Abdominal Exam Flashcards
How should the patient best position themselves for an abdominal assessment?
Lying flat
If the patient struggles with their legs being flat they can bend them
Why should the patient lie flat for an abdominal assessment?
Abdominal muscles are relaxed
What should you be mindful to ensure you are observing for throughout the entirety of an abdominal exam?
Any signs of pain or distress
If any part of the assessment is causing the patient pain or discomfort
How would you best wish the patient to be exposed for an abdominal exam?
Exposed from nipples to knees - allowing for a full view of the abdomen
However, the absence of a shirt will usually be sufficient
What could abdominal distention indicate?
Fluid
Faeces
Flatus
Fat
Foetus
Tumour
You note asymmetry of the contours of the abdomen, what could this indicate?
Organomegaly
Massess
Fluid
What is organomegaly?
general term for the enlargement of an organ
Why should you check for any scars on the patients abdomen?
Scars can indicate any previous pathology requiring surgery
What is Cullens sign?
superficial oedema with bruising in the subcutaneous fatty tissue around the peri-umbilical region
What is Grey Turners sign?
Bruising evident on the flanks - between the last rib and the top of the hip
What can be observed in this photo?
Cullens sign - Bruising evident around the umbilical region
What can be observed in this photo?
Grey Turners sign - Bruising evident on the flanks
What are Cullens sign and Grey Turners sign both indicative of?
Pancreatitis
What can be observed in this photo?
Spider naevi
What are spider naevi?
Visible blood vessels underneath the skin
What do spider naevi often indicate?
Underlying disease, particularly alcoholic cirrhosis of the liver
Why are spider naevi sometimes observed in pregnant women?
In response to pharmacological agents often given in pregnancy
Caput medusae?
Due to portal hypertension
presents as a cluster of swollen veins in the abdomen, often concentrated around the belly button.
Increased pressure in portal vein caused by blood trying to get to the liver
Common cause of caput medusae?
The umbilical veins carry the blood to the heart but the increased pressure causes umbilical veins to become distended – liver cirrhosis
What can be observed in this photo?
Caput Medusae
When are stretch marks often observed?
Pregnancy and rapid weight gain
What can abnormal hair distribution be a sign of?
Endocrine problems
In females - polycystic ovarian syndrome (PCOS)
Where in the abdomen would you observe for pulsation?
Above the umbilical region from sideways on
When might you observe slight pulsation in the umbilical region?
Very thin people
What is a large visible pulsation in the umbilical region a sign of?
Abdominal aortic aneurysm (AAA)
What is a hernia?
occurs when an internal part of the body pushes through a weakness in the muscle or surrounding tissue wall
Where are hernias most commonly seen?
Epigastric
Umbilical
Femoral (in females)
Inguinal (in males)
How do you assess a patient for hernias?
Firstly look with the patient lying down
Then ask the patient to stand up and cough
If a hernia is seen, attempt to push it back in, if there is pain or it will not go back in when pushed, the patient should be referred for investigation
Why do you ask the patient to cough when assessing for hernias?
Coughing helps exaggerate any hernias if present
Name abdominal region 1
Right hypochondriac
Name abdominal region 2
Epigastric region
Name abdominal region 3
Left hypochondriac
Name abdominal region 4
Right Lumbar
Name abdominal region 5
Umbilical region
Name abdominal region 6
Left Lumbar
Name abdominal region 7
Right Iliac
Name abdominal region 8
Hypogastric region
Name abdominal region 9
Left Iliac
What organs are situated in the right hypochondriac?
Larger lobe of liver
Gallbladder
Right kidney
Small intestine
What organs are situated in the epigastric region?
Stomach
Smaller lobe of liver
Pancreas
Spleen
Duodenum (first part of small intestine)
Adrenal glands
What organs are situated in the left hypochondriac?
Spleen
Colon (large intestine)
Left kidney
Pancreas
What organs are situated in the right lumbar?
Base of liver
Right colon
What organs are situated in the umbilical region?
Umbilicus (navel)
Parts of the small intestine
What organs are situated in the left lumbar?
Descending colon (large intestine)
What organs are situated in the right iliac?
Appendix
Cecum
What organs are situated in the hypogastric region?
Urinary bladder
Sigmoid colon (large intestine)
Female reproductive organs
What organs are situated in the left iliac?
Descending colon (large intestine)
Sigmoid colon (large intestine)
Before palpating the abdomen, what should you first do?
Auscultate for bowel sounds
Why should you auscultate before palpating the abdomen?
Palpation of the abdomen can alter bowel sounds
Which side of your stethoscope should you use when auscultating the abdomen?
The diaphragm - picks up higher pitched bowel sounds
What is classed as ‘normal’ bowel sounds?
Irregular gurgling sounds
Frequency of 5-30 in a minute
If you hear over 30 bowel sounds in a minute what is this a sign of?
Hyperactive bowel - such as in diarrhoea
If you hear less than 5 bowel sounds in a minute what is this a sign of?
Underactive bowel - such as in constipation
What do absent bowel sounds indicate?
A possible bowel obstruction
When auscultating the abdomen you hear tinkling sounds, what can this indicate?
Early bowel obstruction.
How long should you ideally listen to bowel sounds in each quadrant?
1 minute
Where should you first auscultate the abdomen?
Right of the umbilicus
Move around the quadrants starting in the LRQ
Name quadrant A
Right upper quadrant (RUQ)
Name quadrant B
Left upper quadrant (LUQ)
Name quadrant C
Lower right quadrant (LRQ)
Name quadrant D
Lower left quadrant (LLQ)
Aside from auscultating for bowel sounds, what should you also auscultate for?
Bruits of the aorta, renal and iliac arteries
What is bruits, what causes it and what does it sound like?
abnormal sounds described as whooshing noises due to turbulent blood flow caused by atherosclerosis
How should you auscultates the aorta, renal and iliac arteries for bruits?
with the bell of your stethoscope - best at picking up low pitched sounds
How do you auscultate the aorta, renal and iliac arteries for bruits?
Firstly listen to the aorta
Then the renal arteries
Lastly the iliac arteries
Where would you best auscultate the aorta?
Just above the umbilicus
Where would you best auscultate the renal arteries?
2cm above the umbilicus and 2cm horizontally either side
Where would you best auscultate the iliac arteries?
2cm down from the umbilicus and 2cm horizontally either side
What would you expect to hear when auscultating for bruits in a healthy individual?
Nothing
Before palpating the patients abdomen, what must you first check?
If they have any pain
If a patient is complaining of pain in their right upper quadrant, what organs could this indicate an issue with ?
Underlying organs such as the liver; right kidney or gall bladder
If a patient is complaining of pain in their left upper quadrant, what organs could this indicate an issue with ?
Pancreas, spleen, left kidney
If a patient is complaining of pain in their lower left quadrant, what organs could this indicate an issue with ?
Descending colon
If a patient is complaining of pain in their lower right quadrant, what organs could this indicate an issue with ?
Ascending colon
Appendix
After palpating lightly in all 4 quadrants what should you do?
Palpate deeply
Test for guarding
What organs would you palpate in the right upper quadrant?
Liver
Gallbladder
What organs would you palpate in the left upper quadrant?
Transverse colon
Spleen
Pancreas
What organs would you palpate in the lower left quadrant?
sigmoid colon
descending colon
What organs would you palpate in the lower right quadrant?
appendix
What organs would you palpate in the hypogastric region?
Urinary bladder
What is guarding?
Guarding is the voluntary contraction of the abdominal muscles over inflamed organs or tissues below - to protect from pain
When would you most likely observe guarding?
Localised inflammation of an organ - for example in peritonitis or appendicitis
Why does guarding make abdominal assessments harder to conduct?
Often unable to feel organs below
Unable to palpate deeply due to patient discomfort
What is rigidity?
Involuntary muscle spasm due to generalised hardness and inflammation of the abdomen
Often global
When would you most expect to observe rigidity?
Peritonitis
When would you most likely expect to observe rebound tenderness?
Appendicitis
Peritonitis
What is McBurney’s point?
McBurney’s point refers to the point on the lower right quadrant of the abdomen at which tenderness is maximal in cases of acute appendicitis
Where is McBurney’s point?
The line between the umbilicus and the iliac crest, moving 1/3 of the way up from iliac crest
If rebound tenderness is observed on palpation of McBurney’s point, what is this indicative of?
Appendicitis
Explain Rosvings sign.
Palpate the lower left quadrant of the abdomen - If referred pain is experienced on the lower right quadrant this is indicative of appendicitis
What condition is rebound tenderness also common in aside from appendicitis?
Peritonitis
How do you test for rebound tenderness?
Palpate an area of the abdomen deeply and release quickly - if pain is experienced when the hand is removed, this is known as rebound tenderness
What is ascites?
Excess fluid in the abdomen
What condition is often the cause of ascites?
Liver failure
How would you percuss for the presence of ascites?
Percuss in a straight line from the umbilicus to the flank
You should hear tympany/hyper-resonance - if you hear any dullness, mark with tape for later reference
What does hyper-resonance/tympany on percussion indicate?
hollow, high, drumlike sounds that indicate the presence of air/gas
If dullness has been observed on percussion of the abdomen, which further 2 tests can you perform to confirm the presence of fluid in the abdomen?
The shifting dullness test - After determining an area of dullness in the abdomen, the patient is asked to roll onto the side of dullness, facing away from the examiner
Wait 30 seconds
Percussion from umbilicus to flank is repeated
A positive test: the area of dullness will shift to the dependent site and the area of tympany will shift towards the top
Fluid wave test - Ask the patient to place the ulnar aspect of their hand vertically above the umbilicus and push down
The examiner then taps one flank, while feeling on the other flank for the tap.
The result is considered positive if tap can be felt on the other side.
Why must a hand be placed in the centre of the abdomen during the fluid wave test?
The pressure on the midline prevents vibrations through the abdominal wall and prevents a false positive from the movement of tissue
Can the spleen often be palpated?
No
In a healthy individual the spleen will not be palpable
If the spleen is palpable, what is this called?
splenomegaly (enlarged spleen)
If the spleen is palpable, what is the common cause?
Glandular fever
Trauma
How do you palpate the spleen?
Stand on the right side of the patient, place your left hand under the LS ribcage to support the abdomen
Start at the umbilicus, move up towards the left upper quadrant palpating for the splenic edge by pushing down and up
Where do the kidneys sit?
Mostly under the ribs on both sides
How do you palpate the kidneys?
Normally unable to palpate
Bi-manual technique (2 handed).
Left hand behind pt just below 12th rib and in the costovertebral angle, lift left kidney upwards and place right hand in right upper quadrant to try to capture the kidney between both hands.
Ask pt to breathe in as palpating.
Repeat for right kidney, left hand underneath with right hand on top.
When palpating the kidneys what are you observing for?
Any tenderness or inflammation
What could tenderness or inflammation during palpation of the kidneys indicate?
pyelonephritis
What is pyelonephritis?
Pyelonephritis is the infection of one or both of the kidneys
What are the most common causes of pyelonephritis?
Untreated UTIs / infections of the bladder leading to the infection of the kidney(s)
Kidney stones
When palpating the liver, what should you feel?
Often not palpable, but if it is it should be smooth and anglular
What is the costal margin?
lower margin of the thoracic wall (bottom of the ribcage)
How do you palpate the liver?
Start by placing fingers in right iliac
Ask patient to breathe in and out, during the expiratory phase, move your fingers into position & during inspiration push inwards, trying to feel the liver edge.
With every breath gradually work your way up to the patient’s right costal margin.
Feel for the edge of the liver hitting your fingers
What might you feel on palpation of the liver that could indicate cirrhosis?
Wobbly surface - usually the liver should feel smooth and angular
If the liver is felt to be protruding below the ribs what could this indicate?
hepatomegaly
(hep-uh-toe-MEG-uh-le)
What is hepatomegaly?
The enlargement of the liver
In what condition is enlargement of the liver often seen?
Hepatitis
How would you test for Murphy’s sign?
Place left hand flat under patients right costal margin (rib cage) 2-3cm from midline
Ask the patient to take a deep breath in, as they breathe out push your hand up under their ribcage
If the patient experiences immediate pain when their gallbladder hits your fingers - this is a positive test
What does a positive Murphy’s test indicate?
Cholecystitis
When is cholecystitis most prevalent?
Heavy drinkers
5 F’s - female, forties, fair, fat, fertile
Why would you percuss the liver?
To assess the size
How would you percuss the liver?
Percuss downwards along the right mid-clavicular line from the top of the chest
Mark where the sound changes from norm-resonant to dull
Then starting at the bottom of the abdomen, percuss upwards until the sound changes from tympany to dull and again mark with tape
Measure the distance between the tape marks
Normal is between 6-12cm
After percussing the liver you measure more than 12cm, what could this indicate?
hepatomegaly - an enlarged liver
exampled in liver disease
When percussing all 4 quadrants of the abdomen what would you expect to hear?
Tympany / hyper-resonance
Unless directly over an organ/structure, where you would expect to hear hypo-resonance
When percussing the abdomen, you note hypo-resonance, what could this indicate?
Indicate an underlying organ, solid or fluid
What does DRE stand for?
Digital Rectal Exam
What exam SHOULD be included in a full abdominal assessment but should NOT be performed in an OSCE?
Digital Rectal Exam
Why should a DRE not be performed in the OSCE?
It is not appropriate or necessary in the situation
What omission should you ensure you note on any paperwork after stating a full abdominal exam has been performed, why?
A digital rectal exam (DRE) has not been performed - so it is not assumed it has been completed and therefore no adverse findings
How would you perform a DRE?
Ask the patient if they want a chaperone present
Get the patient to lay in the left lateral position with their knees tucked up to their chest
Using a gloved and lubricated index finger, insert it into the rectum feeling all 4 quadrants
What are you observing for in a DRE?
Pain
Bleeding
Faeces
Prostrate (men)
Cervix (female)
What is the costal margin?
lower margin of the thoracic wall (bottom of the ribcage)
What can be observed in this photo?
Caput Medusae
