Abdomen Flashcards
You are evaluating a 16-year-old female who presents to the ED with acute onset of right lower quadrant pain. She rates this pain 9/10 since onset 3 hours ago. The pain radiates to the right flank.
What organ systems could be involved?
Kidney, appendix, it could be something GI, reproductive (ovaries)
Where are the kidneys located?
Posterior to the peritoneum
Upper border of 12th rib and T-process of upper lumbar vertebrae
Costovertebral Angle
What are the structures within the pelvis?
Terminal Ureters
Bladder
Pelvic Genitals
Occasionally loops of small and large bowel
Why do we have to be cautious with elderly, peds, intoxicated, pt’s with intellectual disabilities when it comes to taking an abdominal exam
-Elderly may become tachy and will be hypotensive.
-Peds pts will have compensatory measures in place that could potentially misguide you.
-Wont be able to describe where the pain is.
What are abdominal pain associated symptoms
-fever, indigestion, nausea, vomiting- including hematemesis, anorexia, early satiety
-Dysphagia or Odynophagia
-Change in bowel habit
*Diarrhea
*Constipation
-Jaundice
What are urinary symptoms?
Suprapubic pain, dysuria, urgency, frequency, nocturia, polyuria, urinary incontinence, hematuria
*Flank pain/ureteral colic
What are the 3 categories of abdominal pain
- visceral
- parietal
- referred
What is visceral pain?
Crampy, Dull, Achy
Intermittent (Colicky) vs constant
May include pallor, diaphoresis, vomiting
E.g appendicitis
What organs does visceral pain typically affect?
Typically affects hollow organs(stomach, intestine, small bowel) and capsule of solid organs
Typical pain radiates toward the MIDLINE
Poorly localized! (ask pt where is most of your abdominal pain and if they arent sure its poor localization)
What is parietal pain (somatic)
Irritation of the parietal peritoneum
Fibers cause pain in specific area
Think inflammatory causes!
Patients will not want to lay flat as their peritoneum (and its pain fibers) will be stretched (they will be curled up in fetal position)
Described as sharp, severe, well-localized
Often can localize with one finger to the maximal point of pain
Cough will worsen pain
pain will be travel on the same side as the organ
What is referred pain?
Pain felt at location distant from diseased organ
Develops as initial pain increases
Typically, very well localized
Occurs on same side as affected organ
Examples:
Spleen > Left Shoulder
Flank > Testicle
Gallbladder > Right Scapula
Upper abdominal pain/heartburn
pain vs discomfort
discomfort- feeling that is negative but not true to pain
-bloating, nausea, upper abd fullness, heartburn
What disease is realted to chronic upper abdominal symptoms
Dyspepsia
What are the 3 characteristics of dyspepsia?
- Chronic/recurrent discomfort in upper abd
- Epigastric pain/burning
- Post-prandial fullness or early satiety
-Belching, nausea, bloating common
What are the 3 characteristics of dyspepsia?
- Chronic/recurrent discomfort in upper abd
- Epigastric pain/burning
- Post-prandial fullness or early satiety
What is heart burn?
Retrosternal burning pain or discomfort
What are alarm symptoms for heartburn?
uncomplicated GERD who fail empiric tx
>55 years old
Broad differential
XFWATCH FOR INFERIOR MI SYMPTOMS
In acute lower abdominal pain, _______ and _______ is key
onset and exact location
What are the 3 G’s of acute lower abdominal pain?
GI, GU, GYN
Acute lower abdominal pain: RLQ
Appendicitis, Nephrolithiasis, Ectopic Pregnancy, Rupture Ovarian Cyst, PID
Acute lower abdominal pain: LLQ
Diverticulitis, SBO
*Fever, loss of appetitite, N/V, constipation, no flatus
What is important to rule out in a child bearing aged female patient with acute lower abdominal pain?
pregnancy
What are the abdominal pain and associated symptoms?
- Fever
- Nausea/Vomiting
Retching: involuntary spasm of stomach, diaphragm, esophagus -> Vomiting
VS
Regurgitation: Esophageal or gastric contents without vomiting
Inspect and note if possible- color, odor, quantity - Hematemesis– “Coffee ground”
- Anorexia
- Early Satiety
What is dysphagia?
trouble passing food from mouth to stomach
globus sensation
What is Xerostomia?
insufficient saliva; common > 70 y/o’s
What is Odynophagia?
pain on swallowing
What are questions you want to ask patients pertaining to change in bowel habits?
1.How are your bowel movements?
2. How often do they occur in a week?
3. Any change in stool pattern?
4. Excess Flatus
-Excessive swallowing of air, ingestion of certain foods, IBS
What are symptoms that indicate change in bowel movements?
Diarhhea
constipation
jaunduce
Polyuria/Nocturia
Significant urine increase in 24hours – 3L
Waking > 1x overnight
Urinary Incontinence
Stress
Urge
Stress + Urge = Mixed
Overflow
Functional
Hematuria
Gross vs Microscopic
Myoglobin
Painless hematuria
Flank pain
Kidney pain- Visceral – dull, achy, steady
Ureteral Colic
Fever/chills + Flank pain
Pyelonephritis
RUQ organs
liver
gallbladder
duodenum
pancreas
right adrenal gland
kidney
hepatic flexure of colon
section of ascending colon
LUQ organs
left lower part of liver
upper lobe of kidney
splenic flexure of colon
section of transverse colon
section of descending colon
stomach
spleen
pancreas
left adrenal gland
RLQ organs
lower lobe of right kidney
section of ascending colon
R fallopian tube
right ovary
part of uterus
R spermatic cord
cecum
appendix
right ureter
LLQ organs
lower lobe of left kidney
section of descending colon
left spermatic cord
part of uterus
sigmoid colon
left ureter
left ovary
left fallopian tube
Suprapubic pain
Sudden pain- often from bladder distention/retention–> bladder scan
Urinary Incontinence
Stress
Urge
Stress + Urge = Mixed
Overflow
Functional
Hematuria
Gross vs Microscopic
Myoglobin
Painless hematuria
Flank pain
Kidney pain- Visceral – dull, achy, steady
Ureteral Colic
Fever/chills + Flank pain
Pyelonephritis
What are two different red flag symptoms that are associated with an abdominal complaint?
- Visceral – affects hollow organs (stomach, intestine, small bowel) pain typically radiates midline, poorly localized
- Parietal- irritation of parietal peritoenium, pain in a specific area, pt will not want to lay flat
- Referred pain- pain felt at a location distant from disease occurs as same side as affected organ
What are two different red flag symptoms that are associated with an abdominal complaint?
fever, N/V, retching, vomiting, regurgitation, anorexia, early satiety
What should be ruled out first in a 30-year-old patient (female) presenting with 2 days of abdominal pain and nausea?
pregnancy
What are some additional history questions that are pertinent in the patient with a CC of abdominal pain?
Prior sx, colorectal cancer
What is the order of the abdominal exam?
IAPP
INSPECTION
AUSCULTATE ***
PERCUSS
PALPATE
What are two factors you want to ensure you do while performing the abdominal exam?
- keep pts knees flexed
- WHILE EXAMINING THE ABDOMEN , KEEP YOUR EYES ON THE PATIENT’S FACE
Caput Medusae
Dilated Veins over mid abdomen
Portal Hypertension
Cirrhosis
Inferior Vena Cava Syndrome
Cullens sign
Grey turners sign
Mary josephs nodule
What does a marked pulsation suggest?
AAA
When doing ausculatation of the abdomen, you want to note the change in sequence BEFORE you ____ or ____
percussion or palpation
DO NOT PALPATE OR PERCUSS BEFORE AUSCULTATION
FIVE minutes of auscultation are necessary to declare a person has no audible bowel sounds—— with associated
with abdominal pain and rigidity a surgical emergency
Loud prolonged gurgles
borborygmi
Increased bowel sounds
gastroenteritis, intestinal obstruction, hunger
High-pitched tinkling
intestinal fluid/air under pressure (obstruction)
Decreased bowel sounds
peritonitis paralytic ileus, early obstruction
Absent bowel sounds
abdominal pain/rigidity; surgical urgency
When percussing the stomach, _____ is the predominant sound
tympanny
_________ is heard over the organs and solid masses
dullness
Tymnpanny
Musical note of higher pitch than resonance
Over air-filled viscera or hollow structure such as a gastric bubble
Hyper-resonance
Pitch lies between tympany and resonance
Base of left lung
Resonance
Sustained note of moderate pitch
Over lung tissue
Dullness
Short, high-pitched note with little resonance, flat tone
Over solid organs adjacent to air-filled structures, muscle
Measuring the distance of the liver, it should be _______ cm
6-12
What is the castell sign?
Splenic percussion sign
Percuss at lowest interspace in left axillary line
Take deep breath
Should remain tympanic unless splenomegaly
When palpating the abdomen, the abdominal muscles may tense up. What are the two ways this is done
- Voluntary guarding- pt anticipating provider
- Involuntary guarding- muscles are tensing up on their own
_______of the abdominal musculature to protect inflamed viscera should alert you to be careful
Guarding, tensing
What is one of the symptoms you want to lookout for when looking for perotinitis
rigidity
As the inflamed gallbladder comes in contact with fingers, the patient will experience pain and abruptly halt inspiration and this is called _______
MURPHY SIGN
What is ascites?
pathologic increase in fluid in the peritoneal cavity
Ascites fluid settles with gravity, expect to hear dullness in dependent parts of the abdomen and tympany in the upper parts with lighter bowel has risen
In the patient without ascites, the borders will remain
consistent
What does a positive murphys sign suggest?
acute cholecystitis
Rebound tenderness / guarding at McBurney’s point in the lower right quadrant suggests
Appendicitis (positive McBurney’s sign)
You always want to perform a _________ for assessing POSSIBLE APPENDICITIS OR ACUTE ABDOMEN
rectal exam
In women you have to include a ____
pelvic exam
Spinder angioma
blanches with pressure
Normal in pregnancy, liver disease and aging
Diastatis Recti
Very common in females 30s 40s who have had some children and some kids. Separation of two rectus muscles can cause bulging and can be mistaken for a hernia
Linea Nigra
brown hyperpigmetned line that comes down midline and seen in darker skin pts
Signs of liver disease
Icterus
Jaundice
Asterixis- would have pt hold arm straight out and they are unable to keep their hanf up in stop position the.
