Abdomen Flashcards
RUQ content
liver, gallbladder, duodenum, lower pole of right kidney, abd aorta
LUQ content
spleen, stomach, left kidney, pancreas, abd aorta
LLQ content
sig colon, transverse and desc colon, bladder, sacral promontory, utersu and ovaries
RLQ content
bowel loops, appendix, cecum, bladder, uterus and ovaries
Bladder
palpated with at least 300 cc urine. Detrusor muscle is smooth muscle that contracts.
Kidneys
ribs pretect upper portion. CV angle (12th rib and spine) significant for kidney tenderness.
Types of Abdominal pain
Visceral, Parietal, Referred
Visceral Pain
Hollow organs contract forcefully or are stretched- Intestines, biliary tree. Solid organs can have pain r/t stretching, swell against capsulelike liver. Difficult to localize. Usually midline at level of structure. Type: gnawing,, burning, cramping, aching. If severe can be a/w sweating, pallor, N, restlessness.
Parietal Pain
Inflammation of parietal peritoneum. Steady, aching, more severe than visceral pain. Is precisely located over involved structure. Worse with coughing or movement. Pts prefer to lay still. Easily localized
Referred Pain
Felt in distant site, innervated at approx same spinal level. Initally intense and radiates from initial site. May be felt superficially or deeply but is usually localized.
Visceral RUQ pain
biliary tree, or liver (distention from alcoholic hepatitis)
Visceral periumbilical pain
small intestines, proximal colon or early appendicitis- (later changes to parietal pain in RLQ)
Visceral epigastric pain
stomach, duodenum, pancreas
Visceral hypogastric pain
colon, bladder, uterus. Colonic pain may be more diffuse
Visceral suprapubic/sacral pain
rectum
Examples of referred pain
duodenum/pancreas- back
biliary tree- right shoulder/ right post chest
Pleurisy/AMI- epigastric
Renal stones
Colicky crampy pain radiating to R/L lower quad
Kidney stones could be pain from CV angle radiating to RLQ
knifelike epigastric
gallstone pancreatitis
IWMI
indigestion symptoms/ heartburn- precipitated with exertion, relieve with rest.
Abd pain history
timing of pain, acute/chronic, sudden gradual, when started, how long lasted, describe in own words, point to pain, severity of pain, aggravating/alleviating
GERD Risk factors
decr salivary flow, prolongs acid clearance by dampening action of bicarb buffer, delay gastric emptying, selected meds and hiatal hernia
Dyspepsia
chronic/recurrent discomfort/pain in center of upper abdomen. Bloating, N, upper abd fullness, heartburn. Patients may have functional, non ulcer dyspepsia- 3 months nonspecific upper abd discomfort or N not r/t structural abn or PUD. Sx recur and are present for more than 6 months.
Causes of chronic dyspepsia
delayed gastric emptying, gastritis from H pyori, PUD, psychosocial factors.
GERD
if pt has heartburn, acid reflux, regurgitation for more than a week assume GERD until proven otherwise. R/t mucosal damages. May have resp Sx: cough, wheeze, asp PNA, or pharyngeal: hoarseness, chronic sore throat. May have alarm symptoms: dysphasia, odyophagia (painful swallowing), recurrent V, GIB, wt loss, anemia, or RF of gastric CA.
GERD w/alarm Sx
Need endoscopy to look for esophagitis, peptic strictures, Barrett’s esophagus( in this condition squamocolumnar junction displacedprox., replaced by intestinal metapplasia- increasing CA risk 30X). . 50% of GERD have no underlying Dz
Heartburn
restrosternal burning/discomfort- usually caused by food. Ex. ETOH, chocolate, citrus fruit, coffee, onions, peppermint. Could be position changes like bending over, exercising, lifting or lying down. Angina from IWMI- ma present with heartburn.
Appendicitis
RLQ pain, or pain that migrates from periumbilical region, a/w abd rigidity.
In women could also be PID, ruptured ovary, ectopic pregnancy
Tends to be achy
Diverticulitis
LLQ pain with palpable mass
SBO/LBO
Diffuse abd pain with no BS, firm abd, guarding, rebound on palpation
V with SBO
Associated symptoms
LLQ: fever, loss appetite
A, N, V
Colon CA
Change in bowel habits, mass lesion
IBS
Int pain for 12 wks of the preceding year with relief from defocation, change in freq BM, change in consistency. No structural biochemical abn.
Other diseases with A, N, V
DKA, adrenal insuff, hyper Ca, uremia, liver Dz, emo states, adv drug Rx, and more
Bulemia/ Anorexia
B-Induced vomiting w/o Nausea
A- loss/lack of appetite- may be d/t food intolerance.
Nausea
Retching? Regurg? Material, odor, volume, blood, clear/ mucoid, bile colors, black/brown, coffee ground. Dehydrated, electrolyte imbalance, asp?
Hematemesis
Varices, gastritis, PUD
Sx of blood loss: syncope, lightheaded, seen with loss of 500 ml or more
Fecal smelling vomit
SBO , gastrocolic fistula
Regurgitation
GERD, esophageal structure, esophageal CA
color, amount, blood, coffee ground
Burning gnawing
GERD or PUD
Terribly severe
Non localized peritonitis, perforation, ureteral calculi, bowel ischemia, Ao dissection
Increased BS
Diarrhea or early intestinal obstruction
Decreased BS then absent
Adynamic Ileus or peritonitis
High pitched tinkling BS
Intestinal fluid or air under tension in dilated bowel
High pitched rushing BS
Intestinal obstruction
Hepatic bruit
Liver CA or alcoholic hepatitis
Arterial bruit
Partial obstruction of Ao or renal arteries
HTN with bruit
Renal artery stenosis
Arterial insufficiency
Ao, iliacs, femerols with bruit
Hepatic friction rub
Intrahepatic malignancy
Liver percussion
MCL 6-12cm normal, longer swollen enlarged liver
MSL 4-8cm, shorter small hard cirrhotic liver
Friction runs
Rough grating sounds indicative of peritoneal inflammation over organs with large surface areas
Venous hums
Rare, periumbilical from IVC, medium pitch, continuous, may have palpable thrill. Found with portal HTN, cirrhosis
Percussion
Should be tympanic, air/gas filled. dullness heard over solid or enlarged organs, fluid, mass, adipose tissue
Aerophagia
swallowing air- may be cause of belching
Odyophagia
pain with swallowing.
Esophageal ulceration- ? Radiation, caustic ingestion, infections ( Candida, CMV, HSV, HIV). Can be pill induced- NSAIDS, ASA
Chronic lower quadrant bowel pain
ask about change in bowel habits and alternating constipation/diarrhea
Dehydration
prolonged vomiting can lead to dehydration and electrolyte imblance.
Early satiety
abd fullness after light meal, UA to eat full meal. Diabetic gastroparesis, anticholinergic meds, pastric outlet syndrome, gastric cancer, hepatitis.
Dysphagia
difficulty swallowing, suggests structural abn or motiltiy DO. Sensation of lump in throat or restrosternal area are not assosicated w/swallowing- not dysphagia. Ask where dysphagia occurs.
Oropharyngeal dysphagia
drooling, nasopharyngeal regurg, cough from asp in muscluar/neurological DO affecting motility.
Zenker’s diverticulum
gurgling or regurg of undigested food- structural condition
Esophageal dysphagia
point to sternoclavicular notch
Dyspahgia of solid food
Structural esophageal condition: stricture, web, Schatki’s ring, neoplasm.
Increased flatus
aerophagia, legumes, other gas producing foods. IBS, intestinal lactase deficiency
Diarrhea
more than 200grms/24 hrs. Duration, frequency, consistency, mucus, pus, blood, tenesmus (constant urge to defocate), pain, cramps, invol straining, nocturnal, greasy/oily, frothy, fowl, float. . Acute last 2wks/fever- cause infection. Chronic more than 4 weeks- cause nonifectious (Crohn’s, UC)
Type diarrhea
High volume, frequent watery stools: small intestines
Small volume w/tenesmus or diarrhea w/mucus,pus, blood- rectal inflam conditions
Nocturnal diarrhea- pathological significance.
Steatorrhea
fatty diarrheal stools from malabsorption
celiac sprue, pancreatic insufficiency, sm bowel bacterial overgrowth.
Diarrhea causes
meds= PCN, macrolides, Mag based antacids, metformin, herbal/alter. medicine.
Ask about recent travel, diet patterns, baseline bowel habits, RF for immunocompromised.
Constipation
12 wks of past 6m. and 2 or more of: less than 3 BM/wk, 25% or more defocation- straining/sens incomplete evacuation, hard/lumpy stool, manual facilitation
Sigmoid colon obstruction
pencil shaped/apple core shaped hard stool
Causes constipation
Meds= Ca channel blockers, anticholinergic, Fe supplements, opiates. DM, hypothroid, hyperCa, MS, Parkinson, systemic sclerosis.
Obstipation
no gas or stool passage= obstruction
Melena
black tarry stool- as little as 100cc for UGIB
Hematochezia
red/maroon colored. 1000ml or more with LGIB
Hemmorrhoids
blood streak on surface of stool, not within
Jaundice
yellow discoloration of skin from bile pigment when Hgb broken down.
Normal Bilirubin
hepatocytes conjugate with unconj bilirubin, bile becomes water soluble, excreted into bile. Bile goes cystic duct- CBD-extrahepatic ducts-pancreatic ducts- duodenum at ampulla of Vater.
Mechanisms of jaundice
inc prod bilirubin, decr uptake bilirubin by hepatocytes, decr ability of liver to conj bilirubin, decr exc of bilirubin into bile- conj bilirubin gets reabsorbed into blood
Unconj bilirubn
occurs within first 3 mechanisms, hemolytic anemia inc prod and Gilbert’s syndrome
Conj bilirubin
Viral hepatitis, cirrhosis, primary biliary cirrhosis, drug induced cholestasis- OCP, methyl testosterone, chlorpromazine
Intrahepatic jaundice
hepatocellular, imp exc- from damaged hepatocytes or extrahepatic ducts.
Extrahepatic jaundice
obs extrahepatic ducts- commonly CBD, cystic duct.
Jaundice r/t urine color
when conj bilirubin inc in blood, may be excreted in urine- turning urine dark amber/tea colored. Unconj bilirubin not water soluble- not excreted in urine. Dark urine - imp excr of bilirubin into GI tract.
Jaundice r/t stool color
when no bile is excreted into intestines, stool becomes gray/light colored.
Acholic stool
stool without bile- viral hepatitis, obstr jaundice.
Jaunidce r/t itchy skin
Cholestatic/obstr jaundice, pain may signify distended liver capsule, biliary cholic, pancreatic CA
RF for liver disease
Hepatitis, Alcohol hepatitis, alcoholic cirrhosis, toxic liver damage (meds, industrial solvents, env toxins), GB disease/surgery- extrabiliarty obstr., Heriditary
Lloyd’s sign
Symptom of renal calculi. Pain in loin on deep percussion over kidneys
CV tenderness
Palm over CV angle, hit top of hand with ulnar side of fist. If tender: pyelonephritis, peri nephrotic abscess, kidney stones
Colon CA screening
Screening: 50y/o, colonoscopy q10 yrs. FOBT yearly, flex sigmoid Q 5y, barium enema Q5 y..
Screening for increased risk: single adenoma less than 1cm- 3-6 y,
Large adenoma bigger than 1cm 3y,
CRC resection: 1y after,
First degree relative younger than 60y, or 2 or more 10 years before youngest case.
H/O polyps q 3-5 yrs depending on type of polyp, usually adenomatous.
H/o Inflammatory bowel dz, first degree relative w/ polyps, CRC.
Genetic testing for inflam bowel dz.
other factors: DM, ETOH, obesity, smoking, high fat diet.
Protective factors: better diet, inc fruit/veg, high fiber, reg activity, ASA/NSAIDS.
Stress incontinence
Decreased intraurethral pressure
Involuntary/lack of awareness
Cognitive or neurosensory deficit
Men with partial bladder outlet obstruction
BPH, urethral structure
Suprapubic pain
Urinary tract, abdomen or back can be source
Pain of sudden overdistention of bladder
Acute urinary retention
Chronic is painless
Bladder Infection
Pain in Lower abdomen dull and pressure like
Dysuria
May feel like burning. Women- internal urethral discomfort, pressure, or ext burning across inflamed labia. Men burning proximal to glans.
Consider bladder stones, foreign body, tumor, acute prostatitis. Women- urethritis, ext burning- vulvovaginitis.
Prostatic pain
Perineum occasionally rectum
Urgency
May lead to urge incontinence.
Suggests bladder infection or irritation.
Urethritis
In men may have pain with voiding wo frequency or urgency.
Urinary tract symptoms
Urgency, frequency, hesitancy in starting, strain, reduced caliber and force of stream, dribbling
Frequency wo polyuria during day/ night suggests impairment to flow at or below bladder neck
Polyuria
Exceeding 3L in 24hrs. Abnormally high renal production.
Nocturia
Frequency at night. More than once. Volume varies. Clarify intake during day.
Urinary incontinence
Loss with increased abdominal pain or when urge to void. Stress inc- inc abd pressure- dec contractilty of urethral sphincter or poor support of bladder neck. Urge inc- unable to hold urine, detrussor over activity. Overflow inc bladder doesn’t empty fully- anatomical obs by prostatic hypertrophy, strictures or neuro abn. Functional inc- imp cognition, MS
Hematuria
Frank or microscopic. May be pink or brown tinged. Ask about beets, meds, menses
Flank pain
At or below posterior margin near CV angle. May radiate anterior lay toward umbilicus. Visceral pain, dull, achy, steady.
Ureteral colic
Sudden obstruction of ureter. Severe and colicky, at CV angle radiating around trunk into lower quad, upper thigh, testicles, labium. Ask about fever, chills, hematuria. Urinary stones or clots
ETOH
H/o pancreatitis, family Hx, DUI.
Exam: hepatoaplenomagaly, ascites, spider angioma, palmar erythema, peripheral edema, caput medusa ( collateral pathways of recanalized umbilical veins, radiating up abdomen, decompressing portal HTN).
Sequelae: fatal car accidents, suicide, mental health disorders, family disruption, violence, HTN, cirrhosis, malignancies upper Gi and liver.
Substance abuse
Rearranges brain neurotransmitters:
Tolerance, physical dependency, sensitization, craving, relapse.
Alcohol screening
Women: >= 3/occasion, >=7/ week
Men >= 4 /occasion, >=14/week
Hepatitis A RF
Fecal oral. Contaminated food or water, infected households. Hep A vaccine. Treat with immune serum globulin. Good hand washing
Hepatitis B RF
Sexual contact, people w/exposure to percutaneous blood, travelers. Hep B vaccine.
Hepatitis C RF
Blood exposure. High risk IVDA, Transfusion with clotting factors- before 1987. Other RF: HD, partners IVDA, blood Tx/ organ transplant before 1992, unDx liver dz, infants of +mothers, occupational exposure, mult sex partners, infected sex partner. Sexual transmission rare. Avoid tattoos.
Tips for Abd exam
Empty bladder, supine, pillow, arms at sides or folded a Ross chest. Point to pain before palpation, warm hands and stethoscope, avoid long fingernails, war h pt face for pain, if scared or ticklish palpate with patients hand first then use own.
Order inspect, auscultation, percussion, paplaption
Tips for Abd exam
Empty bladder, supine, pillow, arms at sides or folded a Ross chest. Point to pain before palpation, warm hands and stethoscope, avoid long fingernails, war h pt face for pain, if scared or ticklish palpate with patients hand first then use own.
Order inspect, auscultation, percussion, paplaption
Inspection of abdominal skin
scars, straie(pink purple straie with Cushing’s syndrome), dilated veins(hepatic cirrhosis or IVC obstr., rash/lesions
Inspection of umbilicus
contour, location, inflammation, bulges, hernias
Contours of the abdomen
flat, rounded, protuberant or scaphoid(concave/hollow)
Flanks bulge(ascites), local bulges. Suprapubic bulge- distended bladder or pregnant uterus
Check inguina/femerol areas.
Symmetrical- may be assymmetrical- enlarged organ or mass
Peristalsis
May be visible in very thin people. Increase waves- intestinal obstruction
Pulsations
Normal Ao pulsation visible in epigastrum. Increased pulsation- Ao aneurysm or inc pulse pressure
Ausculation
Bowel sounds reflect motility. 5-35X/min= normal.
Borborygmi
prolonged gurgles of hyperparistalsis
Bruit
may suggest vascular occlusive disease.
Listen over epigastrum(systole), and each upper quadrant. when pt sits, listen in CV angles.
Bruit at Renal, Iliac or Femerol arteries suggest S/D components- renal artery stenosis- d/t HTN.
If bruit only systolic- usually not occlusive
If S/D- turbulent flow- part. art. occlussion or arterial insufficiency
Friction Rub
Listen over liver and spleen.
Liver- tumor, gonococcal infection around liver, splenic infarction.
Percussion
Assess amount and distribution of gas in abd, identify possible masses that are solid/fluid- filled. Estimate liver/spleen size.
Percuss in all 4 quads, tympany(gas)/dullness(fluid/feces).
Protuberant abd tympanic throughout
Intestinal obstruction
Large dull areas of percussion
underlying ass, enlarged organ, pregnant uterus, ovarian tumor, large liver/spleen
Protuberant abd, dull sides
Note where dullness starts, may suggest ascites
lower ant chest percussion
right dull d/t liver. left tympanic d/t gastric air bubbles, splenic flexure of colon.
Situs Inversus rare- organs reversed.
Palpation
ID tenderness, muscular resistance, superficial organs, masses. Palpate with light gentle dipping motion.
Restistance on palpation
voluntary gaurding vs involuntary muscular spasm. Relax methods, feel relaxation of abd muscles that normally accompany exhalation, mouth breathe with jaw dropped open: Voluntary guarding decreases with these manuevers
Deep Palpation
To delineate abd masses: location, size, shape, consistency, tenderness, pulsations, mobility with respirations- correlate findings with percussion.
Abd masses
physiologic(pregnant uterus) Inflammatory(diverticulitis) vascular(AAA) neoplastic(CA colon) obstructiove(distended bladder or loop of bowel)
Peritoneal Inflammation
Abd pain/tenderness- esp a/w muscular spasm- suggest inflam of parietal peritoneum. Ask pt to cough- ?induce pain? Palpate to map tender area.
Rebound tenderness
Press fingers down with other handfirmly- withdraw quickly. Worse with pressure or when let go? point to exact pain. Rebound tenderness- peritoneal inflam.
Liver percussion
measure vertical span of dullness in R MCL. Start in area of typany(below umbilicus) and percuss upwards. ID lozer boarder of dullness in MCL.
Upper boarder of liver dullness in MCL: nipple line, lightly percuss from lung resonance down to liver dullness, move breasts aside.
Measure in cm distance between points.
6-12 cm R MCL or 4-8cm in MSL
Span of dullness increased when liver enlarged.
Liver dullness span decreased
decreased when liver small or free air present below diaphragm(perf. hollow viscus). Decreasing span- resolving hepatitis, CHF, progression of fulminant hepatitis.
Liver dullness displaced downward
COPD, span normal
Alter results of percussion
dullness of pleural effusion/lung consolidation may falsely increase estimated liver size. Gas in colon may produce tympany- falsey obscure liver dullness- decreasing liver size.
Palpabe Liver right costal margin
only half palpable- but if palpable, liklihood og hepatomegaly doubles.
Liver palpation
supine, left hand behind 11/12 rib posteriorly and forward- liver up. Right hand right abd, fingertips below lower border of liver dullness. Deep breathfeel liver meet fingers, slip fingers under- normal is soft, sharp, regular with smooth surface. May be tender- normal. Firm/hard, blunt/rounding, irregularity- abn liver.
Inspiration- liver palpable 3 cm below right costal margin in MCL.
If hard to find- move hands closer to coatal margin and repear. Maybe started too high in abd, start lower.
Gallbladder obstruction
oval mass below edge of liver- two are merges, dull- percussion
Hooking technique
use for obese pt., stand at right side facing feet. Use both hands, breath deep, bend fingers around lower edge of liver
Percussion tenderness of liver
left hand flat on lower rib cage, hit with ulnar side of fist of right hand- tenderness may be inflammation(hepatitis) or congestion(HF)
Spleen percussion
If enlarged, expands ant, down, medially-typany replaced with dullness. Becomes palpable at costal margin. Suggests splenic enlargement. 2 techniques:
- Left lower anterior chest wall- resonance above costal margin (Trabue’s soace), percuss towards back. Normally spleen posterior to midaxillary line. If dullness present- splenomegaly 80% chance. If tympany +, esp laterally- unlikely splenomegaly.
- Splenic percussion sign- percuss lowest interspace in left axillary line(tympanic), deep breath, percuss again. If spllen normal, stays tympanic. If dullness, + splenic percussion sign. Could be + with normal spleen.
Spleen palpation
left hand reach over to press back up, right hand press in at costal margin, deep breath and feel tip. 5% normal people have palpable tip. Causes: low, flat diaphragm(COPD) and deep inspiratroy descent. May miss spleen if start too high. Splenomegaly 8X more likely if spleen palpable. Causes: portal HTN, hematologic malignancies, HIV, splenic infarct/hematome.
Repeat in side lying position: left hand on back, right hand pushing in (2cm below left costal margin on deep insp).
Kidney palpation
not usually palpable. left side, right hand behind pt below/parallel to 12th rib, fingertips at CV angle. Left hand in LUQ, deep breath, press left hand in below costal margin to capture kidney between hands. If kidney palpable, note size, contour and tenderness.Repeat on eft side.
Left flank mass
may be splenomegaly or enlarged left kidney. Splenomegaly if notch is plapated on medial border, edge beyond midline, percuss dull, can probe deep to medial/lateral borders but not between mass and costal margin.
Enlarged kidney: normal tympany in LUQ, can probe with fingers between mass and costal margins, not deep to medial/lower borders.
Palpation right kidney
may be palpable, can feel supine, left hand under pushing up.May/may not be tender. May be located more anteriorly- confused with liver. Liver edge sharp/medial/lateral. lower pole kidney rounded.
Kidney enlargement
hydronephrosis, cysts, tumors. Bilateral enlargement- polycystic kidney disease
Percussion tenderness kidneys/CV
palm on back at CV angle, hit with ulnar surface opposite fist. Tenderness- pyelonephritis, may also be musculoskeletal
Bladder palpation
not usually palpable unless distended past symphysis pubis Dome feels smooth, rounded. ? Tenderness.
Bladder distention- outlet obstruction (urethral strictures, prostatic hyperplasia), medications and neurologic(CVA, MS). Suprabic tenderness- bladder infection.
Aorta palpation
deep, firm, slightly to left of midline. Not more than 3cm. RF for AAA: 65 y/o, Hx smoking, male, 1st degree relative with Hx of AAA repair.
Periumblical/upper abdominal mass
with expansive pulsations- more than 3 cm- suggests AAA. Do US after palpation. Pain=sign of rupture. AAA greater than 4cm, 15X more likely to rupture than smaller aneurysms
Ascites
fluid generally is dependant, gas floats. Percuss outward, should have tympany and dullness in circular pattern from rib to rib.
Ascites causes
Increase hydrostatic pressure: cirrhosis, CHF, constr. pericarditis, IVC or hepatic obstr.
Osmotic pressure: nephrotic syndrome, malnutrition, ovarian cancer.
Ascites shifting dullness
turn pt on one side and map tympany/dullness. In pt wo ascites, borders stay same. In ascites, dull is dependant, tympany on top.
Ascites fluid wave
Another person hands on both sides abd and pressin. You tap on one side and see if it you feel it on other side. Often negative with ascites.
Abd mass
Ballotte the organ or mass, with flat hands use ulnar side of palms and jab toward structure.
ppendicitis
Point to pain- usually umbilicus, then shift to RLQ, coughing increases it. Localized tenderness RLQ/flank. Early voluntary guarding may be replaced by invol rigidity. Rebound tenderness- peritoneal inflam
Rectal exam in men, vag exam in women- could be from inflammed seminal vesicle or adnexa
Rovsing’s sign
press deep into LLQ, resulting with pain in RLQ- + finding. Also with rebound tenderness- referred.
Psoas sign
hand above knee, pt raise thigh against hand. then left side- extend right leg, flex left hip. Flexion of leg at hp- muscle contracts extension stretches. Inc abd pain- + psoas muscle- irritation- inflammed appendix.
Obturator sign
flex right thigh at hip, knee bent, rotate leg internally at hip. Stretchs internal obturator muscle. Right hypogastric pain- + obturator sign, can be from irritation of inflamed appendix.
Cutaneous hyperesthesia
Pick a fold of skin without pinching. Localized pain with RLQ pain- appendicitis
Acute Cholecystitis
RUQ pain/tenderness. Murphy’s sign- hook fingers of right hand under costal margin. If liver enlarged- hook fingers and thumb under liver edge- deep breath- note degree of tenderness. + sign is sharp increased tenderness with sudden stop in insp effort. Means cholecystitis. Hepatic tenderness- increase with this manuever but ususally less well localized.
Ventral Hernia
Raise head and shoulders off table- bulge of ventral hernia will appear. Intestinal obstr or peritonitis may be missed by overlooking strangulated hernia.
Abd wall mass
raise head and shoulders. Mass in abd wall remains palpable, intra abd mass is obsured by musclular contractions
Tips for Abd exam
Empty bladder, supine, pillow, arms at sides or folded a Ross chest. Point to pain before palpation, warm hands and stethoscope, avoid long fingernails, war h pt face for pain, if scared or ticklish palpate with patients hand first then use own.
Order inspect, auscultation, percussion, paplaption
