR) is a person's maximum speed of expiration, as measured with a peak flow meter, a small, hand-held device used to monitor a person's ability to breathe out air. It measures the airflow through the bronchi and thus the degree of obstruction in the airways.
is a gentle way of coughing, which speeds airflow while you keep the throat open.
During huff coughing, you gently say the word "huff", which keeps your throat open. Your respiratory therapist will help you with this breathing exercise.To begin, inhale slowly and deeply, then hold your breath for three seconds.Then do a forced exhalation, whispering the word "huff" as you quickly let air out.
Barrel chest describes a rounded, bulging, almost barrel-like appearance of the chest that occurs as a result of long-term overinflation of the lungs. Because the lungs are overinflated with air, the rib cage stays partially expanded, giving the characteristic appearance of a barrel chest.Barrel chest can be due to a variety of reasons, including osteoarthritis and aging, but is also a common finding in the later stages of emphysema. Barrel chest is quite obvious, and can be detected by your healthcare provider during a physical examination.
palmar drift test
palmar drift test is used to assess upper extremity weakness. The client is asked to hold up both arms with the palms up and the eyes closed for 10 to 20 seconds. The weak arm will "drift" downward.
A Romberg test assesses the client's balance when standing.
the ability to recognize objects by touch.
is a set of short jerking muscular contractions.
Glasgow Coma Scale - components
- Decorticate (flexion) - Decorticate posturing is characterized by tonic flexion of the arms and extension of the legs and implies a lesion at the level of the midbrain
- Decerebrate (extension) - Decerebrate posturing is manifest as tonic adduction and extension of the arms and legs and suggests a lesion at the level of the pons.
- 1. LOC - Glasgow Coma Scale
- 2. Pupils - PERRLA
- 3. Motor - (0-5+)
Looking for changes in extremity of local nerves and circulation.
- 5Ps - Pain, Pallor, Paresthesia, Paralysis, Pulselessness
- paresthesia most important
Stereognosis - recognize by feel; place familiar object in hand
Graphthesia - ability to identify shapes, number or letters traced in skin
Two-point discrimination - touching two identical sharp objects in decreasing proximity till feels 2 as 1
Superficial sensation (sensory assessment)
- sharp object - dull or sharp
- checks peripheral nerve problems
Cerebellar Function Tests
assess balance and coordination
- Walk straight heel-to-toe line
- Romberg test - balance; feet together, eyes shut; loss of balance = positive
- Palmar drift - eyes shut, feet together, "hands holding pizza pie"
- RAM - rapid alternating movement e.g. alternating palm and back of hand on thigh
- Touch thumb to each finger of hand
- Heel Slide - supine, heel on knee and move down shin
CN 3,4,6 make my eyes do tricks
- CN 2 - optic: snellen test
- CN 3 - oculomotor - eyelid movement and pupil reactivity
- CN 4 - trochlear - moves eyes towards tip of nose
- six-point gaze
CN 5 - Trigeminal (facial motor and sensory function) - Tic douloureux (trigeminal neuralgia)
- CN 6 - Abducens - eye movement to sides; 6-point gaze
- CN 7 - Facial - check for asymmetry and/or Bell's Palsy; ask to smile, frown, bare teeth, puff cheeks, purse lips
3, 4, 6, 8 how do we accomodate
- CN 8 - Acoustic
- Weber test - tuning fork on patient's crown
- Rinne test - tuning fork on mastoid process
ine; A G
Deep Tendon Reflexes
graded on scale of (0 - 4), 2+ is normal
- biceps - antecubital fossa
- brachioradialis - forearm
- triceps - back of elbow
- patellar - knee
- achilles - ankle
Reflexes - Superficial
- Abdominal - muscle contraction and shift of umbilicus towards stimulus
- Plantar (Babinski) - babies have Babinski
- Cremasteric - stroke inner thigh; scrotum should elevate slightly on stimulated side
- Anal - touch around anus with cotton swab; contracts
- Brudzinski's Sign - knees and hips flex when flex neck to touch chin to chest
- Kernig's Sign - pain or resistance as straigthen flexed leg against resistance
-- both ominous
- turn head to side; eyes move in opposite direction
- doll's eyes is normal; if absent (i.e. eyes stay midline), abnormal/ominous
Physical Assessment of the Abdomen
- - check for petechia (small, pinpoint non-blanching hemorrhages) and/or purpura (reddish-purple non-blanching blotches)
- - NORMAL: 5-35 gurgles/minute
- - tympany (hollow sound) over air-filled; sound similar to tap puffed cheek
- - dullness short, high-pitched note of little resonance over solid organs; sound similar to tap thigh
- liver palpation (NORMAL) - even or 1-2 cm below right costal marginwith sharp, soft edge; (ABNORMAL) enlarged or "boggy"
- sudden increase in pain and "arrest" (gasp) of respiration when palpate gallbladder
- CVA - costovertebral angle (kidney)
- positive for pylonephritis; tenderness
- cholecystitis - inflammation of gallbladder; 90% of acute, due to cholelithiasis (stones in gallballder)
- - S/S: irritated by fatty food consumption; RUQ pain referred to subscapular area; N/V; positive Murphy's sign; steatorrhea
- cholelithiasis - stones in gallbladder
- 4Fs: fat, female, forty, fertile
- s/s of inflammation: ↑ WBC, ↑ neutrophils
- ↑ bilirubin as evidenced by mahogany/cola urine and/or white/clay stool
- treatment (if symptomatic):
- 1. ACH drugs (can't see, can't pee, can't spit, can't shit) for spasms
- 2. analgesics - use demerol since morphine causes spasms of sphincter of Oddi; watch for Demerol (mepiridine) neurotoxicity -- tremors and seizures
- 3. dissolve stones with MTBE or UDCA
- 4. remove it - endoscopic cholecystectomy (90%)
- 5. break it up - shockwave lithitripsy
- starts around 500mL first day; gradually tapers
- not sutured; attach to abdomen or clothing
- change dressing daily
- tube feedings
- - must have functioning GI system
- HOB must be up if tip above pyloric sphincted to prevent aspiration; put feeding on hold (stop) and flush if will lay bed flat
- - check position before use:
- 1. pH test - if ≤ 5, stomach; respiratory ≥ 7
- - also note color
- 2. x-ray
- 3. air burst - no longer recommended
- check residual; if > 200cc, hold and recheck p 1h
- give food at room temperature; cold = cramping
- administer by gravity or pump but not pushing in which may cause damage; use a syringe that is 30 cc or more
- irrigate before/after each med and feeding
- change feeding bag q24h; discard formula q8h
Postprandial Dumping Syndrome
- "too much, too soon = too high
"; 30 min p eating, N/V, cramping, diarrhea, diaphoresis; use smaller meals with no fluids, low carbs, high protein
- TYPES OF FEEDING TUBES
- 1. Nasogastric (NG)
- - short term use (< 1 week); contraindicated with known basal skull fractures
- measure from tip of nose to tragus to xiphoid process
- check nose for patency
- water soluble lubricant
- drink water/swallow to wash tube into stomach
- will stimulate gag reflex; if can't talk, maybe choking; take out
- tape, verify placement then finish taping
- 2. nasoduodenal or nasojejunal
- 8Fr (Dubhoff); physician inserted
- less risk of regurgitation/aspiration
- needs slower rate since less time for absorption; may need 24h feeding e.g. stroke or bedridden
- 3. gastrostomy (G tube)
- if need for extended time (3-4 weeks)
- form stoma in stomach at skin surface
- closes when removed; can use foley temporarily until replacement
- 4. Percutaneous Endoscopic Gastrostomy (PEG)
- retention disk/bumper can become buried
- don't put dressing under bumper
- should be able to rotate bumper
- 5. Jejunostomy (J tube)
- less risk of aspiration; ised if upper GI obstruction
- must give at slow, continuous drop to prevent dumping syndrome
Total Parenteral Nutitrion (TPN)
- When used?
- if GI tract cannot be used
- Rule of Fives - no food for 5 days; not likely to eat for another 5 days
- Weight Loss Rule: if loss of 7% body weight over 2 months and no oral nutrition for > 5- 7 days
usually inserted in central vein which is large volume and high flow; can use peripheral vein if short term with less concentrated solution
- 1. Infection
- media can become excellent growth for bacteria/organisms
- check for phlebitis
- change occlusive dressing on PICC line q72h
- use bottle for only 24h
- 2. Metabolic
- accucheck q4-6h; may need sliding scale insulin
- do not speed up/slow down infusion rate
- if solution on hand ruined, can hang D20W temporarily
- daily weights
- wean off at end
- 3. Mechanical
- avoid kinking
- prevent air embolism; turn on left side in Trendelenberg if suspected (cyanosis, SOB, pain, anxiety, increased respirations)