7.14 Abdomen Flashcards
7 Organs of the abdomen
o Gallbladder o Spleen o Pancreas (not palpable or visible) o Stomach o Small intestine o Large intestine o Appendix
Gallbladder (2 characteristics)
o Clinically: Cannot feel it separately from liver
o Just lateral to midclavicular line, under liver
Where is the staomch
o Just below diaphragm
o Between liver and spleen
Where are ulcers, gastritis?
o Usually in the LUQ of stomach
o Tender when pressed
Small intestine
o Location
o Where where you commonly find pain?
o All 4 quardrants
o Umbilical pain (around belly button)
Large intestine location
o All 4 quadrants
Appendix location
o Near illiocecal junction
Three “related organs of the abdomen”:
o Ovaries
o Bladder
o Kidneys
Palpating ovaries (2):
o Only palpable bimanually, with one hand inside the vagina.
o Not palpable in post menopausal women
Bladder - part of abdomen?
o Pelvic organ
o Only rises into abdomen when filled or distended
Kidneys (3 characteristics)
o Posterior abdominal organs
o Protected by ribs
o R kidney pushed down a little bit by the liver, palpable in some people
Aorta
o Can see, palpate pulsations in abdomen as it descends
Four things to ask about appetite
o Planned / unplanned weight loss?
o Dieting?
o Excessive gas or flatus
o Abdominal fullness or early satiety
Abdominal fullness or early satiety
Associated with cancers
When do hollow organs become painful? (2)
o Forceful constriction
o Distention
When do solid organs become painful?
o 3 descriptions of pain
o 1 other characteristic
When they swell against their capsules
o Gnawing, cramping or aching
o Difficult to localize (eg hepatitis)
What is parietal pain?
o Inflammation from the hollow or solid organs that affect the parietal peritoneum.
o More severe, usually easily localized (appendicitis)
What is referred pain?
o Originates at different site, but shares same innervation from the same spinal level
o When pt gives history of abdominal pain, the pain’s location may not necessarily be over involved organ.
What are two examples of referred pain?
o Gallbladder pain at shoulder
o GERD and heart pain
Shared pain presentation of GERD and heart pain
o Down left arm
o Underneath sternum
o Occasionally up into jaw.
_____ refers to vomit
Emesis
______ refers to dry heaves, which are _______.
Retching (spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed)
Hematochezia
- blood in stool
* Old blood from stomach
Melena
- Black tarry stool
* Old blood from colon
What is the difference between Hematochezia and Melena?
o Hematochezia = blood in stool from stomach
o Melena = blood in stool from colon. Tarry.
What does white or gray stool indicate?
Gall bladder disease
What does iceteic mean?
Yellow
Top two causes of pancreatitis
- # 1 cause: Gallstones
* #2 cause: Alcohol (chronic or binge)
What discomfort might arise from a past surgery?
Adhesions that may grow together
Kidney pain v. Uretal pain
- Kidney infection: Pain is primarily in back
- Kidney stone: Uretal pain
o Goes down into groin
o Colicky pain
o Makes patient want to move around constantly
“Colicky” pain refers to ________
SHARP pain.
“Scathoid” means ________
Concave
Pubic hair shape
o Men: Diamond shape (up to belly button)
o Women: Pubic triangle
What is an incisional hernia?
Muscle has been cut in hernia, organ pushes thru weak wall.
Three causes of pulsation or movement (3)
- Inflammation
- Hernea
- Fat tumors in subcutaneous fat
What part of the stethoscope do you use to auscultate bowel sounds?
Diaphragm
Normal amount of bowel sounds
5-30 / minute
When will you hear hyperactive bowel sounds? (2)
- Diarrhea
* Early obstruction (before illius stops, you’ll have hyperactive bowel sounds as it’s trying to push thru the area.)
When will you hear hypoactive bowel sounds?
- Peritonitis
* peritonic ilius.
In order to declare that there are no bowel sounds, how long do you have to wait?
3-5 minutes
Borborygmi (3)
o Prolonged gurgles of peristalsis
o Can be auscultated without stethoscope
o Can be normal finding, OR something more serious.
3 causes of bruits
o Due to any stenosis
o Due to AAA: Aortic Abdominal Aneurism
o Epigastric systolic bruit may be normal finding in a thin person. (If you’re only hearing it systolically, it’s ok.)
2 characteristics of bruits caused by STENOSIS
- Plaque or other narrowing
* More common when aorta branches
3 characteristics of bruits caused by AAA
“Aortic abdominal aneurism”
• More common than aneurisms at other places in aorta.
• 95% of aortic aneurisms are below the renal arteries and above the iliac arteries
• Risks: Above 50, family history, smokers.
When is Epigastric systolic bruit ok?
If you’re only hearing it on Systole (common in thin people)
What should you percuss for in the stomach (2)?
Tympani and dullness. Tympani should predominate.
Causes of percussed stomach dullness (6)
o Mass or enlarged organ o Fluid o Feces o Fetus o Fibroid o Superpubic dullness due to a full bladder.
Why would someone have fluid in the abdomen?
o CHF
o Liver failure
o Kidney failure
How would percussion sound if there were fluid in the abdomen?
Would sound tympanic in center, dull on the flanks (because fluid is affected by gravity)
How would you test if the dullness sound in abdomen was from feces?
• Test with Ultrasound, Flat plate on the abdomen
Span of liver increases with (2):
- Hepatitis
* CHF (engorgement of liver)
How to measure liver (3)
- First, percuss from resonance to dullness down right midclavicular line (start around nipple)
- Then, percuss from tympani to dullness (start around belly button)
- Measure midclavicular when you can, sternal when you can’t.
What is the normal liver span?
o should be 6-12 cm on right side
o 4-8cm on sternal border
What causes the span of the liver to decrease?
Cirrhosis
Why would you do a liver scratch test?
Can help define liver borders when abdomen is distended or muscles are tense
Liver scratch test - method
- Place stethoscope over liver
- Start in RLQ, scratch with finger tip or tongue blade upward
- When sound becomes magnified, you’ve crossed from hollow organ to solid (liver edge)
What can you learn from a liver scratch test?
If liver is enlarged.
How to assess for an enlarged spleen.
o Where?
o Normal vs abnormal findings
o Go to midaxillary line.
• Percuss at side, should be tympanic
• Ask pt to take a deep breath, percuss again.
Should still be tympanic again. If it goes to dull, it may be due to enlarged spleen.
How big must a spleen be before it is palpable?
3x normal size
Three causes of spleen enlargement:
o Malaria
o Mono
o Cirrhosis
What does “CVA” stand for?
Costovertebral
What do you say if all the organs are of normal size?
“No organomegaly”
Where should you always start abdominal palpations?
Iliocecal junction
What is the purpose of gentle probing?
o To reassure and relax patient
o To note any pain or discomfort
o Identify any superficial organs or masses
Voluntary verses involuntary guarding
o Voluntary: When patient consciously flinches when you touch pt
o Involuntary: Muscles spasm when you touch patient – patient can’t control reaction.
What do you do if patient is ticklish?
You can have him or her touch abdomen first
Breathing techniques to relax the patient during abdominal exam
- Tell patient to breathe out deeply
* Tell patient to breathe through mouth with jaw dropped open.
What would cause pain in RLQ?
Appendicitis
What would cause pain in the LLQ?
Diverticulitis (50+)
What is rebound tenderness? What is the likely cause?
- Press in and it’s a little uncomfortable, when you release it hurts more.
- Likely peritoneal irritation.
When is the liver normally palpable?
When you take a deep breath
When should you use the hook method in finding the liver?
- Fat people
- Pregnant people
- If pt has Ascities (fluid in peritoneal cavity)
What do you say if the kidney is palpable
Catch the kidney
If kidney is palpable, you worry about _______.
Adrenal tumors.
In order to catch the kidney, must palpate where? How do you position hands
Lateral to muscle, hands like a duck bill
How do you palpate aortic pulsation? What are you doing?
- Either use 2 hands, or 1 hand with opposing thumb
* Checking width of pulsations
Aneurism statistics (2)
o How many aneurisms are below renal arteries?
o How many aneurisms are palpable?
o 95% of aneurisms are below renal arteries. You don’t want to miss it.
o 80% of aneurisms are palpable
Normal aortic pulsation width. When is there a serious problem?
o 3-5 cm
o When aorta is really wide
Causes of liver cancer
o Cirrhosis
o Hepatitis C
Murphy’s sign
o What happens?
o What does this indicate?
o Murphy’s sign: If you palpate their liver and they refuse to breathe out because it’s so painful
o That means it’s their gallbladder.
What does “friable” mean? What organ does this apply to?
o Can bleed easily - just touching it can break it
o Enlarged spleen
What do you do to assess ascites?
o Percuss abdomen for areas of tympany and dullness
o Push in a semi circle under diaphragm
Four signs of appendicitis
o Rebound tenderness
o Rosing’s sign
o Psoas sign
o Obturator sign
What is Rovsing’s sign?
• Palpate elsewhere in peritoneal cavity, and it hurts most over appendix.
What is Psoas sign?
- Psoas muscle goes from stomach up to groin
* It will hurt in groin area if you have pt lift leg against pressure
What is the obturator sign?
• Externally rotate the hip, it will irritate the appendix.
How do you assess enlarged gallbladder or cystitis?
o Murphy’s sign – it’s so painful they stop mid-breath.
