Abdominal Assessment Flashcards
What landmarks are used to identify the abdomen?
- Superiorly by the inferior dome of the diaphragm (5th ICS)
- Posteriorly by the lumbar vertebrae
- Anteriorlaterally by rectus abdominis, transversus abdominis, internal & external oblique
- Inferiorly by the pelvic brim
Several organs are often palpable in the abdominal pelvic cavity except:
The stomach and much of the liver and spleen
A careful history alone can diagnosis 76% of abdominal cases. What questions should you ask?
“OLD CARTS”
- Onset
- Location
- Duration
- Characteristics
- Aggravating symptoms
- Relieving symptoms
- Time
- Severity
Also: is it migrating, & past medical, surgical, & social history
Visceral Pain
Typically, nonspecific & difficult to localize
- Palpable near the midline at levels that vary according to the structure
What characteristics might describe visceral pain associated w/ ischemia?
- gnawing, cramping, or aching varying in quality
- as the pain progresses systemic symptoms may follow:
- sweating, pallor, N/V, restlessness
Examples of RUQ visceral pain
- Hepatitis (including alcoholic hepatitis) or biliary pathology from liver distention
What is an example of periumbilical visceral pain?
- Suggestive of early acute appendicitis from distention of an inflamed appendix
- Gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum
What should you suspect if the visceral pain is disproportionate to physical findings?
Intestinal mesenteric ischemia
What is the cause of somatic/parietal pain?
Originates from inflammation of the parietal peritoneum, peritonitis, which can be localized or diffuse
What are the presentation differences of parietal pain compared to visceral?
- Parietal is a steady, aching pain, usually more severe than visceral pain
- More precisely localized over the involved structure
- Typically aggravated by movement or coughing
Common associated gastrointestinal symptoms include:
- indigestion
- nausea
- vomiting (including blood (hematemesis),
- loss of appetite (anorexia)
- early satiety
Referred pain
Felt in more distant sites that are innervated at approximately the same spinal levels as the disordered structures
- Often develops as the initial pain becomes more intense & seems to radiate or travel from the initial site
Pain of duodenal or pancreatic origin will have referred pain to where?
The back, pain from the biliary tree, to the right scapular region or the right posterior thorax
Pain from pleurisy or inferior wall myocardial infarction will have referred pain to where?
The epigastric area
How is discomfort defined?
A subjective negative feeling that is nonpainful (can include various symptoms such as bloating, nausea, upper abdominal fullness, & heartburn)
Which neuropeptides are interconnected to pain, bowel dysfunction, & stress
5-hydroxytryptophan and substance P
Your elderly patient states they cannot tolerate to stand up what should you take from this statement?
- Elderly patients tend to have diminished sensitivity to abdominal pain
- Possible appendicitis
Dyspepsia
Chronic or recurrent discomfort or pain centered in the upper abdomen, characterized by epigastric pain or burning (or both) & postprandial fullness or early satiety (or both)
Abdominal clinical exam should include:
- Make the patient comfortable in the supine position
- Keep arms at the side so the abdominal wall doesn’t stretch & tighten
- Appropriate draping
- Before: ask the patient. to point to any area of pain so that you can examine thses areas LAST
- Stand on the patient’s right side and use a systematic approach: auscultation, percussion, & palpation
- Watch the patient’s face for any signs of pain or discomfort
Signs of peritonitis:
- Guarding
- Rigidity
- Rebound tenderness
Key components of Liver & Spleen exam:
- Estimate the liver size along right MID-CLAVICULAR line by percussion
- Palpate & characterize the liver edge
- Percuss for splenic enlargement along Traube’s space
- Palpate for the splenic edge w/ the patient supine & in the R. lateral decubitus position.
What are the hallmark signs of Cushing syndrome
Pink-purple striae
Dilated veins suggest in the abdomen suggest?
Portal hypertension from cirrhosis (caput medusae) or inferior vena cava obstruction
When might you see ecchymosis of the abdominal wall?
Intraperitoneal or retroperitoneal hemorrhage
Bulging flanks are seen in _______.
Ascites
Suprapubic bulge is a sign of _______ , _______, & _______.
- Distended bladder
- Pregnant uterus
- Ventral, femoral, or inguinal hernias
Abdominal asymmetry suggests what 3 things?
- hernia
- enlarged organ
- a mass
What is the maximum you should auscultate the abdomen?
5 minutes
5-35 = normal range
Tympany during percussion predominates what?
Hollow or gas in the GI tract
Scattered areas of dullness are from what?
From fluid and feces
- sometimes even a full bladder
Guarding
Voluntary contraction of the abdominal wall, often accompanied by a grimace
Rigidity
An involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations
Rebound tenderness
Refers to pain expressed by the patient after the examiner presses down on an area of tenderness & suddenly removes the hand.
- To assess ask the patient “which hurts more”
An palpable liver edge below the ribs is suggestive of what?
Enlarged liver & cirrhosis (increased span/size of liver dullness)
Decreased dullness in alive is = to what?
Liver is small or free air BELOW the diaphragm (tympany)
What causes Liver dullness displaced downward by the low diaphragm. Size remains normal.
COPD
Firmness or hardness of the liver, bluntness or rounding of its edge & surface irregularity are suspicious for what?
Liver disease
You palpate a firm oval mass below the liver edge and an area that is dull to percussion what are you suspicious of?
An obstructed distended gallbladder that may have merged with the liver.
Traube’s space
Check for a splenic percussion sign (CASTELL sign)
- Percuss the lowest costal interspace in the LEFT ANTERIOR axillary line
- This area is usually tympanitic
- Usually does not cross midaxillary line
Causes of splenomegaly:
- Portal hypertension
- Hematologic malignancies
- HIV infection
- Infiltrative disease like amyloidosis
- Splenic infarct or hematoma
Where should you palpate a AAA
Press firmly deep in the epigastrium, slightly to the left of the midline
Age 50 a normal aorta =
< 3 cm wide
Risks factors for AAA:
- Age > 65 years
- History of smoking
- Male
- 1st degree relative w/ a history of AAA repair
Rupture is 15x’s more likely in the AAAs is ______.
> 4 cm
Ascites
A protuberant abdomen with bulging flanks is suspicious for ascites
What is the difference between ascitic fluid vs gas
Ascites - sinks with gravity
- dullness appears in the dependent areas of the abdomen
Gas filled loops of bowel = rise
Ascites may signal decreased osmotic pressure in:
- Nephrotic syndrome
- Malnutrition
- Ovarian cancer
What is a common cause of RLQ abdominal pain?
Appendicitis
What are some of the signs to test for appendicitis?
- McBurney point
- Rovsing sign (indirect tenderness from pushing down on the LLQ)
- psoas sign & obturator sign (involve movement of the thighs & hip)
Acute cholecystitis
RUQ pain, but does not have any tenderness on palpation in the RUQ
- Perform the test for Murphy sign
Ventral hernias
Defect in the abdominal wall that allows tissue to budge through (exclusive of groin hernias)
- ask the patient to raise both legs off the table or perform a Valsalva maneuver to increase intraabdominal pressure
Which hernias merit prompt surgical evaluation?
Strangulated inguinal, femoral, or scrotal hernias are an emergency.
Acute diverticulitis
Confined inflammatory process, usually in the LLQ that involves the SIGMOID colon.
- may be suprapubic or right-sided pain
A hepatic bruit is suggestive of ?
Carcinoma of the liver or cirrhosis
Arterial bruits with both systolic & diastolic components suggest ?
Partial occlusion of the aorta or large arteries
Bruits in the epigastrium are suspicious for ?
Renal artery stenosis or renovascular hypertension
Acute Salpingitis
Frequently bilateral, w/ tenderness usually just above the inguinal ligaments.
- Rebound tenderness & rigidity may be present.
- Motion of the cervix & uterus causes pain during a pelvic exam
