Abdomen Flashcards by Leslie Vargas

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)

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Where are the kidneys located?

Posterior to the peritoneum
Upper border of 12th rib and T-process of upper lumbar vertebrae
Costovertebral Angle

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What are the structures within the pelvis?

Terminal Ureters
Bladder
Pelvic Genitals
Occasionally loops of small and large bowel

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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.

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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

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What are urinary symptoms?

Suprapubic pain, dysuria, urgency, frequency, nocturia, polyuria, urinary incontinence, hematuria
*Flank pain/ureteral colic

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What are the 3 categories of abdominal pain

visceral
parietal
referred

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What is visceral pain?

Crampy, Dull, Achy
Intermittent (Colicky) vs constant
May include pallor, diaphoresis, vomiting
E.g appendicitis

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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)

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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

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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

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Upper abdominal pain/heartburn

pain vs discomfort
discomfort- feeling that is negative but not true to pain
-bloating, nausea, upper abd fullness, heartburn

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What disease is realted to chronic upper abdominal symptoms

Dyspepsia

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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

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What are the 3 characteristics of dyspepsia?

Chronic/recurrent discomfort in upper abd
Epigastric pain/burning
Post-prandial fullness or early satiety

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What is heart burn?

Retrosternal burning pain or discomfort

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What are alarm symptoms for heartburn?

uncomplicated GERD who fail empiric tx
>55 years old
Broad differential

XFWATCH FOR INFERIOR MI SYMPTOMS

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In acute lower abdominal pain, _______ and _______ is key

onset and exact location

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What are the 3 G’s of acute lower abdominal pain?

GI, GU, GYN

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Acute lower abdominal pain: RLQ

Appendicitis, Nephrolithiasis, Ectopic Pregnancy, Rupture Ovarian Cyst, PID

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Acute lower abdominal pain: LLQ

Diverticulitis, SBO
*Fever, loss of appetitite, N/V, constipation, no flatus

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What is important to rule out in a child bearing aged female patient with acute lower abdominal pain?

pregnancy

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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

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What is dysphagia?

trouble passing food from mouth to stomach
globus sensation

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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?

1. Visceral – affects hollow organs (stomach, intestine, small bowel) pain typically radiates midline, poorly localized 2. Parietal- irritation of parietal peritoenium, pain in a specific area, pt will not want to lay flat 3. 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?

1. keep pts knees flexed 2. 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

1. Voluntary guarding- pt anticipating provider 2. 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.