Abdominal Flashcards
What are the indications for abdominal pain
Any patient with a suspected abdominal condition or injury.
What are the contradictions and cautions for abdominal pain?
Contraindications:
> None.
Cautions:
> Severe abdominal pain. Some patients may be in such severe pain that they are unable to tolerate a comprehensive abdominal assessment.
Inspection - abdominal pain
Inspection
> Scars. These indicate previous surgery or injury.
> Swelling. Abdominal swelling can be caused by a variety of things. A useful mnemonic is ‘the five F’s’:
– Fat: an overweight or obese patient will have a swollen abdomen.
– Fluid: ascites is a condition where the abdomen fills with watery fluid. It is seen in heart failure, renal failure, and liver failure.
– Foetus: a heavily pregnant woman will have a swollen abdomen.
– Faeces: a patient with constipation and faecal loading may have a distended abdomen.
– Flatus: this is gas in the bowel. If a patient has a bowel obstruction they will be unable to pass wind so the gas will build up in their bowel causing abdominal distension.
> Localised swelling/protrusion: this is usually
a result of a hernia (small pockets of abdominal contents protruding through the abdominal wall).
> Bruising: small bruises indicate subcutaneous injections (e.g. insulin or heparin). Larger bruises could indicate trauma, a bleeding disorder,
or a retro peritoneal condition such as acute pancreatitis.
> Erythema or rashes: this could indicate an infection or inflammation.
> It is also important to note the general appearance of the patient. For example:
– Do they look sick or not sick?
– Look at the whites of their eyes – do they look yellow? Jaundice is generally a sign of liver disease or obstruction of the bile ducts.
– Are they rolling around with colicky pain, or are they lying still with constant pain?
Auscultation- abdominal pain
The diaphragm of the stethoscope can be placed anywhere on the abdomen. The listener should hear irregular bowel sounds.
> Auscultation should be performed before palpation or percussion as these manoeuvres may alter the bowel sound frequency.
As the bowel moves contents along its length it makes sloshing and gurgling noises which
are associated with peristaltic contractions, and these noises are the ‘bowel sounds’.
> While some conditions can produce unique sounds (usually described as ‘high pitched’ tinkling noises) recognising these can be a challenge.
> Normal sounds include clicks and gurgles at a frequency of 5–34 per minute.
> It is best to simply document the presence or absence of bowel sounds, rather than trying
to decide if a bowel sound is abnormal or not.
The absence of bowel sounds is classically associated with ileus, a condition where peristalsis (contractions) within the bowel stops. This can occur in bowel obstruction or when the bowel is severely inflamed, for example in peritonitis
Palpating - abdominal pain
Palpation of the abdomen should be done with the fingers of the dominant hand. Initial palpation should be light, followed by deeper palpation.
> The patient should always be asked if they have any abdominal pain before palpating their abdomen, as the painful area should always be palpated last.
> The patient should be lying on their back, with the head of the bed totally flat (unless they cannot
lie flat due to shortness of breath) and their arms should be placed by their sides – this allows the abdominal muscles to relax.
> The hands of the examiner should ideally be warmed before palpation, and the examiner should watch the patient’s face during the examination so that any grimacing can be seen.
> Palpate while keeping your hand and forearm on a horizontal plane, with fingers together and flat against the abdomen.
> All segments (see image 2) should be palpated in a logical manner.
> It is unusual to feel individual organs during abdominal palpation. The abdomen should feel uniformly soft.
Image 2: Abdominal regions
> In a thin patient, hard masses may be felt in the
left lower quadrant. This is usually faecal matter in the sigmoid colon, but should still be documented. Pulsation of the aorta may also be found in a thin person above the umbilicus.
The most common abnormal finding on palpation is guarding. This is involuntary contraction of the abdominal wall muscles on palpation. It signifies irritation of the peritoneum. Guarding is usually associated with pain or tenderness.
> The abdomen of a young, fit person with good muscle tone often feels rigid, and in the absence of pain, this rigidity is not relevant.
> Abdominal rigidity is guarding all over the abdomen, not just in one localised area. This is a serious clinical finding.
> Do not test for rebound tenderness. This should not be used as it can be extraordinarily painful and will not provide any more information that palpation and percussion.
Percussion- abdominal pain
Percussion is used to tell if the structure under the skin where you are pressing is solid or hollow.
> Percussion is performed by tapping your middle finger which is resting on the patient’s abdomen, as seen in image 3. Depending on the area of the abdomen you are percussing, will depend on the sound elicited. As a general rule, if the percussion note is dull this indicates a solid structure underneath (such as the liver or spleen), whereas a tympanic percussion note indicates a hollow underlying structure (such as the stomach or intestine).
> Percussion notes can be very difficult to hear, particularly if you are in a noisy environment such as a moving ambulance.
> If the abdomen of someone with peritoneal irritation is percussed, it will be painful. This is a very useful test but should only be done once in each quadrant if there is pain or tenderness
Demonstrate a comprehensive abdominal assessment
A competent demonstration includes:
1 Explain the procedure and gain informed consent.
2 Inspect the abdomen for scars, swelling, protrusion and bruising.
3 Auscultate the abdomen and note the presence, regularity and type of bowel sounds.
4 Palpate the abdomen and note any abnormalities.
5 Percuss the abdomen and note any abnormalities.
6 Document the findings of the abdominal assessment on the eprf
