Abdominal Flashcards
1
Q
what do the horizontal and vertical lines divide the abdomen into?
A
quadrants: right and left, upper and lower
2
Q
eipgastric, umbilical and hypogastric/suprapubic regions of abdomen
A
epigastric: above belly button
umbilical: level of belly button
hypogastric/suprapubic:below belly button to pubic bone
3
Q
which quadrant would the sigmoid colon be palpable?
A
LLQ
4
Q
which quadrant would the ascending be palpable?
A
RLQ
5
Q
which quadrant would the transverse/descending colon be palpable?
A
RUQ and LUQ
6
Q
which quadrant would the lower liver border be palpable?
A
RUQ
7
Q
which quadrant would the aorta be palpable?
A
umbilical/epigastric
8
Q
what are normally not palpable in the abdomen?
A
Much of liver, stomach Spleen Gallbladder, duodenum, pancreas Bladder (unless distended) Uterus
9
Q
where is the spleen generally located?
A
9th, 10th, 11th ribs against the diaphragm, posterior to left midaxillary line, behind and lateral to stomach above left kidney
10
Q
CVA tenderness indicates what?
A
kidney tenderness (costovertebral angle)
11
Q
where is the costovertebral (CVA) angle located ?
A
lower border of 12th rib and upper lumbar vertebrae
12
Q
three categories of abdominal pain
A
visceral, parietal and referred
13
Q
what is visceral pain and what quality and symptoms will it present?
A
When an organ becomes stretched or distended
Quality may be gnawing, burning, cramping, or aching
Sweating, pallor, nausea, vomiting, restlessness when severe
14
Q
where will visceral pain be felt?
A
as we develop, organs shift around from there original place (embryo/infancy)- but they keep the same nerve innervation- so the pain felt from the viscera may be felt (on the skin) in a different area-
15
Q
visceral pain from liver/biliary tree (gallbladder) is felt where?
A
Liver or biliary tree (gallbladder) – RUQ or epigastric
16
Q
visceral pain from stomach, duodenum and pancreas is felt where?
A
eipgastric region
17
Q
visceral pain from small intestines, appendix and proximal colon felt where?
A
periumbilical
18
Q
visceral pain from colon, bladder, uterus felt where?
A
hypogastric
19
Q
visceral pain from rectum, bladder felt where?
A
suprapubic
20
Q
what is parietal pain?
A
Inflammation from parietal peritoneum
Aching, more severe than visceral, more localized, aggravated by movement
- more precisely located
21
Q
what is referred pain?
A
As pain becomes more severe it sometimes felt at distant site innervated at approximately same spinal level
(as opposed to radiating pain that is a pathway of pain.. these are two separate points)
22
Q
abdominal pain may be referred from…
A
Abdominal pain may be referred from chest, spine, pelvis making assessment more difficult
23
Q
what is suprapubic pain likely from? severe pain from?
A
Bladder infection common cause and usually dull or “pressure” sensation
Severe pain is from sudden overdistention in acute urinary retention
24
Q
dull/achy kidney/flank/CVA pain usually from?
what if it is severe,colicky ?
A
Usually from kidney infection (pyelonephritis) if dull, achy, persistent; or obstruction of ureter (stone or blood clot) if severe, colicky
25
what is "colicky" pain?
collicky pain- usually from an obstruction of a tube- comes in waves (peristalsis pushing and relaxing, pain follows this kind of pain)
-nothing to do with a collicky baby..
26
what is jaundice/icterus caused by?
Increased levels of bilirubin (derived from breakdown of hemoglobin)
What normally happens:
-->Hepatocytes turn unconjugated (non-water soluble) bilirubin to conjugated (water soluble) with other stuff
-->excreted into the bile
-->Then excreted from liver
27
4 mechanisms of jaundice
1. Increased production of bilirubin – hemolytic anemia (RBCs being broken down)
2. Decreased uptake of bilirubin by hepatocytes–hemolytic anemia
3. Decreased ability of liver to conjugate – hemolytic anemia
4. Decreased excretion into bile results in absorption of conjugated bilirubin back into blood-viral hepatitis, cirrhosis
28
intrahepatic vs extrahepatic jaundice
Intrahepatic jaundice – damage to hepatocytes (hepatocellular) or impaired excretion (cholestatic)
Extrahepatic jaundice – obstruction of extrahepatic bile ducts (commonly cystic and common bile duct as in gallstones or pancreatic cancer)
29
icterus is...
jaundice of the eyes- yellowing of sclera
30
Impaired excretion of bilirubin into GI tract will give _____
dark urine
31
When bile completely obstructed from intestine, pt will get what kind of stools?
gray , light colored, or acholic (without bile)
32
what may be the first symptom of impending jaundice?
Generalized pruritus
33
4 parts of PE
Inspection
Auscultation
Percussion
Palpation
34
examine areas of pain ____, and watch for _____
Examine areas of pain LAST, Watch patients face for signs of pain
35
inspection of skin (5)
```
Scars
Striae
Dilated Veins
Rashes
Lesions
```
36
not "painful" to palpation but "____" to palpation
tender
37
what to note when inspecting the contour of the abdomen (6)
```
Flat, Distended, Obese, Protuberant
Symmetry
Enlarged organs
Masses
Peristalsis
Pulsations
```
38
7 parts of overall inspection
View tangentially
Skin – scars, striae, rashes, lesions, veins
Umbilicus – inflammation, hernias
Contour – flat, round, protuberant, scaphoid. Is it symmetric? Any visible masses or lesions?
Umbilicus - ?hernias
Movements – peristalsis (? obstruction)
Pulsations
39
what are striae?
wide purple stretch marks
40
what is caput medusae ?
Portal hypertension causes recanalization of umbilical vein which closes very early after birth
- will look like snakes over the abdomen from shunting of blood to other veins b/c can't go through occluded main vessel
41
spider angioma
A spider angioma is a type of telangiectasis (swollen blood vessels) found slightly beneath the skin surface, often containing a central red spot and reddish extensions which radiate outwards like a spider's web
42
when do you document cullens sign vs grey turners sign?
document if someone has pancreatitis w/ one of these
| - grey turners mean its more serious
43
common location for hernia?
umbilicus (especially in newborns)
44
what is cullens sign?
superficial edema and bruising of subQ fat around umbilicus - from free pancreatic enzymes (body is breaking down its own pancreas)
45
what is grey turners sign?
bruising of the flanks, the part of the body between the last rib and the top of the hip
blue discoloration, and is a sign of retroperitoneal hemorrhage, or bleeding behind the peritoneum
- can be from severe pancreatitis
46
two types of hernias
incarcerated hernia (cut off) and strangulated hernia (dead- red and tender)
47
auscultation of the abdomen: should be done _____ percussion and palpation
before - so you don't CAUSE sounds to occur
48
normal bowel sounds are ___ to ____ per min
5 to 34
49
Bowel sounds are transmitted well through the abdomen so usually you can listen in just one spot,____is a good place. However, if they are not heard there ...
RLQ
| ...search all the areas and don’t say “bowel sounds throughout”
50
borboygmi
long,prolonged bowel sounds (like stomach grumbling when hungry)
51
listen to liver and spleen for what? What does this indicate?
friction rubs : indicates inflammation of the outer capsule and peritoneum
Liver bruits can indicate liver cell carcinoma or acute alcoholic hepatitis
52
what three sounds are we auscultating for?
bowel sounds, bruits, rubs
53
when are bowel sounds increased and decreased?
Increased: Normal, diarrhea, or early mechanical obstruction
Decreased or absent:Intestinal paralysis (ileus associated with distension)
Peritonitis
54
4 places where we listen for bruits? what may this be an indication of?
Aortic, Renal, Iliac, femoral
Arteriosclerosis or aneurysm
Renal bruits can explain HTN
55
what would tympany vs dullness indicate in the abdomen?
Tympany throughout suggests intestinal obstruction
| Large dull areas suggest mass- pregnancy, distended bladder, organomegaly
56
what is "shifting dullness" used to evaluate? how is this maneuver performed?
to evaluate for ascites.
manuever: patient supine. Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.
patient rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated
57
what is "traub's point" (splenic percussion sign)? where is it and what are we looking for?
9th intercostal space: anterior axillary line to the midaxillary line SHOULD be tympanic (spleen lies just posterior to this area)
between lungs and costal margin: SHOULD be tympanic
-percuss this area to see if there is dullness in these locations--> may indicate splenomegaly
58
distended bladder will show percussion ____ to ____
tympany to dullness
(unclear note from Airey)..
59
technique for light palpation
Use flat hand, fingers together, light and gentle motion.
| Remove hand completely when changing places
60
light palpation to identify what 3 things?
Identify tenderness, muscle resistance, superficial masses
61
light palpation technique IF pt is guarding
Palpate when patient exhales
Have patient mouth breath
If patient too ticklish put hand over theirs
62
how do you palpate for the borders of the liver?
Midclavicular line at umbilicus (tympany) percuss up to dullness of liver edge
Next percuss midclavicular line resonance of lung down to dullness of liver
63
what width is normal for the liver at midsternal line? midclavicular line?
4-8cm
| 6-12cm
64
If you are unable to assess the liver by palpation you can _________________
how do you do this?
percuss it for tenderness.
put your left hand flat on the lower right rib cage and strike it with the ulnar surface of your right fist. Compare with same on left side.
65
visceral vs parietal pain
visceral- cramping/nausea/sweating/pallor
| parietal pain - localized stabbing/sharp/don’t want to move pain
66
kidney palpation technique
Stand on the patient’s side of kidney to be palpated
One hand at CVA lifting up
Other hand in upper quadrant lateral and parallel to rectus muscle
Patient to take a deep breath and at height of inspiration try to “capture” the kidney
67
aorta is usually not more that ___cm wide to palpation (feeling for pulsations)
3
68
how to distinguish between a mass IN the abdomen vs in the Abdominal wall
While supine have patient raise head and shoulders off of table (like doing a "crunch"). If mass still palpable then probably abdominal wall. If not palpable then probably abdomen
69
what is diastasis recti?
separation of the linea alba (vertical line between right and left abdominal muscles)
-will show a linear protruding mass (hernia) in the midabdominal region when lying supine)
70
Pain with cough, light percussion, or light palpation may indicate... ?
peritoneal inflammation
71
evaluation for peritoneal inflammation
Localize it as best as possible
May need to do rebound tenderness: press down slowly with fingers then let go quickly. If letting go is more painful than pushing down then positive for rebound
If pain felt elsewhere then that may be the source of the problem
72
Painful areas are not always ____
tender
73
Rebound tenderness indicates the ....
irritation of the parietal peritoneum
74
Do not deeply palpate a _______ or __________
grossly enlarged spleen or an obviously pulsating mass in the abdomen
75
CVA tenderness indicates _________
acute infection (pyelonephritis)or obstruction (hydronephrosis)
76
Rovsing's sign: what does it test for and what is the technique?
to test for appendicitis...
Press deeply and slowly in left lower quadrant (LLQ)
Quickly remove hand
Pain felt in right lower quadrant (RLQ)
77
psoas vs obterator sign : what is it for and what is the technique?
test for appendicitis...
Psoas sign is elicited by having the patient lie on his or her left side while the right thigh is flexed backward. Pain may indicate an inflamed appendix overlying the psoas muscle. ...
A positive obturator sign is pain that is elicited in a supine patient by internally and externally rotating the flexed right hip
pain indicates appendix overlying obturator muscle
78
cutaneous hyperesthesia
Gently pick up folds of skin without pinching.
| If painful in RLQ may be appendicitis
79
aaron's sign
Pain felt in epigastrium upon continuous firm pressure over McBurney’s point (line from belly button to ASIS)
-pain = appendicitis
80
markle sign (heel jar, drop test) : technique
With patient lying, hit bottom of feet one at a time
Patient standing knees straight, raises up on toes and drops on heels
Positive if painful
Pain will be in area of irritation
81
what is markle's sign a test for?
localized peritonitis due to acute appendicitis
82
what is murphys sign a test for?
cholecystitis
83
murphy's sign technique
Hook thumb or hands under costal margin at lateral border of rectus muscle
Ask patient to inhale
Push hand under costal margin (or under enlarged liver margin)
Marked pain, cease in inspiration = positive sign
84
pneumoperitoneum
Air under the diaphragm from a perforated viscus
85
any irritation of the peritoneum will cause ....
pain and possible rigidity in the abdomen
86
what do we look at air/fluid levels for?
mechanical obstruction picking up a tangled mess of
example: hose- the water would collect where the loops hung down (inferiorly)- air/fluid level
- when gut stops working- nothing moving forward- air backs up b/c you cant pass gas
air in the gut vs fluid
87
toxic megacolon is from what?
Ulcerative colitis
88
what is Ileus?
very tympanic- very air filled, protuberant abdomen
bowel is not working- not necessarily a mechanical obstruction (where air/fluid levels are off) but gut is not moving - happens after surgery or pancreatitis (something irritating the gut)
89
history for abdominal exam
Indigestion
Heartburn
Excessive gas – belching vs flatus
Early satiety/abdominal fullness – gastroparesis, gastric outlet obstruction, gastric cancer
Anorexia – loss or lack of appetite
Regurgitation – esophageal or gastric contents (esophageal narrowing)
Vomitus – what’s it look like. Bloody or “coffee grounds” is termed hematemesis
90
history continued..
```
N/V, diarrhea
Bright red blood (hematochezia); common for hemorrhoids
Melena is dark blood in stool
Surgeries
Medications (NSAID’s)
```
91
questions about pain for abdominal
```
Pain
Dysphagia is difficulty swallowing
Odynophagia is pain with swallowing
Change in bowel function
Constipation/Diarrhea
Jaundice
```
92
risk factors for abdominal complaints
```
ETOH use
Smoking
Medications (NSAID’s, OTC anti - acids)
Diet
Multiple sex partners
Family history (Crohn’s, IBS, cancer)
```
93
colon cancer screening starts at what age?
50
94
dysuria vs urgency vs frequency
Dysuria is pain or burning when urinating. Usually from infection (cystitis, urethritis)
95
polyuria
Polyuria is increase in volume. Consider diabetes
96
nocturia
awakening at night to void
97
urgency vs frequency
Urgency is immediate desire to void. Usually from infection.
Can lead to urge incontinence – unable to hold urine (detrussor overactivity)
Frequency is abnormally frequent voiding. With small volume infection, large volume diabetes
98
four parts of urinary incontinence
Urge
Stress
Overflow
Functional
99
incontinence urge
unable to hold urine (detrussor/bladder muscle overactivity)
100
incontinence stress
decreased contractility of urethral sphincter or poor support of bladder neck with increased intra-abdominal pressure
101
incontinence overflow
– bladder cannot be emptied until bladder pressure exceeds urethral pressure (anatomical obstruction or neurogenic abnormalities)
102
functional incontinence
urinary tract intact; impaired cognition, musculoskeletal problems, immobility
103
hematuria
Blood in urine
Gross hematuria can be seen with the naked eye
Microscopic hematuria only seen under microscope or on dipstick
Painless hematuria may be the first sign of kidney or bladder cancer
