Abdomen/Pelvis Flashcards
- Epigastric region
- umbilical region
- hypogastric or suprapubic region
- right hypochondriac region
- left hypochondriac region
- right lumbar region
- left lumbar region
- right inguinal region
- left inguinal region
What are the 5 categories of abdominal pain?
Colic
Viseral
Ischemia
Inflammation
Referred
What is Colic pain?
Infection w/ bacteria/virus
forceful peristaltic contraction or body attempt to force contents through obstruction
What is visceral pain?
hollow organs contract or are distended, may be difficult to localize.
typically palpable near the midline.
How is visceral pain described?
gnawing
burning
cramping
aching
With severe visceral pain what associated symptoms can we see?
sweating
pallor
nausea
vomiting
restlessness
What is ischemia pain?
intense and continuous often related to strangulation/obstruction
What is parietal/inflammation pain?
originates from inflammation in the parietal peritoneum.
How is parietal pain described/localized?
What aggravates the pain?
Steady aching pain usually more severe, more precisely localized over the involved structure. Usually aggravated by movement or coughing.
What is Referred pain?
felt in more distant sites, often develops as the initial pain becomes more intense and seems to radiate.
May be felt superficially or deeply but is localized.
What is voluntary guarding?
pt consciously flinches when you touch him
What is involuntary guarding?
muscles spasm when you touch the patient, but he cannot control the reaction
What are the details of the health history we want to know for abdominal pain?
timing of the pain
acute vs chronic
describe in the patients own words
point to the pain site
difficulty swallowing
food intolerances
changes in bowel function, diarrhea, constipation, characteristics
any remedies tried
What additional health history for abdominal pain do we want to know?
rank the severity of the pain
factors that aggravate or relieve the pain
appetite changes
any indigestion, nausea, vomiting
past surgical history especially abdominal (adhesions)
Okay, last health history for abdomen?
Changes in urine color/odor
recent travel, blood transfusions, ETOH intake, environmental exposures
Family hx
urinary symptoms
screening for colon cancer
Females: menstrual/reproductive hx
Males: urinary, prostate issues
History Taking of Problems of the Abdomen:
GI Tract
How is the patient’s appetite?
Any symptoms of the following?
Heartburn
Excessive gas
abdominal fullness or early satiety
anorexia
What are the symptoms of heartburn?
a burning sensation in the epigastric area radiating into the throat; often associated with regurgitation/reflux
What are the symptoms of excessive gas?
needing to belch or pas gas by the rectum; patients often state they feel bloated
What is anorexia?
lack of an appetite
What is regurgitation?
the reflux of food and stomach acid back into the mouth; brine-like taste
What questions do we ask when pt c/o vomiting?
Amount?
type of vomit?
What types of vomit are there?
food
green- or yellow colored bile
mucus
blood
coffee ground emesis
What is blood or coffee ground emesis known as?
hematemesis
Questions to ask the patient about bowel movements?
Frequency?
Consistency?
Pain?
blood/black tarry stool?
color?
Ask about prior medical problems related to the abdomen such as?
hepatitis
cirrhosis
gallbladder problems
pancreatitis
Ask about what for abdomen history?
prior surgeries
foreign travel and occupational hazards
tobacco, alcohol, illicit drugs
hereditary d/o affecting the abdomen in family history
Questions to ask the patient about urinary history?
frequency
urgency
pain
color/smell
difficulty starting to urinate
leakage of urine
back pain at costovertebral angle (kidney) and lower back in men (prostate)
ask men about symptoms in the penis and scrotum
Pain in the RUQ could be?
Duodenal ulcer
hepatitis
hepatomegaly
pneumonia
cholecystitis
Pain in the LUQ can be?
Ruptured spleen
Gastric ulcer
aortic aneurysm
perforated colon
Pneumonia
Pain the RLQ could be?
Appendicitis
Salpingitis
Ovarian cyst
ruptured ectopic pregnancy
renal or uretal stone
strangulated hernia
Meckel diverticulitis
regional ileitis
perforated cecum
Pain in the LLQ could be?
Sigmoid diverticulitis
salpingitis
ovarian cyst
ruptured ectopic pregnancy
renal or ureteral stones
strangulated hernia
perforated colon
regional ileitis
ulcerative colitis
Periumbilical pain could be?
Intestinal obstruction
acute pancreatitis
early appendicitis
mesenteric thrombosis
aortic aneurysm
diverticulitis
Abdominal emergency
Subjective information
Progressive intractable vomiting
Lightheadedness w/ standing
Acute onset of pain
Pain that is becoming more intense over time
Abdominal Emergency
Objective information
Involuntary guarding
progressive distention
orthostatic hypotension
fever
leukocytosis and granulocytosis
decreased urine output
Acute Pain Surgical Emergency
Perforation or rupture of appendix leads to?
Peritonitis
Acute Pain Surgical Emergency
sudden onset spotting and persistent cramping lower quadrant shortly after missed period
female childbearing age think of?
ruptured ectopic pregnancy
Acute Pain Surgical Emergency
Sudden onset crampy umbilical (usually) pain could be?
Obstruction
Acute Pain Surgical Emergency
Sudden onset excruciating pain in chest or abdomen, radiates to legs and back
rupture/dissection of abdominal aortic aneurysm
What history supports AAA?
age > 65 y/o
hx of smoking
male gender
1* relative with hx of AAA with/without repair
Acute Abdominal Pain - Differentials
Steady pain unrelieved by position, LUQ into back
Acute pancreatitis
Acute Abdominal Pain - Differentials
Sudden onset colicky pain that progresses into constant, involuntary guarding
Appendicitis
Acute Abdominal Pain - Differentials
Colicky pain progressing into constant RUQ radiating to right scapular area
cholecystitis or cholelithiasis
Acute Abdominal Pain - Differentials
Sudden onset, crampy pain in umbilical area
Obstruction
Acute Abdominal Pain - Differentials
Constant severe pain RLQ or LLQ which increases with coughing or straining
Incarcerated hernia
Acute Abdominal pain - Differentials
Additional differentials
MI
Peritonitis
Mesenteric adenitis
Ureterolithiasis
UTI
Pyelonephritis
PID
Salpingitis
Intussusception
malrotation
volvulus
Pneumonia
Henoch-Schonlein purpura
Chronic Abdominal Pain Differentials - Lower
Crampy hypogastric pain that is variable, infrequent duration with gas, bloating, distention present 3 mo or more (functional)
IBS
Chronic Abdominal Pain Differentials - Lower
Abdominal pain or cramping, abdominal tenderness, diarrhea, urgency, rectal bleeding may be present (pathological)
Chron’s
Chronic Abdominal Pain Differentials - Lower
Abdominal pain or cramping, urgent persistent diarrhea with progressively looser stools, bloody stools, loss of appetite, weight loss (Pathological)
Ulcerative colitis
Chronic Abdominal Pain Differentials - Lower
Localized abdominal pain and tenderness
Diverticular disease
Chronic Abdominal Pain Differentials - Lower
Infrequent, dry stools and abdominal bloating
Simple constipation
Chronic Abdominal Pain Differentials - Lower
Lifelong history of constipation w/o PE abnormalities or occult blood
Habitual constipation
Chronic Abdominal Pain Differentials - Lower
Additional Diagnoses
lactose intolerance
dysmenorrhea
uterine fibroids
hernia
ovarian cysts
abdominal wall d/o
Chronic Abdominal Pain Differentials - Upper
Burning, gnawing pain mid epigastrium, regurgitation
GERD
Chronic Abdominal Pain Differentials - Upper
Burning, gnawing pain with EMPTY stomach, stress, ETOH intake
Peptic Ulcer
Chronic Abdominal Pain Differentials - Upper
Constant burning pain in epigastric area with/without nausea, vomiting, diarrhea, fever
Gastritis
Chronic Abdominal Pain Differentials - Upper
Diffuse, crampy pain, with/without nausea, vomiting, diarrhea, fever, and hyperactive bowel sounds (ova, parasite giardia)
Gastroenteritis
Chronic Abdominal Pain Differentials - Upper
Episodic periumbilical pain more than 1 hour with accompanied nausea, photophobia, headache, vomiting
Abdominal migraine
Examination of the abdomen - Inspection
Look for?
Empty bladder
comfortable positioning
presence of peristalsis
Umbilicus - any inflammation or bulges (ventral hernia)
Contour of the abdomen - flat, rounded, protuberant, scaphoid
Examination of the abdomen - Inspection
Skin
Color changes
scars
striae
dilated veins
rashes
ecchymosis
Examination of the Abdomen - Inspection
observe what for bulges?
is the abdomen ____?
are there any visible ___ or ___?
Any ____?
flanks, inguinal and femoral areas
symmetric
organs; masses
pulsations
When auscultating the abdomen what part of the stethoscope do you use?
diaphragm
What is Borborygmus?
rumbling bowel sounds
Auscultation
listen where?
if the patient has high blood pressure - auscultate where and for what?
listen for bruits where?
listen over the liver and spleen for what?
all four quadrants
epigastrium and in each upper quadrant for bruits
over the aorta, the iliac arteries, and femoral arteries
friction rubs
When during the assessment do you auscultate?
before palpating or percussing
Where to percus?
lightly in all four quadrants
Where to expect tympanic sound?
gastric air bubble
Where to expect hyperresonant sound?
base of the left lung
Where to expect resonant sounds?
normal lung
Where to expect dull sounds?
liver, spleen
Where to expect flat sounds?
thigh
Percuss the left lower anterior chest wall between lung resonance above the costal margin (Traube’s space). What does dullness mean?
What does tympany mean?
Dullness can indicate an enlarged spleen
When tympany is prominent, splenomegaly is not likely
Percuss the lowest interspace in the left anterior axillary line. This area is usually tympanic. Then have the patient take a deep breath and percuss again. What does tympany mean? What does shifting from tympany to dullness with inspiration suggest? This is a?
spleen is a normal size
enlarged spleen
positive splenic percussion sign
Light Palpation goes how deep?
Feels for?
1-2 cm
abdominal tenderness, muscular resistance
some superficial organs and masses
Deep palpation goes how deep?
Feels for?
3-4 cm
bowel masses, voluntary guarding, rigidity, rebound tenderness
Palpating McBurney Point feels for?
appendiceal irritation
Where is McBurney point?
just below the middle of a line joining the umbilicus and the anterior superior iliac spine
How to properly palpate the liver?
using the left hand support the back at the level of the 11th and 12th rib
the right hand presses on the abdomen inferior to the border of the liver and continues to palpate superiorly until the liver is palpated
While palpating the liver, asking the patient to take a deep breath can do what?
Illicit pain in patients with liver or gallbladder disease
makes it easier to find the inferior border of the liver
Why does the patient taking a deep breath make it easier to palpate the inferior border of the liver?
the diaphragm during deep inspiration forces the liver downward
How to palpate the liver in obese patients?
the “hooking technique”
place both hands side by side, on the right abdomen below the border of liver dullness
press in with the fingers and go up toward the costal margin.
Ask the patient to take a deep breath.
The liver should be palpable under the finger pads of both hands.
How to palpate the spleen?
Similar to palpating the liver, support the back with the left hand and the right hand palpating the abdomen
What does it mean if you can palpate the splenic tip?
may indicate splenomegaly because generally the spleen cannot be palpated even with inspiration.
How to palpate the gallbladder?
Located under the liver in the RUQ
Hooking technique
inspiratory arrest
What does pain radiating to the R shoulder indicate?
gallbladder problems
How to palpate the left kindey?
move to the patients L side. Place your right hand under the 12th rib. Lift it up, trying to displace the kidney anteriorly. Place your left hand in the left upper quadrant.
Ask the patient to take a deep breath. At the peak of inspiration, press your left hand deeply into the left upper quadrant trying to “capture” the kidney between your hands
How to Palpate the right kidney?
Return to the patients right side. Use your L hand to lift the back while your R hand feels deeply into the RUQ repeat the same steps as used for the L kidney
Where to palpate for kidney tenderness?
the costovertebral angel on each side of the back
Where to palpate for bladder tenderness?
suprapubic area
A protuberant abdomen with bulging flanks is suspicious for?
Ascites
fluid in the abdomen from diseases such as CA
Where is tympany and dullness expected in the abdomen? why?
dullness should be located along the lateral sides of the abdomen, while the anterior portion should by tympanic
Testing for shifting dullness: after mapping out the areas of tympany and dullness, have the patient roll to one side. Remap the areas of tympany and dullness. What is the expected finding in ascites?
there should be a shift due to free fluid moving with gravity
Test for a fluid wave: have the patient or an assistant press hands firmly down the midline. This pressure stops the transmission of the wave through fat tissue. What next?
Now tap on one flank sharply and feel with your own hand if the wave transmits to the other flank.
Assessing for appendicitis
Check for involuntary guarding and rebound tenderness where?
RLQ
Assessing for appendicitis
Check for Rovsing’s sign, which is what?
Patient lying, press in LLQ
Pain in RLQ is positive
Assessing for appendicitis
Check for Psoas sign, which is what?
Supine position, place hand over lower thigh and have patient raise the leg, flexing at the hip while you push downward against hip
Pain in lower quadrant is a positive sign
Assessing for appendicitis
Check for the Obturator sign, which is what?
supine position, flex right leg at hip and knee to 90 degrees. Hold leg just above the knee, grasp ankle, rotate leg laterally and medially.
Pain in hypogastric region is positive sign
Assessing for appendicitis
Markle heel drop test which is?
Patient stands with straightened knee rises on toes, then relaxes and allows heels to hit the floor, jarring the body/abdomen
Pain in the abdomen is positive
Abdominal Exam
General inspection looking for?
distension and painful areas as identified by patient
Abdominal exam
Auscultate for?
bowel sounds starting from pain free area and moving toward painful/tender areas
Abdominal exam
Percuss for?
Abnormal tones (dullness indicates air has been replaced with fluid or solid tissue)
Abdominal exam
Palpate for?
guarding, rigidity, tenderness
proceed from pain free to painful/tender areas
Absent bowel sounds can indicate?
ileus or peritonitis
Hyperactive bowel sounds can indicate?
gastroenteritis, early pyloric or intestinal obstruction, GI bleed
High pitched tinkling can indicate?
obstruction
Palpation
Involuntary guarding can indicate?
parietal peritonitis
Palpation
Mass can indicate?
neoplasm
obstruction
hernia
feces
Palpation
Pulsating mass in upper abdomen indicates?
aortic aneurysm
Palpation
groin incarceration indicates
hernia or ovary
Palpation
Groin torsion
ovary or testicle
Peritonitis acronym
P-
pain; front back, sides, shoulder
Peritonitis acronym
E
Electrolytes fall, shock
Peritonitis acronym
R
Rigidity or rebound of anterior abdominal wall
Peritonitis acronym
I
Immobile abdomen and patient
increasing pulse rate, decreasing BP
Increasing abdominal girth
Peritonitis acronym
T
Tenderness w/ involuntary guarding
Temp falls and then rises; tachypnea
Peritonitis acronym
O
Obstruction
Peritonitis acronym
N
nausea and vomiting
Peritonitis acronym
S
Silent abdomen
