Abdominal Assessment Flashcards
Organ by quadrant
Abdominal Pain ( Visceral Pain )
Visceral pain is directly related to the organ involved and most organs do not
have an abundance of nerve fibers. Visceral pain is usually difficult to localized. The pain is
usually dull or aching, it can be constant or intermittent.
Abdominal pain ( Parietal Pain )
Parietal pain occurs when there is an irritation of the peritoneal lining. The
peritoneum has a higher number of sensitive nerve fibers, so the pain is generally more severe
and easier to localize. Pain is usually sharp, constant and on one side or the other.
Abdominal pain ( Referred Pain )
Referred pain is visceral pain that is felt in another area of the body and occurs
when organs share a common nerve pathway. It is poorly localized and generally constant in
nature. An example is a patient with a gallbladder problem that experiences referred pain in
the right scapula.
Abdominal assessment ( Review of Systems )
•General: weight gain or loss, skin color changes, fatigue
•Skin: yellowing of skin or eyes
•CV & Pulm: chest pain, SOB
•GI: last colonoscopy? Ever had an endoscopy? N/V/D/C, melena.
•GU: LMP, STI history, pregnancy history, kidney stones, urinary symptoms (different for male vs. female)
1 - inspection
Begin the abdomen exam with general inspection of the patient:
• Is the patient pale, diaphoretic, confused, writhing with discomfort, lying to one side,
hunched over, lying quietly?
Next, expose the abdomen and begin your visual inspection (drape the rest of the patient for modesty).
• Skin – temp, color, scars, striae, dilated veins, rashes, eccyhmoses
• Umbilicus – note any inflammation or bulges suggesting a hernia
• Contour - flat, rounded, protuberant, or scaphoid (markedly concave or hollowed)?
Symmetric? Inguinal or femoral hernias? Visible masses?
• Pulsations - aortic pulsation may be visible in thin patients or patients with large aneurysms
Flat
Scaphoid
Rounded
Protuberant
Umbilical hernia
Incisional hernia
2 - Auscultation
Auscultate the abdomen before performing percussion or palpation, maneuvers that may alter the characteristics of the bowel sounds.
If an abdominal pulsatile mass is seen on physical examination, auscultation over the
mass may identify the presence of turbulent flow (bruits) within the aorta
3 - Percussion
Tympany usually predominates because of gas in the GI tract, but scattered areas of dullness
from fluid and feces are also common.
3- Light Palpation
Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses.
If resistance is present, try to distinguish voluntary guarding from involuntary guarding or rigidity.
- Involuntary guarding signifies potentially serious
intra-abdominal problems! - Voluntary guarding usually decreases with the
following techniques:
• Ask the patient to bend the lower extremities at the
hip to make the abdominal muscles less tense. • Ask the patient to mouth-breathe with the jaws wide
open.
• Palpate after asking the patient to exhale, which
usually relaxes the abdominal muscles.
3- Deep Palpation
Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. Use one hand over the other.
Assessing Possible Peritonitis:
• Before palpation, ask the patient to cough and identify
where the cough produces pain.
• Then palpate gently to localize the area of pain. As you
palpate, check for the peritoneal signs of involuntary
guarding, rigidity, and rebound tenderness.
• Rebound tenderness is when the patient experiences
more pain after you release your hand from deep
palpation than they did from the palpation itself.
“Which hurts more, when I press or let go?
Assessing for Possible Appendicitis:
Patients with RLQ pain should be assessed for the possibility of appendicitis. • Assess for
• McBurney point tenderness
• Rovsing sign (indirect tenderness)
• Psoas sign
• Obturator sign
Assessing for Possible Cholecystitis:
Patients with RUQ pain should be assessed for the possibility of cholecystitis. • Assess for
• Murphy’s sign
complaints may require a rectal exam.
• Assessment of the prostate (particularly symptoms of
outflow obstruction) – we’ll discuss prostate exam in
our male genital exam section
• When there has been gastrointestinal bleeding
• Constipation
• Change of bowel habit
• Problems with fecal continence
• Specific rectal complaints
1- Abdominal Pain
Assess if the pain is acute or chronic.
Abdominal pain- alarm symptoms
• Sudden, severe onset
• Abdominal pain with fever
• Abdominal pain with discolored urine
• Abdominal pain with bloody stool or melanic stool
• Abdominal pain with hematemesis or severe, intractable vomiting
• Abdominal pain with jaundice
• Abdominal pain with unstable vital signs
Narrowing differential by pain location ( RUQ )
Gallbladder? Liver? Lower lung?
Narrowing differential by pain location ( LUQ )
Stomach? Pancreas? Lower lung?
Narrowing differential by pain location ( RLQ )
Appendix? Colon? Ovary?
Narrowing differential by pain location ( LLQ )
Colon? Ovary?
Narrowing differential by pain location ( Epigastric )
Stomach? Pancreas? Heart?
Narrowing differential by pain location ( Periumplical )
Stomach? Small Bowel? Aorta?
Narrowing differential by pain location (diffuse abdominal pain )
Bowel? Ruptured or Perforated Organs? Metabolic conditions?
Differential diagnosis
2 - constipation
The first step is determining whether the patient has constipation.
Range of normal is from 3 bowel movements per week to several per day. Patients preoccupied with their bowels may have unreasonable expectation of “regularity.“
• What do you mean when you say that you are constipated? •
What is “normal” frequency of bowel movements for you prior
to this?
• When you can defecate, what is the stool like?
Determine if the constipation is acute or chronic and if the patient has ever had similar episodes in the past.
constipation - alarm symptoms ( acute )
Acute-onset constipation should raise more alarm than chronic constipation. Acute constipation with any of the following are concerning for serious illness:
• Fever
• Severe abdominal pain
• Melena or frank GI bleeding
• Severe vomiting
constipation - narrowing differential
Once you have eliminated alarm symptoms, review the patient’s medical conditions, diet and medications to identify if any of those may be the source of the constipation
• Patients taken frequent antacids, opioids, sedentary lifestyle or lack of fiber are common
causes.
constipation - differential diagnosis
3- diarrhea
The most important first step is to determine the duration. The causes of acute and chronic diarrhea tend to be very different. In addition, acute diarrhea can cause rapid volume loss which should also be assessed for during both history and exam.
diarrhea - alarm symptoms
Most episodes of acute diarrhea will be self-limited and resolve within a few days. The biggest concern to evaluate for signs of volume depletion or electrolyte imbalances such as thirst, fatigue, muscle weakness or dizziness that may warrant intravenous fluid resuscitation and/or hospitalization.
Additional alarm symptoms include:
• Weight loss (>5lbs)
• Fever
• Recent antibiotic use
• Bloody diarrhea
• Awakening from sleep or incontinence while sleeping
• Immunosuppressed individuals
diarrhea - narrowing differential
Asking about:
• Quality: Is it frequent and voluminous? Is it intermittent and soft? Does it alternate with
constipation?
• Time course: Did it start suddenly? Was there any recent exposure or event? Has this been
gradual or is there a pattern?
• Associated symptoms: Is there bloating or gas? Does it occur after eating certain things?
• Relevant History: Have the traveled recently? Where do they work? Pets? Eating disorders?
These areas can begin to differentiate functional diarrhea (ie, IBS) from other causes.
diarrhea - differential diagnosis
4- nausea and vomiting
The approach to a patient with nausea and vomiting begins by: • Clearly defining the symptoms
Then characterizing their duration, severity, and
associated factors
nausea and vomiting - alarm symptoms
First, if this is a female patient, is she pregnant?
Next, assess for life-threatening causes. Nausea & Vomiting associated with:
• Bloody emesis or coffee-ground emesis
• Recent head injury, headache or altered mental status
• Neurological symptoms like weakness, blurred vision, paresthesia
• Severe abdominal pain
• Chest pain
• Inability to retain oral liquids (>8hrs in a child or >12hrs in adults)
nausea and vomiting - narrowing differential
Once you have eliminated pregnancy and alarm symptoms.
Continue to determine the symptom characteristics:
• Duration & time course (acute or chronic?): occurs at a specific time? With certain foods?
• Frequency: every morning? Every meal? Every hour? Constant nausea?
• Severity: unable to perform basic activities?
• Quality and quantity of vomitus: projectile? Undigested food? Spit?
• Associated symptoms: Diarrhea? Weight loss? Vertigo?
• Modifying factors: Only happens at certain times (riding in car)?
nausea and vomiting - differential diagnosis
constipation - alarm symptoms ( chronic )
Chronic constipation can also raise alarm when any of the following symptoms are also associated:
• Weight loss
• Melena or bleeding
• Family history of colon cancer
• Family history of inflammatory bowel
disease
• Age of onset over 50
Difficulty passing stools (even normally formed or soft stool)
defecation disorde
Sense of bloating and incomplete passage of stool
IBS
Lifelong dependence of laxatives since childhood/or history of laxative abuse
transitory disorder
