Abdomen Content Questions Flashcards
What are the organs located in the RUQ?
- Organs: Liver, gallbladder, pylorus, duodenum, hepatic flexure of the colon, and head of the pancreas
What are the organs located in the LUQ?
Spleen, splenic flexure of colon, stomach, body, and tail of the pancreas, and transverse colon
What are the organs located in the LLQ?
Sigmoid colon, descending colon, left ovary
What are the organs located in the RLQ?
Cecum, appendix, ascending colon, right ovary
What structures are normally palpable/not palpable in the RUQ?
- The liver is soft and is soft difficult to palpate through the abdominal wall. The liver edge is often palpable at the right costal margin.
- The gallbladder and duodenum are generally not palpable
- The abdominal aorta often has visible pulsations and is usually
- palpable in the upper abdomen, or epigastrium
What structures are normally palpable/not palpable in the LUQ?
- The 9th, 10th, and 11th ribs protect most of the spleen. The tip of the spleen may be palpable below the left costal margin in a small percentage of adults
- It is easily palpable with splenic enlargement or splenomegaly
- In healthy people the pancreas cannot be detected.
What structures are normally palpable/not palpable in the LLQ?
- You can often palpate the firm, narrow, tubular sigmoid colon.
- Portions of the transverse and descending colon may
also be palpable, especially ifstool is present
What structures are normally palpable/not palpable in the RLQ?
Bowel loops and the appendix at the base of the cecum near the junction of the small and large intestines. In healthy people, these are not palpable.
What is visceral pain? Describe the type of pain and what qualities and what symptoms may be associated with this type of pain
- Pain that occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched
- Visceral pain varies in quality and may be gnawing, burning, cramping, or aching.
- When it becomes severe: sweating, pallor, nausea, vomiting, and restlessness may follow.
What is parietal pain? Describe the type of pain and what qualities and what symptoms may be associated with this type of pain
- Is pain that originates from inflammation of the parietal peritoneum, called peritonitis.
- It is a steady, aching pain that is usually more severe than visceral
pain and more precisely localized over the involved structure. - It is typically aggravated by movement or coughing. Patients usually prefer to lie still.
What is referred pain? Describe the type of pain and what qualities and what symptoms may be associated with this type of pain
- Referred pain is felt at distant sites which are innervated at the same spinal levels as the disordered structures.
- Referred pain often develops as the initial pain becomes more intense and seems to radiate or travel from the initial site.
- It may be palpated superficially or deeply but is usually localized.
What are some conditions that can cause acute RLQ pain?
- RLQ pain or pain that migrates from the periumbilical region, combined with abdominal wall rigidity on palpation, is suspicious for appendicitis
- In women, consider pelvic inflammatory disease, ruptured ovarian follicle, and ectopic pregnancy.
What are some conditions that can cause acute LLQ pain?
-
Diverticulitis - LLQ pain, especially with a palpable
mass - Small/large bowel obstruction - Diffuse abdominal pain with abdominal distention, hyperactive high-pitched bowel sounds, and tenderness on palpation
- Peritonitis - pain with absent bowel sounds, rigidity, percussion tenderness, and guarding
What are some conditions that can cause acute epigastric pain?
Epigastric pain occurs with gastroesophageal reflex disease (GERD), pancreatitis, and perforated ulcers
What are some conditions that can cause acute RUQ pain?
RUQ and upper abdominal pain are common in cholecystitis and cholangitis
In what order should you examine the abdomen?
inspection, auscultation, percussion, and palpation
What are the normal findings when inspecting the abdomen?
- Symmetrical
- Old silver striae or stretch marks are normal
- A few small veins may be visible normally
- Peristalsis is visible in very thin people
- The normal aortic pulsation is frequently visible in the epigastrium
What are the abnormal findings when inspecting the abdomen?
- Pink–purple striae are a hallmark of Cushing syndrome.
- Dilated veins suggest portal hypertension from cirrhosis (caput medusae) or inferior vena cava obstruction.
- Ecchymosis of the abdominal wall is seen in intraperitoneal or retroperitoneal hemorrhage
- Asymmetry suggests a hernia, an enlarged organ, or a mass.
- Inspect for the increased peristaltic waves of intestinal obstruction.
- Inspect for the increased pulsations of an abdominal aortic aneurysm (AAA) or increased pulse pressure.
What are the normal findings when auscultating the abdomen?
- Normal bowel sounds occur at a frequency of 5-34/min.
- Stomach growling (borborygmi) is normal when heard occasionally
What are the abnormal findings when auscultating the abdomen?
- Hyperactive bowel sounds - Seen in diarrhea / early intesnital obstruction
-
Hypoactive bowel sounds - Seen w/ an ileus / peritonitis.
- Before deciding that bowel sounds are absent, sit down and listen where shown for 2 min or even longer.
-
Bruits
- A hepatic bruit suggests carcinoma of the liver or cirrhosis.
- Arterial bruits suggest partial occlusion of the aorta or large arteries. Such bruits in the epigastrium are suspicious for renal artery stenosis or renovascular hypertension.
What are some techniques when lightly palpating the abdomen?
- Keeping your hand and forearm on a horizontal plane, with fingers together and flat on the abdominal wall, palpate the abdomen with a light gentle dipping motion.
- As you move your hand to different quadrants, raise it just off the skin. Gliding smoothly, palpate in all four quadrants
What is deep palpation used for?
Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses
What are some techniques when deeply palpating the abdomen?
- Again using the palmar surfaces of your fingers, press down in all four quadrants
- Identify any masses; note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or pressure from the examining hand.
- Correlate your findings from palpation with their percussion notes.
What are the 5 signs of peritonitis?
- Positive cough test - before palpation, ask the patient to cough and identify where the cough produces pain
- Guarding - voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted
- Rigidity - is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations
- Rebound tenderness - refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand.
- Percussion tenderness - Tenderness over an area percussed.
How do you correctly percuss the liver?
- Start at the right midclavicular line and move to a level well below the umbilicus in the RLQ
- Percuss upward toward the liver and identify the first area of dullness (this is the lower border of the liver)
- Next, start at the nipple line, and percuss downward while at the midclavicular line, and note the first sound of dullness. (this is the upper border of the liver)
- Measure the distance between the 2 points in cm and this is your vertical span of liver dullness.
How would you percuss the spleen?
- Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space.
- As you percuss along the routes marked by the arrows in the Figures 11-20 and 11-21, note the lateral extent of tympany
- If tympany is prominent, especially laterally, splenomegaly is unlikely
- Percuss the lowest interspace in the left anterior axillary line (Fig. 11-22). This area is usually tympanitic. Then ask the patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains tympanitic
How would you palpate the spleen?
- Ask pt. to keep arms at sides and if needed, flex the neck and legs
- With your left hand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue.
- With your right hand below the left costal margin, press in toward the spleen.
- Ask the patient to take a deep breath. Try to feel the tip or edge of the spleen as it comes down to meet your fingertips
- Note any tenderness, assess the splenic contour, and measure the distance between the spleen’s lowest point and the left costal margin. Approximately 5% of normal adults
have a palpable spleen tip.Splenomegaly is eight times more likely when the spleen is palpable
How do you percuss patients with ascites?
- Percuss for dullness outward in several directions from the central area of tympany. Map the border between tympany and dullness (Fig. 11-33).
How do you test for shifting dullness in ascites?
- Percuss the border of tympany and dullness with the patient supine, then ask the patient to roll onto one side.
- Percuss and mark the borders again (Fig. 11-34).
- In a person without ascites, the border between tympany and dullness usually stays relatively constant.
- In ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top
Where is Mcburney’s point located?
Classically, “McBurney point” lies 2 inches from the anterior superior spinous process of ilium on a line drawn from that process to the umbilicus (Fig. 11-38).
How do you conduct Rovsing sign?
- Press deeply and evenly in the LLQ. Then quickly withdraw your fingers
- Pain in the RLQ during left-sided pressure is a positive Rovsing sign
How do you conduct the psoas sign?
- Place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand.
- Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right leg at the hip. Flexion of the leg at the hip makes the psoas muscle contract; extension stretches it.
- Increased abdominal pain on either maneuver is a positive psoas sign, suggesting irritation of the psoas muscle by an inflamed appendix.
What is the obturator sign?
- Flex the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle.
- Right hypogastric pain is a positive obturator sign, from irritation of the obturator muscle by an inflamed appendix. This sign has very low sensitivity.
What is murphy’s sign and what does a positive sign indicate?
- Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin.
- Or alternatively, palpate the RUQ with the fingers of your right hand near the costal margin.
- Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Watch the patient’s breathing and note the degree of tenderness.
A sharp increase in tenderness with inspiratory effort is a positive Murphy sign. When positive, Murphy sign triples the likelihood of acute cholecystitis
How do you assess for Ventral Hernias?
- Ventral hernias are hernias in the abdominal wall exclusive of groin hernias.
- If you suspect but do not see an umbilical or incisional hernia, ask the patient to raise both head and shoulders off the table
- The bulge of a hernia will usually appear with this action
