Abdominal Assessment

Question 1

what organs are located in the the RUQ and what could pain indicate there?

Answer 1

Liver, Gall Bladder, Duodenum, Head of the pancreas, Right kidney and adrenal gland, Hepatic flexure of the colon (ascending and transverse). Pain here could indicate possible: liver cirrhosis, hepatitis, biliary / renal colic, duodenal ulcer, cholecystitis and pancreatitis.

Question 2

What organs are located in the LUQ and what could pain indicate there?

Answer 2

LUQ = Spleen, Stomach, Left lobe of liver, body of the pancreas, L kidney and adrenal gland, Splenic fixture of the colon (transverse and Descending). Pain here could indicate possible: splenic rupture, pancreatitis (more commonly radiates to this quadrant than right), renal colic or idiopathic pain.

Question 3

What organs are located in the RLQ and what could pain indicate there?

Answer 3

Caecum, appendix, ascending colon , right ovary / fallopian tube, right ureter, right side of full bladder & right spermatic cord.
Pain here could indicate : Kidney stones or kidney infection, adrenal gland tumour, UTI, appendicitis, ureteral colic, localised caecum infection, polycystic ovaries, pelvic inflammatory disease, menarche, ectopic pregnancy, crohns (common in this quadrant), IBS, flatulence, ulcerative colitis.

Question 4

What organs are located in the LLQ and what could pain there indiciate?

Answer 4

Descending colon, sigmoid colon, left ovary and fallopian tube, left ureter , left side of full bladder & left spermatic cord.
Pain here could indicate : Diverticulititis (common in sigmoid colon), UTI, Bowel obstruction (common here but can occur any where), ureteral colic, polycystic ovaries, ectopic pregnancy, kidney stones or infection, adrenal gland tumour, pelvic inflammatory disease, menarche, IBS, flatulence, ulcerative colitis

Question 5

What could pain in the epigastric site indicate

Answer 5

pain could indicate: MI, AAA, Peptic or duodenum ulcer, oesophagitis, gastritis, pancreatitis, Mallory–Weiss syndrome & hiatus hernia.

Question 6

General inspection:hands,arms,axilla,face/ IAPP

Answer 6

General inspection:hands,arms,axilla,face/ IAPP,
If you palpate or percuss before auscultation you may stimulate a peristalsis.

Question 6

in what posistion should the patient be when doing an abdominal assessment?

Answer 6

Supine position:Knees bent with pillow under knees, pillow under head

Question 7

What is included in a general inspection

Answer 7

Look around bedside for treatments or adjuncts– feeding tubes /stoma bags /drains
Patient’s appearance –pain / agitation / confusion
Body habitus– obese / low BMI / cachectic
Scars –midline scars(laparotomy) /RIF(appendectomy) /right subcostal(cholecystectomy)
Jaundice–cirrhosis / hepatitis
Anaemia –obvious pallor suggests significant anaemia –e.g. GI bleeding
Abdominal distention –ascites / bowel distension / large masses
Masses –may suggest malignancy / organomegaly
Dressings –may be covering wound sites – infection / bleeding
Needle track marks –Hepatitis / HIV
Excoriations –pruritus –cholestasis

Question 8

What should you look for on a hand inspection and what do these signs mean?
-clubbing
-koilonychia
-leukonychia
-palmar erythema
-dupuytrens contracture

Answer 8

Clubbing –inflammatory bowel disease / cirrhosis / coeliac disease
Koilonychia –spooning of the nails– chronic iron deficiency
Leukonychia –whitened nail bed– hypoalbuminemia (liver failure/ enteropathy)
Palmar erythema –reddening of palms – liver disease / pregnancy
Dupuytren’scontracture:
Thickening of the palmar fascia
Associated with alcohol excess / family history

Question 9

What is the hepatic flap

Answer 9

Ask patient to stretch out arms, with hands dorsiflexed and fingersoutstretched
Ask them to hold their hands in that position for 15 seconds
The hands will flap(flex/extend at the wrist)in an irregular fashion if positive
Causes include – hepatic encephalopathy/uraemia / CO2 retention

Question 10

what should you inspect on the arms and axillae

Answer 10

Bruising –may suggest abnormal coagulation – e.g. secondary toliver failure
Petechiae –low platelets –e.g. splenomegaly
Excoriations –cholestasis
Track marks –intravenous drug use– Hepatitis / HIV

Axillae
Lymphadenopathy–malignancy / infection
Hair loss –malnourishment / iron deficiency anaemia
Acanthosis nigricans(hyperpigmentation)–GI adenocarcinomas / obesity

Question 11

what should you inspect on the eyes and what do these mean?
-Xanthelasma
-Conjunctival pallor
-Jaundice

Answer 11

Xanthelasma –raised yellow deposits surrounding eyes–hyperlipidaemia
Ask patient to lower one of their eyelids with their finger. Inspect for the signs below.
Conjunctival pallor –suggests significant anaemia
Jaundice –noted in the sclera –haemolysis / hepatitis / cirrhosis/ biliary obstruction

Question 12

What should you insepct in the mouth and what do these mean?
-Angular stomatitis
-Oral candidiasis
-mouth ulcers
-tongue(glossitis)

Answer 12

Angular stomatitis –inflamedred areas at the corners of the mouth –iron/B12 deficiency
Oral candidiasis –white slough on oral mucous membranes –iron deficiency / immunodeficiency
Mouth ulcers –Crohn’sdisease / coeliac disease
Tongue (glossitis) –smooth swelling of the tongue with associated erythema –iron/B12/folate deficiency

Question 14

What should you inspect on the neck and what do these signs mean?
-Cervical lymph nodes
-Virchow’s node

Answer 14

Cervical lymph nodes –lymphadenopathy may indicate infection / metastatic malignancy
Virchow’s node –left supraclavicular fossa –suggestive of gastric malignancy

Question 15

What should you inspect on the chest and what do these signs mean?
-Spider naevi
-gynaecomastia
-Hair loss

Answer 15

Spider naevi– central red spot with reddish extensions (>5 significant) –chronic liver disease
Gynaecomastia –overdevelopment of male mammary glands (pseudofeminisation)–liver cirrhosis / digoxin/ spironolactone
Hair loss –pseudofeminisation/ malnourishment / iron deficiency anaemia

Question 16

What is included in a detailed abdominal assessment during inspection?

Answer 16

-Position the patient supine, with their arms by their side and legs uncrossed
-Scars –midline scars(laparotomy)/ RIF(appendectomy)/ right subcostal(cholecystectomy)
-Masses–assess (size/position/consistency/mobility)– organomegaly /malignancy
-Pulsation –a central pulsatile and expansile mass may indicate an abdominal aortic aneurysm(AAA)
-Cullen’s sign –bruising surrounding umbilicus –retroperitoneal bleed (pancreatitis/ruptured AAA)
-Grey-Turner’s sign– bruising in the flanks–retroperitoneal bleed(pancreatitis/ruptured AAA)
-Abdominal distension –fluid(ascites) /fat(obesity) /faeces(constipation) /flatus/fetus(pregnancy)
-Striae–reddish/pink(new)or white/silverish(chronic) – abdominal distension
-Caputmedusae–engorgedparaumbilical veins–portal hypertension
-Stomas –colostomy(LIF) /ileostomy(RIF) /urostomy(RIF and containsurine)

Question 17

What are the main causes of distension and what do they mean?

Answer 17

Fat - obesity
Fluid – ascites
Flatus – obstruction / ileus
Faeces – constipation
Foetus – pregnancy

Question 18

What do striae or stretch marks on the abdomen indicate?

Answer 18

old silver stretch marks are normal where pink or purple striae can be due to Cushing’s syndrome (endocrine disorder that increases the amount of Adrenocorticotropic hormone produced).

Question 19

What do veins visible on the abdomen indicate?

Answer 19

(Caput medusae ) due to cirrhosis of the liver - obstruction of the inferior vena cava - portal hypertension

Question 20

What is ascites associated with?

Answer 20

heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis and cancer.

Question 21

What does a positive cullens sign and a positive greys turner sign indicate?

Answer 21

Cullen’s – Pancreatitis, could be peritoneal bleed.
Grey – Turner’s – Pancreatitis, peritoneal bleed or kidney damage.

Question 22

What should you do during auscultation and what should you listen for ?

Answer 22

Bowel sounds – Originate in the small intestine
Quality – Normal? Hyperactive? Hypoactive?
Start in Right Lower Quadrant (normally present)
Normal = clicks/gurgles (approx. 5-34 per minute)
If suspect no bowel sounds – ideally listen for five minutes to be sure.
-Bowel sounds
-Normal –gurgling
-Abnormal –e.g. “tinkling”(bowel obstruction)
-Absent– ileus / peritonitis

-Bruits
-Aortic bruits –auscultate just above the —umbilicus –AAA
-Renal bruits –auscultate just above the –umbilicus, slightly lateral to the midline

Question 23

What does hyperactive and hypoactive bowl sounds mean?

Answer 23

-Hyperactive bowel sounds – increased motility - early mechanical obstruction, gastroenteritis, diarrhoea, laxative use or subsiding paralytic ileus.
-Hypoactive – decreased motility – peritonitis, paralytic ileus following surgery or late obstruction.

Question 24

Why is percussion used and what should you feel, listen for?

Answer 24

-Percussion of the abdomen is used to help you to assess the amount and distribution of gas in the abdomen and to identify possible masses that are solid or fluid filled. It can also be used to estimate the size of the liver and spleen.
-Percuss the abdomen lightly in all four quadrants moving clockwise to assess the distribution of tympany and dullness………
Tympany usually predominates because of gas in the GI tract…..but scattered areas of dullness and fluid from faeces are also typical.
A protuberant abdomen that is tympanitic throughout suggests intestinal gaseous obstruction.

-Percussion is also useful for assessing peritoneal tenderness………sharp pain.
Abdominal pain when coughing or with light percussion suggests peritoneal inflammation. Percussion can stimulate and cause peritoneal pain.

Question 25

What should you look,feel for during palpations and how is it preformed?

Answer 25

-Light palpation first to about 1 cm depth, keep your hand low and flat no sharp prodding that could make the patient tense up, palpate the abdomen with light , gentle dipping motion. Keep your voice low and soft to help the patient relax and use imagery if necessary (Sunny beaches, warm sand, etc). Mild tenderness is normal over the sigmoid colon.
Ensure you lift your hand prior to moving to the next quadrant do not drag and move clockwise. Start away from painful area.

Feeling the abdomen gently is especially helpful for identifying abdominal tenderness, muscular resistance and some superficial organ enlargement and masses. It also serves to reassure and relax the patient.

If resistance is present try and distinguish between voluntary guarding and involuntary muscular spasm.

Voluntary guarding ………….occurs when the person is cold, tense or ticklish and is normally felt bi-laterally.
Feel for the relaxation of abdominal muscles that normally accompanies exhalation.
If a patient is particularly ticklish you can put your hand on top of the patient’ hand initially to overcome this.

Involuntary rigidity…………….is constant and board-like. It is a protective mechanism, accompanying acute inflammation of the peritoneum. It can be uni-lateral and the same area will elicit pain when the patient attempts to sit up. A board like rigidity is a serious sign.

Following light palpation instigate deep palpation of the abdomen in all quadrants (4-6 cm deep)
(this will be painful if the practitioner has long nails). With obese patients two hands may be required.

Localise the pain as accurately as possible…..ask patient to cough to help localise the pain. Then palpate gently with one finger attempting to map out the exact area of tenderness

If a mass is found you need to record;
Location
Shape
Size
Consistency
Surface (nodular or smooth)
Mobility (fixed or free)
Pulsatility
Tenderness
-Rebound tenderness–pain is worsened on releasing the pressure–peritonitis

Question 26

What is murphy’s sign and what does a positive result indicate?

Answer 26

Hook fingers under the liver border ask patient to deep breath
The liver descends during inspiration and the gall bladder will push against your hand
When this happens the patient may stop inspiration because it is painful. This is then said to be positive.

60 year olds - this test is unlikely to elicit the same result as 25% are shown not to have any tenderness.

A positive Murphy’s sign is associated with cholecystitis

Question 27

what is rovsing sign and what does a positive sign indicate ?

Answer 27

-Procedure:
1. The healthcare provider applies deep pressure to the left lower quadrant
of the patient’s abdomen.
2. The pressure is then gradually released while observing the patient’s
response.
2. Positive Rovsing’s Sign:
1. If the patient feels pain in the right lower quadrant when pressure is
applied or released from the left lower quadrant, this is considered a positive
Rovsing’s sign.
2. The pain occurs due to the shifting of gas or the movement of the
peritoneum, which causes irritation of the inflamed appendix on the right
side.
Why It’s Useful:
* A positive Rovsing’s sign strongly suggests appendicitis, as the referred pain
indicates inflammation of the peritoneum near the appendix.
* It complements other clinical signs (e.g., McBurney’s point tenderness, Psoas sign) to
strengthen the suspicion of appendicitis.
In summary, Rovsing’s sign tests for referred pain in the right lower quadrant when
pressure is applied to the left lower quadrant, aiding in the diagnosis of acute
appendicitis.

Question 28

What is bloombergs sign and what does it indicate?

Answer 28

If palpation does not establish an area of peritoneal inflammation then attempt to elicit rebound tenderness.
Press down with your fingers firmly (no long nails again) and slowly, then withdraw them quickly.
Watch and listen to the patient for signs of discomfort……….ask the patient if it hurts more pressing down or when removing fingers……..pain induced or increased by quick withdrawal constitutes rebound tenderness caused by rapid movement of an inflamed peritoneum associated with an appendicitis.

Question 29

What is lliopsoas muscle test and what does it indicate?

Answer 29

The Psoas sign is a clinical test used to help diagnose appendicitis or other conditions causing irritation of the psoas
muscle in the abdomen. It specifically tests for inflammation near the right iliopsoas muscle, which can become irritated
when the appendix is inflamed, particularly in cases of retrocecal appendicitis (when the appendix is positioned behind the
cecum).
How the Psoas Sign Test Works:
1. Positioning:
1. The patient is usually lying on their back (supine) or on their left side.
2. Procedure: There are two ways to test for the Psoas sign:
1. Passive extension method (more common):
1. The patient lies on their back while the healthcare provider gently extends (pulls backward) the
patient’s right leg at the hip joint, keeping the knee straight.
2. This stretches the psoas muscle.
2. Active flexion method:
1. The patient lies on their left side, and the healthcare provider extends the right leg backward,
asking the patient to actively flex (lift) the right leg against resistance.
2. Flexing the hip contracts the psoas muscle.
3. Positive Psoas Sign:
1. If the patient experiences pain in the lower right quadrant of the abdomen during either maneuver,
the test is considered positive.
2. This pain occurs because stretching or contracting the psoas muscle causes irritation to the inflamed
appendix, especially when the appendix is located close to or behind the psoas muscle.
Why It’s Useful:
* The Psoas sign is particularly helpful for diagnosing retrocecal appendicitis, where the appendix is positioned
behind the cecum and can irritate the iliopsoas muscle, leading to pain.
* It can also be used to differentiate appendicitis from other causes of abdominal pain, especially if pain is absent with
other common tests (like McBurney’s point palpation).
In summary, the Psoas sign test looks for pain with stretching or contraction of the psoas muscle, which can indicate
appendicitis or other abdominal inflammation near the muscle

Question 30

What is the mc burneys point?

Answer 30

Mc Burney’s Point is the name given to the area exactly above the appendix.

Question 31

what is the mucburnys signs and what does it indicate?

Answer 31

he McBurney’s point test is a clinical test used to help diagnose appendicitis, specifically by identifying tenderness at a
specific location on the abdomen. McBurney’s point is a spot on the lower right side of the abdomen, and tenderness in this
area is a key indicator of appendicitis.
How the McBurney’s Point Test Works:
1. Location of McBurney’s Point:
1. McBurney’s point is located about 1/3 of the way along a line drawn from the right anterior superior
iliac spine (the front of the hip bone) to the umbilicus (belly button).
2. Procedure:
1. The doctor or healthcare provider palpates (presses) on McBurney’s point to assess for tenderness or
pain.
2. The patient is asked whether they feel pain when pressure is applied, and they are also observed for signs
of discomfort or guarding (involuntary tightening of the abdominal muscles).
3. Positive McBurney’s Point Sign:
1. If pressing on McBurney’s point produces severe localized pain, this is a strong indication of acute
appendicitis.
2. Rebound tenderness may also be tested, where the examiner applies pressure and then quickly
releases it. If there is increased pain upon releasing the pressure, it suggests peritoneal irritation, a
sign that the appendix may be inflamed or ruptured.
Why It’s Useful:
* Localized pain at McBurney’s point correlates with the location of the appendix, especially in the early stages of
appendicitis when the appendix is inflamed but not yet ruptured.
* It helps differentiate appendicitis from other causes of abdominal pain, especially if combined with other symptoms
like fever, nausea, and elevated white blood cell count.
However, not all cases of appendicitis present with pain at McBurney’s point, as the appendix can vary in its position in the
abdomen, especially in children or pregnant women, where the appendix may be displaced. Therefore, the McBurney’s point
test is one part of a broader clinical assessment for appendicitis.

Question 32

What is the obturator sign and what does it indicate?

Answer 32

The Obturator sign is a clinical test used to help diagnose appendicitis, particularly when the inflamed appendix is located
in the pelvis. It tests for irritation of the obturator internus muscle, which can be affected when an inflamed appendix is in
close proximity.
How the Obturator Sign Test Works:
1. Positioning:
1. The patient lies on their back (supine).
2. Procedure:
1. The healthcare provider lifts the patient’s right leg and flexes the hip and knee to 90 degrees (bending the
leg at the hip and knee).
2. The provider then internally rotates the hip by gently moving the patient’s ankle outward while keeping
the knee stationary. This movement stretches the obturator internus muscle.
3. Positive Obturator Sign:
1. If the patient experiences pain in the lower abdomen, particularly in the right lower quadrant,
during this maneuver, it is considered a positive Obturator sign.
2. This pain occurs because the internal rotation of the hip causes the obturator internus muscle to rub
against the inflamed appendix, especially if the appendix is located in the pelvis or lower right part of the
abdomen.
Why It’s Useful:
* The Obturator sign is particularly helpful when the appendix is located in the pelvis or if there is suspicion of pelvic
appendicitis, which might not cause the usual pain in the typical McBurney’s point area.
* Along with other clinical signs (such as McBurney’s point tenderness and the Psoas sign), it helps to further pinpoint
the location of inflammation, contributing to the diagnosis of acute appendicitis.
In summary, the Obturator sign tests for pain caused by the irritation of the obturator internus muscle during hip movement,
which can indicate pelvic appendicitis or other nearby inflammatory processes.