Abdomen Flashcards
parietal peritoneum
lines internal surface of the abdominal wall
visceral peritoneum
lines organs within the abdominal cavity
Retroperitoneal organs
- Kidneys
- Ascending and descending colon (portions)
- Pancreas
- Duodenum (portions)
- Aorta
- Vena cava
- Periaortic lymph nodes
-Will present with back pain if there is a problem with these
appendicitis pain
epigastric pain that goes through to the back, does not wrap around
-visceral at first from distention of inflamed appendix - periumbilical then changes to pain in RLQ from inflammation of adjacent parietal peritoneum
visceral pain innervation
autonomic
Ex) liver when stretched
parietal pain innervation
skeletal
-Steady, aching pain - usually more sever than visceral pain and precisely localized over structure
referred pain
often develops as initial pain as initial pain becomes more intense
described as radiating or traveling from initial site
direct tenderness
when you push something it hurts
guarding
voluntary and involuntary
rebound tenderness
tenderness is when you let go, not when you push in
referred tenderness
when you push on some place, another place hurts
position for abdominal exam
Patient should be lying supine on table Hands at sides Head against table Knees bent with feet on table Drape above and below abdomen Respect patient’s comfort and modesty Keep the patient warm
Order of abdominal exam
inspection
auscultation
percussion
palpation
Inspection of abdomen
- skin (scars, striae, varicosities, rashes/lesions)
- umbilicus
- contour (round, flat, protuberant, distended, symmetry, visible masses)
- Peristalsis
- pulsations
mary joseph nodule
-aka sister mary joseph sign
palpable nodule bulgin into umbilicus due to metastasis of cancer in pelvis or abdomen
cause of protuberant abdomen
- sticks out farther than usual
- could be due to excess subcutaneous fat, loss of muscle tone, buildup of substances
distention of abdomen
air or fluid in abdominal space
Auscultation for bowel sounds
(diaphragm)
- Borborygmi – prolonged growling
- Obstructive bowel sounds
- Absent bowel sounds: wait, wait, wait!
typical quadrant to listen for bowel sounds
LLQ
percussion of abdomen
- Percuss all four quadrants
- -Tympany vs dullness
- -Distinguish gas from liquid from solid contents
- -Assess for peritoneal tenderness
- Percuss abdominal organs
- -Liver
- -Spleen
- -Gastric air bubble
- -Bladder
fluid sounds more dull than air filled spaces
all four quadrants should be slightly tympanic
palpation of the abdomen
- Light palpation
- -In all 4 quadrants
- -Assess for guarding, tenderness, obvious masses
- Deep palpation
- -In all 4 quadrants
- -Assess for tenderness, masses, organs
- Assess for rebound tenderness or peritoneal inflammation
- Palpate abdominal organs: liver, spleen, kidneys, aorta, bladder
- Be systematic and thorough
What is normally palpable
- sigmoid colon (LLQ)
- Liver edge (RUQ)
- Abdominal aorta (above umbilicus)
- Spleen (if enlarged) (LUQ)
- Kidneys (if enlarged) (either/both flanks)
Percussion of liver
- Liver span: R MCL nipple to umbilicus, normally 6-12cm
- tenderness
Palpation of liver
- RUQ, on patient’s right
- liver border at/below costal margin
percussion of spleen
- LUQ below costal margin in Traube’s space
- Splenic percussion sign @ L ant axillary line
palpation of spleen
- LUQ, on patient’s right
- patient in RLD position
Palpation of kidneys
- left kidney from patient’s left or right side
- right kidney from patient’s right side
CVA tenderness
pain with percussion suggests inflammation (pyelonephritis)
Auscultation of aorta
listening for bruits with bell
palpation of aorta
- mid abdomen for pulsations
- measure size (normal <3cm)
Percussion of bladder
dullness above pubic symphysis
palpation of bladder
- if distended above pubic symphysis, smooth and round
- tenderness may indicate infection
- beware of full bladder
inguinal lymph nodes
- superficial and deep nodes; only superficial are palpable
- superficial inguinal nodes;
- -horizontal group (drains superficial portions of lower abdomen, et.)
- -vertical group (drains region of leg)
Murphy’s sign
- Palpate deeply in RUQ
- Ask pt to inhale fully
- Positive Murphy’s sign = ARREST OF BREATHING and sharp increase in tenderness as inflamed gallbladder bumps into examiner’s hand
- Note that tenderness alone does not equal a positive Murphy’s sign, but should be noted
- Test for acute cholecystitis
Acute abdomen: peritoneal inflammaiton
- Appendicitis and other causes of acute peritonitis can be evaluated with several special techniques
- -Rovsing’s sign (referred rebound tenderness)
- -Psoas sign
- -Obturator sign
- Rebound tenderness, jar tenderness (smacking the side of the bed or asking if they experience pain going over bumps in the car), involuntary guarding, and other signs will likely be present in patients with acute abdomen
ascites
- Ascites can be present in a distended abdomen from many different causes
- Abdomen will be dull to percussion
- Special techniques can be used to confirm ascites
- -Fluid wave test
- -Shifting dullness
Fluid wave
- Ask the patient to press the hand down the midline of the abdomen and tap the side of the abdomen
- A positive fluid wave will be felt on the opposite hand
Shifting dullness
- Percuss abdomen with patient supine, and then with patient lying on one side
- In ascites, dullness shifts to the dependent position and tympany shifts to the top (air is lighter than fluid)
the ticklish patient
- Never take your hand off the abdomen
- Have warm hands and firm touch
- No sudden moves
- Distract patient with conversation
- Put patient’s own hand against abdomen, put your hand over theirs to palpate
Examining a child’s abdomen
- If child is apprehensive, it’s mostly an indirect exam
- Ask child to hop up and down or skip
- Ask them to show you their belly button
- Have parent do the palpation
- Use stethoscope to palpate
GU and Rectal Exams
- Part of the abdominal examination
- Generally performed after abdominal exam
- GU and pelvic problems often present with abdominal symptoms
pain
a patient’s experience, what they tell you
tenderness
objective measurement of the patients experience of pain
Pleurisy or acute MI Referred Pain
chest, spine, or pelvis
Pancreatic or duodenal Referred Pain
back
Biliary tree referred pain
right shoulder or right posterior chest
Auscultate for Bruits
(bell)
- Aorta
- Renal
- Iliac
- Femoral
shifting dullness or flank dullness can mean?
ascites
