Abdomen Flashcards
Categories of Abdominal Pain:
Visceral
Hollow organs are stretched OR forcefully contract OR distended (bloat)
Symptoms: sweating, nausea, vomiting, restless aka DIFFICULT to localize aka general uncomfortable
ex. early acute appendicitis
Categories of Abdominal Pain
Parietal
Inflammation in parietal peritoneum
Symps: steady achy pain, worsens w/ movement or coughing, more severe than visceral so MORE PRECISEly localized
ex. late acute appendicitis
Categories of Abdominal Pain
Referred
superficial OR deep, develops as initial pain worsens
starts vague»_space; localized
peritoneum
function
Holds abdominal organs in place w/i abdominal wall
EXCEPTION: kidneys retroperitoneal, not the same
OPQRST to always ask
onset, prior episodes, progression, palliate/provoke
OPPPP
OPQRST that’s helpful
quality, region, radiation, associated symps
QRRS
Contents of epigastric region
abdominal aorta + stomach + pancreas
Contents of hypogastric/suprapubic
bladder (if distended) + uterus
RUQ
liver + gallbladder + portion of R kidney
RLQ
cecum + appendix + R ovary + salpinx (fallopian tube)
LUQ
spleen + stomach
LLQ
sigmoid colon + L ovary + salpinx
Conditions of RUQ
cholecystitis/cholelithiasis
hepatitis
duodenal ulcer
pancreatitis
nephrolithiasis (basically everywhere)
bc liver, gallbladder, kidney
Conditions of Epigastric
AAA (abdominal aorta)
gastritis
GERD
pancreatitis
peptic ulcer
AA, stomach, pancreas
Conditions of LUQ
splenic rupture
gastritis
nephrolithiasis
colitis
peptic ulcer
spleen, stomach
Conditions of RLQ
appendicitis
ovarian torsion
ectopic pregnancy
PID
colitis
nephrolithiasis
appendix
Conditions of Hypogastric
cystitis
endometriosis
uterine fibroids
PID
bladder and uterus
Conditions of LLQ
diverticulitis most common
nephrolithiasis
ovarian torsion
ectopic pregnancy
PID
colitis
sigmoid colon, left ovary/salpinx
Radiation to right shoulder
Gall Bladder problems
Radiation to back
pancreatitis
OPQRST other important parts
PMH
PSH (scarring, adhesions) * C sections DO COUNT
Meds (side effects)
Social: smoking, alc, sex, travel, sick contacts
Alc screening CAGE
felt like you should CUT down?
people ANNOYED you by criticizing?
felt bad or GUILTY?
ever had a drink first thing in the morning to stead nerves OR get rid of hangover? (EYE opening)
Alc screening general
How many times in past year have you had 3+ drinks/day (women) OR 4+ drinks/day (men)
1 drink
beer
12 fl oz (5% alc)
1 drink
Malt Liquor
8-9 fl oz (7% alc)
1 drink
wine
5 fl oz (12% alc)
1 drink
shots
1.5 fl oz (40% alc)
80 proof
Risk Factors Colorectal Cancer
1.older than 50
2. history of colorectal cancer or FAP
3.personal history intestinal polyps or inflammatory bowel (crohns or ulcerative colitis)
3.obesity
4.smoking
5.lack exercise
6.alc consumption
important to screen bc high mortality
When to screen 45-49
Family history, vulnerable to risk factors, certain populations (black people)
What to do at age 75
screening
Assess health-
if good health then continue screens
if bad (won’t live next 5-10 yrs) then stop
FIT Screening
colorectal cancer
every year
non-invasive, doesn’t matter what’s eaten prior, check for hemoglobin in stool
fecal immunochemical test
Stool DNA-FIT
every 1-3 yrs
Computed tomography colongraphy
invasive
every 5 yrs
alternative: do every 10 years + annual FIT
Colonoscopy
invasive
every 10 yrs
Exam Tips
pt supine and abdomen fully exposed
entire exam from right side (optional)
hands and stethoscope warm
good light source
watch pt face for signs of pain since won’t say
examine painful area last
empty bladder if needed
Exam Sequence
HAVE TO KNOW FOR OSCE
- INSPECTION
- AUSCULATION
- PERCUSSION
- PALPATION
will mess up bowel sounds if do percussion or palpation before
Inspection
things to look for
Pt behavior
shape of abdomen (flat, rounded, scaphoid)
discoloration (jaundice, redness, ecchymosis, linea nigra)
striae or scars
umbilical hernia (common under 1 so give time)
dilated veins»_space; cirrosis of liver
Ecchymosis
AAA, ectopic preg, pancreatitis
Ruptured things»_space; lots of trauma
Signs of ecchymosis
2
- Grey-Turners: flank, from blood tracking subcutaneuosly from retroperitoneal or intraperitoneal source
- Cullens sign: periumbilical, suggests hemoperitoneum
kidneys are retro
Auscultation
how to do
use diaphragm in AT LEAST 1 quadrant
use bell for bruits in epigastrium and both upper quadrants
listen over the liver and spleen for friction rubs
want 1 quadrant to be LLQ bc end of digestive tract so if heard here the
How long to listen for bowel sounds before concerning
full 2 minutes
increased bowel sounds
gastroenteritis, early obstruction, hunger
decreased bowel sounds
constipation, peritonitis
high-pitched tinkling
potentially small bowel obstruction
absent sounds
surgical emergency
Percussion
pt legs extended
helps assess amount/distribution of gas/masses/ size of liver and spleen
Percussion
distended abdomen
if diffusely tympanitic suggests intestinal obstruction
Tympany
Percussion
normal
@over air filled viscera
higher pitch than resonance
Dullness
Percussion
@over solid organs adjacent to air filled structures or stool
short note w/little resonance
Resonance
@over lung tissue and sometimes abdomen
sustained moderate pitch
Hyperresonance
@base of lung
b/t tympany and resonance
Liver Span
measure vertical span @ R midclavicular line
start RLQ work up until dull
start nipple line work down until dull
distance should be 6-12 cm
Palpation Sequence
pt flex knees to relax muscles
palpate all 4 quadrants
- light palpation (1 cm)
- deep palpation (2 hands)
- organs
Liver palpation
option 1
left hand under pt lower ribs
right hand on right abdomen lateral to rectus muscle
palpate on inspiration in midclavicular line 3 cm below R costal margin
Liver palpation
option 2
stand to R of pt chest
both hands on R abdomen below liver
press in and up toward costal margin
helpful for obese pts
Spleen palpation
left hand lift lower L rib cage
R hand below L costal margin press in
repeat on other side if needed w/legs flexed
Enlarged Liver
hepatomegaly
hepatitis
NASH (fatty liver)
cirrhosis
Enlarged spleen
splenomegaly
portal hypertension
hematologic malignancies (leukemia)
Kidney Palpation
L hand under patient 12th rib and lift
R hand in RUQ or LUQ
try to capture b/t hands
Enlarged kidneys
polycystic kidneys
wilms tumor (peds renal tumor)
Lloyd’s test
kidney pain/costovertebral angle tenderness
palpate first then light thump w/ heel of hand
only thump if can tolerate since very painful
Lloyd’s test
kidney pain/costovertebral angle tenderness
palpate first then light thump w/ heel of hand
only thump if can tolerate since very painful
Bladder palpation
can’t do unless very full (at least 400 ml)
check suprapubic tenderness
Aorta palpation
press firmly/deep in upper ab w/ thumb and index finger @slightly left midline
assess width if 50+ yr
normal width less than 3 cm
Peritonitis
imflammation of peritoneum
from infection, bleeding, autoimmune
Guarding
voluntary contraction
in response to peritonitis to assess
Rigidity
involuntary contraction but not as serious
Rebound tenderness
pain when hand removed/let go from ab
bc peritoneum irritated
Percussion Tenderness
self explanatory, assess for petitonitis
Rovsing’s Sign
Paritoneal
pain in RLQ when palpate deep LLQ
opposite
Psoas Sign
Peritoneum
pt flex hip vs resistance supine
if pain then positive
Obturator sign
Peritoneum
flex hip and knee 90 degrees then internal/external rotate
Heel jar test
Peritoneal
pt stand with knees straight on toes then drop to flat foot
Ascites
Tests
fluid wave:
hands on both sides of ab with pt hand at midline depressing 2-3 cm
tap briskly on one side - will feel wave fluid
shifting dullness:
percuss from umbillicus laterally toward flank pt supine
then pt turn on side- percuss superior to table
dullness will shift to the side against the table
Acute cholecystitis
Murphy’s sign
RUQ palpate
hook fingers under costal margin @midclav line, if halt inspiration when deep breath then positive
Appendicitis
McBurney’s point
1/3 from ASIS to umbilicus palpate
Ascites
causes
heart failure- pump back up
cirrhosis-block hepatic portal vein
cancer- also block hepatic vein
