17 - Abdominal Examination Flashcards
1
Q
Basic exam sequence
A
Look, listen, feel
2
Q
Equipment
A
Stethoscope, ruler, marking pen and measuring tape
3
Q
Exam basics
A
- Right side
- Maximize comfort
- Supine & double draped
- Head supported
- Knees slightly flexed
- Hands by side or on chest
- Your hands WARM
- Watch patients face for signs of distress
- Painful area examined last
- Tip: Good light, full exposure and empty bladder
4
Q
Visceral pain
A
Solid organs when capsule stretches
Hollow organs
Difficult to localize
Varies in quality (gnawing, burning, crampy or achy)
Associated symptoms (sweating, pallor, nausea, vomiting and restlessness)
5
Q
Parietal pain
A
Inflammation in parietal peritoneum
Steady, achy
More severe than visceral
Worsens with movement
6
Q
Referred pain
A
Develops as initial pain worsens
Felt superficially or deep
Usually localized
May be referred from other areas such as chest, spine or pelvis
7
Q
Right upper quadrant
A
Liver & gallbladder Pylorus Duodenum Head of pancreas Right adrenal gland Portion of right kidney Hepatic flexure of colon Portions of ascending & transverse colon
8
Q
Right lower quadrant
A
Lower pole of right kidney Cecum & appendix Bladder (if distended) Ovary & salpinx Uterus (if enlarged) Right spermatic cord Right ureter Portion of ascending colon
9
Q
Left upper quadrant
A
Left lobe liver Spleen Stomach Body Pancreas Left adrenal gland & part of left kidney Splenic flexure Part of transverse & descending colon
10
Q
Left lower quadrant
A
Lower pole Left kidney Sigmoid colon Bladder (if distended) Ovary & salpinx Uterus (if enlarged) Left spermatic cord Left ureter Portion of descending colon
11
Q
Sister Mary Joseph’s
A
Periumbilical nodule or hard mass
Clinically valuable : it reflects metastatic disease
Causes: intrapelvic or intraabdominal malignancies
12
Q
Grey-Turners sign
A
Bruising of the Flanks
Causes: pancreatitis, abdominal trauma, ruptured AAA, ruptured ectopic pregnancy
FYI: has a low specificity & disappointing sensitivity
13
Q
Cullen’s sign
A
Periumbilical ecchymosis
Suggests hemoperitoneum
Causes: pancreatitis, ruptured ectopic pregnancy
FYI: same low specificity & disappointing sensitivity as Grey Turner
14
Q
A localized bulge in the abdominal wall may suggest a ________
A
Hernia
15
Q
Patients with ________ have increased pain with sudden movements of the abdomen.
A
PERITONITIS
Heel jar or Markle
16
Q
Linea Nigra
A
A line of pigmentation that often develops during pregnancy
17
Q
Caput Medusa
A
Dilated tortuous, superficial veins radiating upwards from the umbilicus
18
Q
Diastasis Recti
A
A separation between the left and right side of the rectus abdominus muscle.
19
Q
Scaphoid
A
Malnutrition
20
Q
Distended lower half
A
Bladder distention
Pregnancy, ovarian mass
Sigmoid tumor
21
Q
Protuberant
A
Excess gas, Ascites
Organ enlargement
Obesity
22
Q
Auscultation
A
Listen with diaphragm of stethoscope until you hear bowel sounds
Listen for bruits in the epigastrium and both upper quadrants for arteriosclerotic vascular disease
Listen for bruits over both femoral arteries
23
Q
Loud prolonged gurgles
A
Borborygmi: normal sounds
Occur at a rate of 5-35 per minute
Stomach growling
24
Q
Increased sounds
A
Gastroenteritis, early obstruction or hunger
25
High-pitched tinkling
Intestinal fluid & air under pressure
| Early obstruction
26
Decreased sounds
Peritonitis (an inflammation of the peritoneum, the thin tissue that lines the inner wall of the abdomen and covers most of the abdominal organs)
Paralytic ileus ( Obstruction of the intestine due to paralysis of the intestinal muscles)
27
Absent sounds
Must listen for a full five minutes
Associated with pain and rigidity, surgical emergency
28
Listen with the ___ of the stethoscope for bruits
Bell
Aortic
Renal
Iliac
Femoral
29
Umbilicus: venous hum
increased collateral circulation between portal and systemic venous systems
30
Percussion basics
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Indirect
Percuss lightly in all quadrants
Liver
Spleen
Gastric bubble
Kidneys
```
31
Normal percussion
Normal abdomen has both tympanitic areas (gas-filled bowel) and dull areas (fluid-filled bowel)
32
Percussion of a protuberant abdomen
A protuberant abdomen that is diffusely tympanitic suggests intestinal obstruction
33
Fluid wave
Test for suspected ascites (an abnormal collection of fluid in the intra-abdominal cavity).
- Place patients edge of hand at midline of abdomen, depressing 2-3 cm.
- Provider places one hand on each side of abdomen.
- Tap briskly on one side while holding other hand firmly on the other side of the abdomen.
- If present: wave moves under midline hand and felt on examiners opposite hand.
34
Shifting dullness
Test for ascites
- Uses gravity principle
- Patient supine, fluid pulls posteriorly.
- Percussion from umbilicus laterally toward flank.
- Mark the area of dullness (upper level of dullness on the side).
- Have patient turn on side (lateral decubitus).
- If fluid present, will shift to side against the table.
- Repeat percussion, start superiorly, working downward to the table.
- Mark the level of dullness.
- If free fluid present, dullness shifts from first mark to the next.
35
Lloyd's punch test
Costovertebral angle tenderness (kidneys)
- Test can be very painful.
- First palpate the areas.
- If tolerated, continue to next step.
- Lightly thump.
36
Palpation
- Supine, right side
- Flex knees, may help
- All quadrants
- Usually avoid “Hot Spots”
- Palpate liver, gallbladder, spleen, aorta, bladder & kidneys
- Palpate inguinal areas for tenderness, swelling and adenopathy
37
Light palpation
No more than 1 cm
- Palmer surface of fingers
- Circular motion
- Detect muscular resistance & areas of tenderness
- Voluntary or Involuntary
- Guarding or Rigidity
38
Deep
- Palmer surface of extended
- Press deeply & evenly
- Two handed
39
Organ palpation
- A normal liver edge may be palpable
- A normal kidney is not palpable
- A palpable spleen is considered enlarged
- The aorta may be palpable
40
Peritonitis
Peritonitis is an inflammation of the peritoneum. Typically made worse by patient movement, abdominal wall percussion, and with palpation.
41
Tenderness
Tenderness is discomfort elicited by palpation.
42
Guarding
Guarding is a VOLUNTARY contraction of the abdominal musculature due to tenderness, fear, the examiner’s cold hands, or patient’s anxiety.
43
Rebound
Rebound is abdominal tenderness that is WORSE when palpating fingers are quickly removed from the place of palpable tenderness.
44
Rigidity
Rigidity is an INVOLUNTARY contraction of the abdominal musculature in response to peritoneal inflammation. Also known as involuntary guarding.
45
McBurney' s point
McBurney' s point is 1/3rd the distance along the imaginary line drawn from the anterior superior iliac spine to the umbilicus. It represents the approximate position of the appendix in a non-pregnant adult.
46
Murphy's sign
Murphy’s sign is a brief inspiratory arrest secondary to patient discomfort when the examiner presses their fingers inward in the RUQ mid-clavicular line. It is associated with acute cholecystitis.
47
Dance
absence of bowel sounds in RLQ (intussusception)
48
Romberg-Howship
pain medial aspect thigh to knee ( strangulated obturator hernia)
49
Rovsing
RLQ pain worsened by palpation of LLQ (peritoneal irritation or appendicitis)
50
Recognize possible related diagnosis based on the characteristics of the pain!
```
Burning: peptic ulcer
Cramping: biliary colic, gastroenteritis
Colicky: appendicitis with impacted feces, renal stone
Aching: appendiceal irritation
Knifelike: pancreatitis
Ripping or tearing: aortic dissection
Gradual: infection
Sudden: duodenal ulcer, acute pancreatitis, obstruction or perforation
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51
Pancreatitis
```
Sudden LUQ, epigastric, or umbilical pain
May refer to left shoulder
Associated: vomiting, fever, shock
PE:
Epigastric tenderness
(+) Grey turner (+) Cullen
Most common causes of acute pancreatitis are gallstones and excessive consumption alcohol
Less commonly hypertriglyceridemia
```
52
Cholecytitis
Severe, unrelenting RUQ or epigastric pain
Refers to right subscapular area
Associated: anorexia, vomiting, fever, possible jaundice
PE:
RUQ tenderness
(+) Murphy sign
53
Diverticulitis
```
LLQ pain or localized to diseased area
Associated: fever, anorexia, diarrhea
PE
LLQ pain on palpation, borborygmus
A common disease of the bowel particularly the large intestine. Develops from diverticulosis, which involves the formation of pouches (diverticula) on the outside of the colon. Diverticulitis results if one of these diverticula becomes inflamed
```
54
Pelvic inflammatory disease
Lower quadrant pain in a sexually active female
Associated: nausea, vomiting, cervical discharge, dyspareunia
PE:
Adnexal and cervical tenderness
PID is a generic term for infection of the female uterus, fallopian tubes, and/or ovaries as it progresses to scar formation with adhesions to nearby tissues and organs. C. trachomatis was estimated to be the cause in about 60% of the cases of salpingitis
55
Appendicitis
Initially present with periumbilical or epigastric pain that localizes to RLQ
Colicky
Associated symptoms: fever, nausea, vomiting, anorexia
PE:
Guarding
(+) obturator, iliopsoas, Rovsing, Markle, McBurney signs
Or epityphlitis is a condition characterized by inflammation of the appendix. While mild cases may resolve without treatment, most require removal of the inflamed appendix, either by laparotomy or laparoscopy. Untreated, mortality is high, mainly due to peritonitis and shock.
56
Colon cancer risk factors
Age older than 50 years
Family history Syndromic colon cancer including familial adenomatous polyposis (FAP), familial hereditary nonpolyposis colorectal cancer (HNPCC), Peutz-Jeghers syndrome & juvenile polyposis
Personal history colon cancer, intestinal polyps, chronic inflammatory disease (Crohn’s or ulcerative colitis), FAP, & HNPCC
Personal history ovarian or endometrial cancer
Ethnic background: Ashkenazi Jewish descent
Low-fiber & high-fat diet
Low fruit & vegetable intake
Obesity
Smoking
Lack of regular exercise
Alcohol: risk increases with amounts
57
Onto the peds abdominal exa...
Just a heads up
58
Where to examine?
Newborn in the nursery: usually on the warmer or in crib
Clinic: may allow the baby to be on parent’s lap. This is most comfortable
Toddler: sitting on parents lap
Older child: exam table
59
Umbilical hernia
Shows up more with straining and cough, crying
Benign, reassure parents
60
Inspection
Shape of the normal newborn abdomen is rounded and dome shaped because the abdominal musculature has not fully developed
Abdomen and chest movements should be synchronous
Distension is abnormal
Scaphoid is abnormal
61
Umbilical cord
Jelly consistency for a few days. Dries up and falls off by 14 days of age
62
Todler inspection
Remember that the standing toddler has a lumbar lordosis which may give the sense of abdominal distension….
Lay this patient down to be certain
63
Auscultation and Percussion
Do not differ from the adult exam
Different liver spans with different ages
Percussion may identify the liver 1-3cm below the costal margin in infants so start 3-4 cm below the costal margin
64
Hepatomegaly
Hepatomegaly is when the liver is below this level and may be a sign of:
- congestive heart failure
- Infection (hepatitis A, B , EBV, CMV)
- liver failure
65
Palpation
Best done with a calm baby but is possible even when crying
66
How do you get the baby to be calm?
Eating
Sucking on pacifier
Allow to stay on parent’s lap
67
Palpation tips
You may need to palpate more firmly
You may even place the child’s hand under yours during palpation. This seems less ticklish to the patient.
68
Omphalitis
Infection of the umbilical area that may stay localized or extend into the umbilical wall, fascia, and peritoneum and portal vessels
69
Omphalitis treatment
Treatment is with Intravenous anti staphylococcal antibiotics
