Abdomen, Ascites Flashcards
What is the most important part of abdomen exam?
history and physical exam; 90% of diagnosis
What do you do before palpating/percuss abdomen?
listen
How many click/gurgles per minute?
5-34 per minute
Borborygmi
prolonged gurgles
Bruit + HTN=
renal artery stenosis
Bruit + tachycardia=
abdominal aneurysm
Where are most aneurysms?
bifurcation
What should the GI sound like during percussion?
Most tympanic with scattered dullness (stool/fluid)
Abnormal percussion sounds
Protuberant with increase in tympany
Large area of dullness
Dullness in flanks
What is the size of the liver at midclavicular line?
6-12cm
What are we assessing at Traube space?
size of spleen
When percussing Traube space laterally what do we expect to hear for a normal size spleen?
tympany
List peritoneal indicators
tender with movement tender with cough tender with light palpitation/percussion hyperaesthesia rebound tenderness tap tender
Rebound tenderness
increase in pain on release
Where do we palpate the gallbladder?
mid-liver body
Who do we use the hooking technique on?
obese and very pregnant ladies
Disease associated with splenomegaly
portal HTN, HIV, splenic infarct, hematoma, mononucleosis
If spleen is enlarged, where is it palpable?
2cm below L. costal margin on inspiration
If percussion is normal on spleen, do you palpate?
NO
In order to palpate the bladder, how much fluid needs to be in the bladder?
400-600mL
Symptoms associated with abdominal pain
anorexia, nausea, vomit, diarrhea, fever, chills, pain
Normal size of aorta
less than 3cm
Pain with distention/stretching of hollow abdominal organs (stomach and intestine). It is difficult to localize but is palpable near the midline. Pain described as gnawing, crampy and aching. If severe ptn present with pallor, N/V and restlessness.
Visceral pain
Pain associated with inflammation, usually in the parietal peritoneum. Pain described as steady, aching pain. It is localized over the involved structure and can be pointed at with an index finger. It is aggravated by moving and coughing. The patient usually wants to lay still.
Parietal pain
Pain felt in distant sites that are usually innervated at the same spinal level. It can be superficial or deep but is usually localized. For example, patient can feel pain in shoulder when have gallbladder pain.
Referred Pain
4 cardinal signs of appendicitis
anorexia, periumbilical pain, pain migrating to R. side of abdomen, vomit once they eat
When does the span of liver dullness increase?
liver enlarged
Disease associated with small liver
hepatitis and heart failure
What is dullness is percussed in Traub space?
splenomegaly or fluid/solids in the stomach
What is a positive spleen percussion sign?
change in percussion note from tympany to dullness on inspiration, suggestive of splenic enlargement
4 tests to assess for Ascites
Border of tympany and dullness
Shifting dullness
Fluid wave
Ballotte
Border of tympany
Percuss out in several directions from the central area of tympany and map the border between tympany and dullness. Patient is in supine position
Shifting dullness
After ascites border is completed, have patient turn to side and percuss the border. A normal result would be the border between tympany and dullness remain the same. Abnormal is the dullness shifts to the dependent side and the tympany shifts upward
Fluid wave
Press the edge of both hands down the midline of the abdomen. The pressure helps stop transmission of the sound wave through fat. Tap one flank sharply with fingertips and feel on the opposite flank for an impulse through fluid. Not the best test, a lot of false positives and negatives.
Ballotte
Straighten/stiffen fingers in one hand and jab the abdominal surface toward an anticipated structure, like the liver. The quick movement displaces the fluid so the fingertips can feel the organ surface.
4 tests for appendicitis
McBurney point, Rovsing sign, Poas, Obturator
McBurney point
Line two inches from the anterior superior spinous process of the ilium to the umbilicus. Check for guarding, rigidity and rebound tenderness.
Rovsing
Test for referred rebound tenderness. Press deep and even in the LLQ and quickly redraw. A positive is if pain is in the RLQ during L. side pressure.
Psoas
Two ways:
1. Place hand above patient R. knee and ask patient to raise thigh against hand.
2. Patient lays on left side and you extend R. leg to the hip.
Flexion= psoas will contract
Extension= psoas stretch
Increase in abdominal pain when test is done is a positive result and due to the irritation of the muscle by inflammation of appendix
Obturator
Flex the patients R. thigh at hip with knee bent and rotate the leg internally at the hip. This stretches the internal obturator muscle. If R. hypogastric pain is present, then it is a positive sign and due to the irritation of obturator muscle by inflammation of the appendix.
What does Murphy sign assess for?
acute cholecystitis
Clinical signs ascites
- anterior abdomen tympanic
- flanks dull
- fluid shifts
