Abdomen and Rectum PE

Question 1

common symptoms of abdominal disease

Answer 1

Pain
Nausea and vomiting
Change in bowel habits (constipation & diarrhea)
Rectal bleeding
Jaundice
Abdominal distention
Abdominal mass
Indigestion
Anorexia
Dysphagia
Hematemesis
Melena
Change in stool size
Weight loss

Question 2

types of abdominal pain

Answer 2

• visceral pain (colic pain) - source is usually hollow organ caused by distention or stretching. comes and goes, crescendo/decrescendo pattern. not well localized
• parietal pain - caused by inflamm of the peritoneum, steady aching pain that is usually well localized
• referred pain - from a distant site. R shoulder - gallbladder; L shoulder - spleen; back - pancreas or aorta

Question 3

adequate exposure of ab

Answer 3

xiphoid to pubis

Question 4

inspection of ab

Answer 4

skin - scars, striae, superficial veins

umbilicus - hernia, caput medusa

contour - flat, scaphoid, protuberant

pulsations or peristalsis

Question 5

auscultation of ab

Answer 5

• listen for bowel sounds before palpation and percussion (all 4 quadrants, RLQ best place to listen d/t cecum)
• normal bowel sounds - high pitched “tinkle” about every 3-5 sec
• no bowel sounds after 2 min - report as absent

Question 6

borborygmi

Answer 6

• increased, hyperactive bowel sounds
• low pitched rumbling
• hyperperistalsis

Question 7

abdominal bruits

Answer 7

soft sound made by disrupted arterial flow through a narrowed artery

aortic - b/w umbilicus and xiphoid
renal - lateral to aorta
femoral - along inguinal ligament

Question 8

percussion of ab

Answer 8

helps eval presence of: gaseous distention, fluid, solid masses, size and location of the liver and spleen

best done with pts in supine

percuss all 4 quadrants

Question 9

tympany

Answer 9

• most common percussion note

- presence of gas in the stomach and small bowel

Question 10

percussion of liver

Answer 10

• percuss along the R MCL from top to bottom
• resonant (lungs) to dull (liver) to tympanic (intestine)
• normal size <10cm

Question 11

ascites - fluid wave

Answer 11

place pt’s or assistant’s hand in midline. tap on one flank and palpate with the other hand. an easily palpable impulse suggests ascites

Question 12

ascites - shifting dullness

Answer 12

percuss the pt on their back and then their side. note where the sound changes from tympany to dull and the shift of the sound when the pt is turned to the side

Question 13

light palpation

Answer 13

1. detect tenderness and areas of muscular spasm or rigidity

2. use finger tips with a gentle motion

Question 14

deep palpation

Answer 14

1. used to eval organ size, abnormal masses, aorta, deep pain
2. one hand placed on top of the other

Question 15

rebound tenderness

Answer 15

eval for peritoneal tenderness and inflamm

tech: in the suspected area of the ab, slowly, gently, and deeply palpate. then, quickly remove the palpating hand

pt exp pain = + rebound tenderness

Question 16

Rovsing’s sign

Answer 16

referred rebound tenderness. press on the LLQ and release, pos if pain in the RLQ

Question 17

palpation of the liver

Answer 17

1. L hand under R 11th and 12th rib
2. R hand in the RUQ
3. instruct pt to breath deeply as examiner gently presses inward and upward with the R hand

Question 18

hooking technique

Answer 18

1. stand near the pt’s head
2. with both hands, hook your fingers around the lower R costal margin
3. instruct the pt to breath deeply while gently pulling inward and upward with both hands to palpate the liver

Question 19

palpation of the spleen

Answer 19

1. place L hand under the 11th and 12 ribs
2. place R hand in the LUQ under the costal margin
3. instruct pt to breath deeply as the examiner gently presses inward and upward

spleen not palpated in normal conditions

Question 20

palpation of the aorta

Answer 20

press firmly and deep in the upper abdomen with 2 hands

normal aorta - 2.5-3cm wide

Question 21

aortic aneurysm

Answer 21

pathologic dilation of the aorta. can be assoc with a bruit

assess with an ultrasound or CT scan

Question 22

palpation of the kidneys

sandwich method

Answer 22

1. place hand above and below the costal margins just lateral to the midline
2. deep and gently palpation attempts to palpate the lower pole of each kidney

kidneys not palpated under normal conditions

Question 23

percussion of kidneys 
CVA tenderness (Lloyd's sign)

Answer 23

with fist, gently hit the area over the costovertebral angle on each side of the spine

pain over a kidney may indicate an inflamm or infectious process of the kidney

examiner may also place a flat hand over the CVA and strike hand

Question 24

rectal exam

palpation or DRE

Answer 24

1. inform pt of what is going to happen
2. lubricate your gloved index finger
3. place your finger on the external sphincter and ask the pt to relax the sphincter mm
4. slowly insert the finger as the sphincter relaxes as far as possible
5. rotate your hand to palpate as much of the rectal surface as possible (in male, palpate prostate gland)
6. gently withdraw the glove and note the color of the fecal material and test for occult blood

note: nodules, irregularities, masses, tenderness, induation

Question 25

fecal occult blood testing

Answer 25

pt with pos FOBT req a thorough eval for CRC colonoscopy is the study of choice sigmoidoscopy and air contrast barium enema are acceptable alt

Question 26

anal warts

Answer 26

condyloma acuminata - HPV | condylomata lata - syphili

Question 27

appendicits - etiology

Answer 27

obstruction of the appendicular lumen, fecal or foreign matter, tumors or lymphomas

Question 28

appendicits - hx

Answer 28

pain starts peri-umbilical then shifts to the R lower quadrant nausea and vomiting anorexia fever

Question 29

appendicits - PE

Answer 29

``` RLQ pain and RLQ rebound tenderness decreased or absent bowel sounds + Rovsing's sign + psoas sign + obturator sign always do rectal exam and pelvic exam on female ```

Question 30

appendicitis - diagnostic work up

Answer 30

CBC - moderate leukocytosis with L shift urine - may contain a few WBC or RBC, helps R/O any GU condition plain x-ray - rarely helpful ultrasound - enlarged and thick walled appendix CT scan - most sensitive female pt - must do pregnancy test to R/O ectopic pregnancy BMP - eval electrolytes and renal functions, esp if pt has been vomiting

Question 31

acute cholecystitis - etiology

Answer 31

obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm

Question 32

acute cholecystitis - hx

Answer 32

RUQ postprandial pain, biliary colic pain pain radiating to the R shoulder nausea and vomiting anorexia obesity dever 5 Fs - female, fat, fertile, fair, flatulent

Question 33

acute cholecystitis - PE

Answer 33

RUQ pain and rebound tenderness decreased or absent bowel sounds abdominal distention + Murphy's sign - RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder diagnostic triad - RUQ pain, fever and leukocytosis

Question 34

acute cholecystitis - diagnostic work up

Answer 34

``` CBC - leukocytosis with L shift serum bilirubin - mildly elevated AST/ALT - elevated ultrasound - detect stones, thicken GB wall, dilated bile duct and fluid HIDA scan - radionuclide biliary scan CT scan ```