abdomen exam 3 Flashcards
common or concerning symptoms of GI disorders
-Abdominal pain, acute and chronic -Associated gastrointestinal symptoms including indigestion, nausea, vomiting including blood (hematemesis), loss of appetite (anorexia), early satiety
-Difficulty swallowing (dysphagia) and/or painful swallowing (odynophagia)
-Change in bowel function Diarrhea
-Constipation
-Jaundice
common or concerning symptoms of urinary and renal disorders
-Urinary symptoms including suprapubic pain; dysuria,
urgency, or frequency; nocturia or polyuria; urinary incontinence; hematuria
-Flank pain and ureteral colic
Visceral pain in the RUQ suggests
liver distention against its capsule from the various causes of hepatitis, including alcoholic hepatitis or biliary pathology.
Visceral periumbilical pain can be suggestive of
early acute appendicitis from distention of an inflamed appendix. It gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum.
For pain disproportionate to physical findings, suspect
intestinal mesenteric ischemia
contents of quadrants
RUQ= liver, gallbladder, pylorus, duodenum, hepativ flexure, head of pancreas
LUQ=spleen, splenic flexure, stomach, body and tail of pancreas
RLQ=cecum, appendix, ascending colon, terminal ileum, right ovary
LLQ= sigmoid colon, descending colon, left ovary
arteries of the abdomen
aorta, renal, iliac, femoral
Describe the difference between visceral, parietal, and colicky pain.
- Visceral= can be gnawing, cramping, or aching pain
- Parietal= steady, aching pain, more severe than visceral
- Colicky= crampy, intermittent
Name the correct sequence of performing the abdominal exam and explain why it is performed in this manner.
- Inspection
- Auscultation
- Percussion
- Light palpation
- Deep palpation
- Special tests
. Define normal from hyper and hypo active bowel sounds
- Hypoactive bowel sounds= frequency <5 per minute
- Hyperactive bowel sounds= frequency >34 per minute
. Describe generalized deep palpation of the abdomen
- Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. Use one hand over the other to perform this technique. Again, using the palmar surfaces of your fingers, press down in all four quadrants
percussion and palpation of the liver
o Estimate liver size along right midclavicular line by percussion
o Palpate and characterize the liver edge (surface, consistency, tenderness)
percussion and palpation of the spleen
o Percuss for the splenic enlargement along the traube space
o Palpate for the splenic edge with the patient supine and in the right lateral decubitus position
percussion of the kidneys
o Check for costovertebral angle (CVA) tenderness using fist percussion
Describe the assessment of ascites by the “fluid wave” technique
o Detects impulse transmitted through ascitic fluid from one flank to the opposite side, negative if no fluid wave
Describe the anatomic location of “McBurney’s point” and discuss the possible clinical implication of tenderness in this area
o Appendicitis 3x more likely if there is tenderness in McBurney’s point (McBurney sign)
rovsing sign
o Pain in RLQ caused by palpating in LLQ
when pt cant sit still think
kidney stone
condition that gets worse a few hours after meals
duodenal ulcer
condition triggered by exertion and relieved by rest
angina from inferior wall CAD
condition worsened by alcohol, chocolate, citrus, or coffee
gerd
explore pts hx
-chronic alcohol use
-chronic nsaid use
-increases in stress
food sticks or doesnt go down
xerostomia (insufficient saliva)
define acute persistent and chronic diarrhea
acute- less than 14 days
persistent - 14-30 days
chronic- more than 30 days
hx taking for diarrhea
-what meds are you taking
-does it occur at night
-have you travelled recently
hx taking constipation
-ask color and bulk
-what remedies have u tried
-ask about pas med hx
-what meds r u on
-ask if they have obstipation
-ask about blood in stool
obstipation
no passage of stool or gas
hx taking for urinary tract
-ask about frequency and urgency
-ask about any pain with urination
-ask about odor and smell
-ask about difficulty STARTING to urinate (especially men)
-ask about costovertebral angle pain
-ask about penis and scrotum in men
pain and obstruction in left colon cancer vs right colon cancer
right colon= illdefined pain and infrequent obstruction
left colon= colicky pain and common obstruction
causes of jaundice
either liver parenchymal disease or obstruction of bile flow
physical exam : inspection
-look at skin
-look at umbilicus
-look at contour of abdomen
cullens sign
-periumbilical ecchymosis
-abdominal wall hemorrhage (hemoperitoneum)
physical examination: auscultation
-always auscultate before palpating or percussing abdomen
-place diaphragm over abdomen to hear bowel sounds *normal frequency 5-34 sounds per minute
-place BELL over aorta, renal, iliac, and femoral arteries to listen for bruits
-place DIAPHRAGM over liver or spleen ot listen for friction rub
physical exam: percussion
percuss all 4 quadrants
-you should hear TYMPANY (hollow sound) over air filled structures such as the stomach
-you should hear DULLNESS over solid organs or you may hear dullness over an abdominal mass
percussing the liver
-percuss mid clav line 3rd -5th intercostal space until you hear dullness adn mark spot
-percuse umbilicus and up until you hear dullness again
midclavicular percussion should be 6-12 cm; longer than this indicated hepatomegaly
percussing the spleen
two techniques
1-pt supine, percuss 6th rib at anterior axillary line to costal margin (traubes space)
2-castells sign
*percuss interspace in left anterior axillary line and then have pt take deep breath and percuss again; if spleen normal percussion remains tympanic
physical exam: light palpation
-start with gentle probing with one hand
-identify any superficial organs or masses
-asses for voluntary guarding vs involuntary guarding
-use relaxation techniques to assess voluntary guarding
physical exam: rebound tenderness
*seen in peritonitis
occurs if pain increases when examiner decreases pressure against the abdomen
signs of peritonitis
-guarding- voluntary
-rigidity- pt INVOLUNTARILY contracts abdominal wall
-rebound tenderness
physical exam: liver palpation
-use back hand to support at 11-12th rib
-right hand pressures on abdomen inferior to border of liver and continue to palpate superiorly until liver border is palpated
-ask pt to take a deep breath= this makes it easier to find inferior border of liver
-hooking technique helpful if pt is obese
physical exam: spleen palpation
-palpate spleen with the left hand supporting the back and the right hand palpating the abdomen
physical exam: kidney plapation
left kidney
-move to pt left side and place right hand under 12th rib
-lift up to displace kidney anteriorly
-place left hand deeply into left upper quadrant while pt is at peak of inspiration and try to capture kidney between hands
right kidney
-return to pt right side
-use left hand to lift back while right hand feels deeply into right upper quadrant
-repeat same steps used for left kidney
physical exam: the aorta
inspection-look for pulsatile mass
palpation- assess width of aorta by pressing deeply into upper abdomen with one hand on each side of aorta
normal= less than 3 cm
murphys sign
pt stops breathing in and winces with a ‘catch’ in breath due to inflamed gallbladder being palpated as it descends on inspiration
due to gravity where should tympany and dullness be located on the abdomen in ascites
dullness should be located along lateral sides of abdomen while anterior portion should be tympanic
***when pt rolls to side there should be a shift in areas of tympany and dullness due to free fluid moving with gravity
special technique for ascites
testing for a fluid wave
psoas sign and obturator sign
*two other special techniques for appendicitis
psoas- hip extension
obturator- rotation of right flexed hip
