abdominal and renal lab Flashcards
whats the correct order of abdominal exam?
1) inspect
2) auscultate
3) percuss
4) palpate (superficial then deep)
striae
Stretch marks; linear changes associated
with rapid stretching of skin. Examples include
pregnancy and rapid weight gain.
Pathologic causes include Cushings Disease or
Syndrome (secondary to high dose steroids).
Hernia:
Ventral, Umbilical, surgical
Separation of muscle wall that permits
extravasation of abdominal contents. Appears as a
protuberant mass of the abdomen
-gentle pressure applied will reduce (return the
abdominal content) through a defect in the
abdominal wall musculature.
-localized tenderness worsened with lifting or using
surrounding muscles
Incarcerated hernia
inability to reduce without
surgery
Strangulated hernia:
compromise of the vascular
supply; surgical emergency
diastasis recti
separation of the rectus abdominis
muscle causing a midline ridge formed by
abdominal contents. ONLY appears when the
supine patient raises head above the shoulder.
Clinically benign. Common in obesity, chronic lung
disease and after repeated pregnancies.
ascites
accumulation of serous fluid in the
peritoneal cavity. Causes include CHF, liver disease
obstruction of inferior vena cava and portal
hypertension; abdomen appears uniformly
distended
bulging flanks
fluid causes distension of the flanks
when the patient is supine.
what test for ascites as the best specificity and the best sensitivity?
specificity= fluid wave sensitivity= shifting dullness
how do you perform a fluid wave two examiners?
Patient is supine; one person has hands over each
flank. Second person places the ulnar surface of
each hand over the patient’s umbilicus and along
the abdominal vertical midline. The first person
then uses one hand to tap the flank and assesses
for a moderate to strong wave on the opposite
side. (fig. 11-35 in Bates’)
how do you perform a fluid wave one examiner?
the patient places the ulnar surface
of one hand along the midline to act as a baffle.
The physician taps one flank and monitors for a
fluid wave on the opposite side.
what does the fluid wave test detect? what is the sensitivity and specificity?
detects large volumes of free
intrabdominal fluid. It has a specificity of 80-90%; a
positive finding rules in ascites. However, its
sensitivity is ~50%, so a negative test does not
exclude ascites (i.e. it is volume dependent).
what is the puddle sign?
This is an auscultatory percussion
sign that requires the patient to support
themselves on their hands and knees for 5 minutes.
how do you perform the puddle sign?
The operator then listens with the diaphragm while
flicking a finger over a localized flank area of the
abdomen starting at the lowest point and moving
over to the opposite flank.
what is a positive sign for puddle sign
A positive sign is a
sudden increase in intensity and clarity of the
sound, signaling that the stethoscope has passed
the edge of the peritoneal fluid.
what is the sensitivity of the puddle sign
The puddle sign has a sensitivity of ~40 – 50%
especially with small amounts of ascites.
Positioning the patient makes it very difficult to
evaluate.
how do you perform shifting dullness
percuss the abdomen to identify
the borders of the dullness. Reposition the patient
on their side and percuss again to the borders of
the dullness. With ascites, the border of dullness
shifts to the dependent side (with gravity).
icterus
aka jaundice is yellow integument
secondary to bile pigments (scleral icterus)
when would you see caput medusa?
portal HTN (congestion of superficial veins)
what are other PE findings associated with liver disease?
- asterixis (liver flap)
- palmar erythema
whats asterixis
Course flapping tremor when
the arms are outstretched and hands dorsiflexed.
Movements are jerky forward movements every 5-
10 seconds.
what is palmar erythema?
warm redness of the skin over
the palms and soles of the feet in the Caucasian
populations. Darker skin tones may change from a
tan color to a gray appearance. Other signs of liver
disease should also be assessed, as this can also be
a normal finding in some individuals.
what are signs of liver failure?
asterixis, jaundice, ascites,
palmar erythema, spider nevi
small bowel obstruction risk factors
findings vary depending
on the location of the obstruction within the gut.
Individuals at risk for obstruction or that have had
prior obstruction, abdominal surgery or radiation,
or abdominal comorbidities such as inflammatory
bowel disease, cancer, etc.
what would you see on 2 view abd xray with SBO?
Air-fluid loops of bowel on
upright view
describe the abdominal pain, N/V, abdominal distention and bowel sounds in SBO
Abdominal pain: varies from vague to crampy;
constant or intermittent;
Nausea & vomiting: bilious or fecal odor
Abdominal distension: tympanic to percussion
or hyperresonant
Bowel sounds are high pitched and hyperactive.
Borborygmi may also be present. (the loud
sounds when you are hungry)
treatment for SBO
stabilize (fluid and pain management) -placement of NG tube to decompress cut and relieve vomiting. -Surgical consult
sympathetics upper GI
T5-10
sympathetics SI/ascending colon
T9-11
sympathetics ascending and transverse colon
T10-L2
sympathetics descending and sigmoid colon/rectum
T12-L2
Parasympathetic: Vagus nerve (OA/AA)
-Esophagus, upper GI, small Intestine, ascending
and transverse colon
Parasympathetic:S2-S4 (sacrum, pelvic splanchnic)
-Colon, rectum
Sympathetic: Genitourinary tract (includes bladder)-
T10-L2
Sympathetic: ureter
upper= T10-T11 lower= T12-L2
Parasympathetic:
-Kidneys, upper ureter
Vagus nerve (OA/AA)
Parasympathetic: -Bladder, lower ureter
S2-S4 (sacrum); pelvic splanchnic
kidney chapmans point
1 inch lateral, 1 inch superior to
umbilicus
bladder chapmans point
around the umbilicus
esophagus chapmans point
2nd ICS b/l
T2 b/l
pylorus chapmans point
sternal
right T10 at costotransverse joint
liver chapmans point
5th ICS on right
bw T5 and T6 on right
gallbladder chapmans point
6th ICS on right
b/w T5 and T6 b/l
pancreas chapmans point
7th ICS on right
b/w T7 and T8 on right
stomach acidity chapmans point
5th ICS on left
b/w T5 and T6 on left
spleen chapmans point
7th ICS on left
b/w T7 and T8 on left
small intestine chapmans pint
8-10 ICS b/l
upper= b/w T8 and T9 middle= b.w T9 and T10 lower= b/w T11 and T12
appendix chapmans point
tip of 12th rib
cecum, ascending and 1st half of transverse colon chapmans point
ant right thigh proximal to distal
prostate chapmans point
posterior lateral thigh
rectum, sigmoid colon, descending colon, 2nd half of transverse colon chapmans point
anterior left thigh- proximal to distal
CULLEN SIGN
ecchymosis around umbilicus secondary to hemorrhage
grey turner sign
flank ecchymosis secondary to hemorrhage
normal bowel sounds
5-34 clicks or gurgles per minutes
expected liver span on percussion
6-12 cm at the midclavicular line on right
expected spleen span on percussion
from ribs 6-10 at mid axillary line on left
what does rebound tenderness indicate?
peritoneal inflammation
what is visceral pain secondary to?
• Secondary to distention, stretching or
contracting of hollow organs, stretching the
capsule of solid organs or organ ischemia
• Usually felt in the midline at the level of the
structure involved
• Not localized
what is parietal (somatic pain) secondary to?
Parietal (Somatic)Pain
• Secondary to inflammation in the parietal
peritoneum
• Usually constant and more severe than visceral pain
- localized
- Aggravated by movement or coughing
- Alleviated by remaining still
Mcburneys point
McBurney’s Point: Rebound tenderness or pain
1/3 of the distance from the ASIS to the umbilicus.
Indicates possible appendicitis/peritoneal
irritation.
Clinically Significant Test- a positive test
helps to rule in appendicitis, while a negative test
makes appendicitis less likely.
rovsings sign
Pain in the RLQ upon palpation in
the LLQ. Indicates possible appendicitis
Clinically Significant Test- a positive test
helps to rule in appendicitis, while a negative test
makes appendicitis less likely.
iliopsoas muscle test
Have the patient flex their
hip against your resistance. Increased abdominal
pain is a positive test. Indicates irritation of the
psoas muscle from inflammation of the
appendix
Historical Test- May be referred to in a test
question but has low sensitivity and specificity for
appendicitis
obturator muscle test
Flex the patient’s right
thigh at the hip, with the knee bent, and rotate the
leg internally at the hip. Right hypogastric pain is
a positive test. Indicates irritation of the
obturator muscle from inflammation of the
appendix
Historical Test- May be referred to in a test
question but has low sensitivity and specificity for
appendicitis
heel strike
With patient supine, strike patient’s
heel. Positive test is abdominal pain. Indicates
possible appendicitis or peritonitis.
murphys sign
Palpate deeply under right costal margin during inspiration. Positive test is pain and/or sudden stop in inspiratory effort. Indicates acute cholecystitis or cholelithiasis.
courvoisiers sign
Enlarged non-tender
gallbladder. Indicates pancreatic
disease/cancer
lloyds punch/ CVA tenderness
Gently tap the area of the
back overlying the kidney (costovertebral
angles). Positive test is pain. Indicates an
infection around the kidney
(perinephric abscess), pyelonephritis,
or renal stone.
what is the expected width of aorta?
2-3 cm
presence of pulsatile mass suggest aneurysm
