Abdominal Exam Flashcards
Abdominal Anatomy
- top & bottom landmarks
- quadrants
- Regions
- organs in each quadrant
exposing from the xiphoid process of the sternum to the pubis symphysis & to the costal margins
Quadrants
- RUQ
- LUQ
- LLQ
- RLQ
Regions (9)
- epigastric (middle uppermost)
- right hypocondriac
- left hypocondriac
- umbillical (middle of middle)
- right lumbar
- left lumbar
- hypogastric (suprapubic) (middle of bottom)
- right illiac/inguinal
left illac/inguinal
Organs in quadrants
RIGHT UPPER Q
- liver
- gallbladder
- lower pole of right kidney
- part of the colon
LEFT UPPER Q
- pancreas
- spleen
- stomach
- part of colon
RIGHT LOWER Q
- ascending colon
- cecum
LEFT LOWER Q
- decending colon
ABDOMINAL ORGANS
- Kidney Specifics
- at what rib level
Kidneys
- two: sitting retroperitoneal in the cavity
- sit at the level of the 11th and 12th rib
- the right kidney sits lower because of the liver
ABDOMINAL ORGANS
- vasculature
- abdominal aorta
- branches to the renals
- branches to the illac to the legs
- branches to the femorals
- Vena Cava on the right hand side
ROS
- what systems do you include
- types of abdominal pain (viseral v parietal)
GI: pain, vomiting, nausea, bowel changes, weight cahnges, heart burn, jaundice
Renal/ Urinary: suprapubic tenderness, color of urine, requency, urgency, flank pain
- DONT FORGET ASSOCIATED symtpoms: weight loss, night sweats, N/V/D, fever
ABD PAIN
visceral : pain due to streching or distention of the hollow organs
- ischemia can cause visceral pain
- poorly localized to a specific area : because there arent great pain receptors on the organs themselves
- will be gnawing, cramping, aching pain
parietal: due to inflammation in the parietal peritoneum
- usually well localized over the point of inflammation
- aching, sharp pain thats steady
- worse with movements and coughing
- usually parietal pain is more severe than visceral
- dont forget referred pain: appendicitis, cholescystitis
- referred pain is a result of the dermatomal patterns of nerve innervation
ROS
- Indigestion
- Nausea
- Vomiting
- Diarrhea
- Constipation
- Fecal Incontinence
- Jaundice
- Dysphagia
- Odynophagia
Indigestion
- distress correlated to eating
- ask to described: heartburn, reflux, burping etc.
Nausea
- ask if its associated with vomiting
- triggers: time of day, foods, etc.
Vomting
- color and quality (hematemisis: brigh red think upper GI, ground coffee: think lower GI)
Diarrhea
- triggers
- quality and color
- abx. intake
Constipation
- alternating with diarrhea?
- color of blood?b bright red or black/tarry
- ask about medications
Fecal Incontinence
- laxitive use
- ask about timing of meals
Jaundice
- ask about alcohol or drug use
- hepatitis risk
- sexual behaviors
Dysphagis
- difficult to swallow
- solids: think structural etiology
- solids and liquids: think motility disorder
- location: above or below the chest
Odynophagia
- painful swallowing
- differentiate between this and a sore throat
Urinary ROS
- dysuria
- urinary frequency
- hematuria
Dysuria
- discomfort with urination
- pain, burning, color change
- ask about sexual behaviors
- any flank pain, suprapubic or radiation to elsewhere
Frequency
- change from baseline?
- ask about diuretics
- nighttime frequency ?
Hematuria
- timing, is it through entire urination stream or no
- meds
The Abdomnial Exam
- Inspection
- specifics signs on inspection
- Striae
- Cullen’s Sign
- Sister Mary Joseph Nodes
(standing on right side)
Inspect for
- bulges, peristalsis , color, brusies, jaundice, scars lesions, etc.
Cullen’s Sign
- blue around umbiliical region: a sign of intraabdominal bleeding
Striae
- weight gain/loss (benign)
- newer: blue
- older: shiny and white
–pathological striae : Cushings Disease
- deep, purple/pink striae
Sister Mary Joseph Nodules
- a painful umbilicus is a KEY of an intraabdominal malignancy that has metastized
The Abdomen Exam
- venous patterns & fow
- abdomnial contour (flat v scaphoid)
Venous Patterns
- above the umbilicus: toward the head
- below the umbiilius: to the feet
DIiated Veins
- think obstruction
- portal HTN & venous backup
Contour
- Flat: think athletes
- Schaphoid: almost concave
- in kids: the abdomen will be rounded!
- should be symmetrical
The Abdominal Exam
- Distention
- Bulges and Masses
- Abd. Movements (peristalsis)
Distention
- evenly bloated: obestiy, gas, fluid or enlarged organs
- distentsion from the umbilicus to the pubic symphysis: uterine fibroids, ovarian tumor, distended bladder
- Distention from umbilicus upwards: pancreatic cyst, gastric dilation
Bulges & Masses
- ventral, femoral and ingunial hernias = bulges
- distended bladder or pregnant uterus
- Masses: asymmetry: indicates the mass
Abdomnial Movement
- expect smooth symmetric movement with respirations
- visable peristalsis: ripple effect (benign or obstruction)
Hernias
Ventral Hernia
Umbilical hernia
Diastasis Recti
hernias : protrusion of the abd. organs through the abd. wall = increase abd. pressure will make them pop
ventral hernia : see midline epigastric (above umbilicus)
umbilical hernia : hernia within the belly button
- common in infants
- can be reducable or not: pushed in swelling
Diastasis Recti: not a hernia; but an abnormality of the rectus muscles due to weakness that travels from the xiphoid process to the pubic symphisis
- benign finding
Auscultation of Abdomen
when do you hear increased (hyperactive) bowels
when do you hear decreased
high-pinged tinkling
absent bowel sounds
- done before palpation & at right side with diaphragm of stethescope max 5 minutes
- at RLQ: listen from normal bowel sounds of clicks and gurgles: 5-34/minute
- IF you hear abnormal sounds: listen in all quadrants
Hyperactive BS
- diarrhea
- gastroenteritis
- early intestinal obstruction (trying to move through??)
- hunger
Hypoactive BS
- peritonitis
- paralytic ileus (slowed peristalsis)
High-Pitched Tinkling
- intestinal air or fluid
No Bowel Sounds
- after 5minutes? think
- late intestinal obstruction
- paralytic ileus
- SURGICAL EMERGENCY!!!
Additional Abd. Exam Sounds
- Friction Rubs
- Bruits
- Venous Hum
Friction Rub
- can be heard over the liver and the spleen in times of inflammation
- the viseral peritoneum gets inflammed: sounds like leather
- high pitched, assocaited with respiration
Bruits
- heard over the aorta, renal, illac and femoral arteries
- using the bell
- a vascualr sounds, harsh/musical and intermittent
- turbulent flow throgh the vessels: think vascualture issue
Venous Hum
- use bell: listen in epigastric area and around umbilicus
- soft, lowe pitched and continuous
- increased blood flow in the collateral channels (portal system) you will hear
Percussion of the Abdomen
- sounds
- Liver percussion
- Spleen (two ways)
Sounds
- tympany and dullness: tympany in the air of stomach and intestines
- dullness over masses: feces, organs, fluid (ascites will be dull) or solid masses
- tympanny is higher pitched than respiratory disorders
- gastric bubble: will be heard over Lower left rib cage and left epigastric region (will be lower pitched than tympany)
Liver
- percuss the liver from teh umbilicus upwards listening for tympant to dullness shift, then down from nipple line
- normal 6-12 cm
- 12 cm + = hepatomegaly
- 6cm or less : atrophy
Spleen
- percuss the from cardiac boarder at 6th rib to the anterior axillary line down costal margins (Traube’s sign)
- tympanny should be heard the entier time: if you hear dullness: think spleenomegaly
Spleen (second technique)
- Castell’s sign : percuss lowest intercostal space in axillary line & ask pt. to take a breathe & hold it
- percuss; tympany should remain
- if it changes when they hold breath to be dull; spleenomegaly
Palpation of the Abdomen
- light v deep
- reasons for tenderness
- knees bent “relaxes abd. wall muscles”
- palpate most tender location last
Light palpation: fingers flat
- assessing for superfiscal masss and musclar resistance
- Muscle Resistance : voluntary or involuntary: ask to exhale as you palpate to avoi this
- involuntary muscle resistance: think pertonitis, large mass or distended structure
Deep Palpation
- two hads: Top exertes the pressure & bottom used to sense/feel
- assess for masses
Reasons for tenderness
- abd. wall pain : difficult to characterize the pain
- viseral abd. pain : poorly localized, dull pain & hurts more deep palpation
- pain due to inflammation of peritoneum (peritonitis)
- pain in extraabdominal structure (pleura or repro. organs)
Abdomen Palpation
- Carnett’s Signs
- peritonitis
Carnett’s Sign
- positive: when abd. pain persists and increased when the pt. lifts thier head off the exam table
- indicates abdominal wall pain
- in this maneuver: if its viseral (organ) pain : the pain will improve (not be felt when head is up)
Peritonitis
- sharp severe pain
- diffuse or localized to the area involved
- can be due to : appendicitis, pancreatits, cholycystitis, bowel perf or ischmia
- pt. will be gaurded, rigid abd. rebounder tenderness, pain with coughing and percussion
Rebound Tenderness
- hold hand at 90 degress and extended fingers: press down to the region away from pain: reproducable pain in the area where they are complaining off is + ( think rousuvings for appendicitis)
Appendicitis
- what is it
- Mucburneys & rousuvigs
What
- inflammation of teh appendix mostly due to obstruction from fecalith (fecal mass)
- pain localized to the RLQ: Mcburneys point
Signs
- tenderness to palpate over RLQ
- signs of peritonitis (rebound tenderness)
- + rousuvigs
- + psoas
- + obtorators
Rovsigs
- LLQ palapte: pain in RLQ = +
Psoas
- hand above pt. knee: resistant their force upwards
- + test = pain in RLQ
Obturatos
- felx hip to 90 degrees: then internally rotate
- pain with lateral and medial rotation = +
Abdominal Palpation
- Masses (what could feel like one)
- Umbilical Ring
- Liver
Masses
- note size, shape consistenct, moves with breathing?, associated tedenress, location & pulsations
Masses could just be…
- feces in colon
- lateral boards of teh muscles
- uterus
- aorta
- illac arteries
Umbilical Ring
- one finger presses on umbilical ring: other finger presses down on the area around the ring
- asses for : bulginf, nodules and granulations
Liver
- left hand under 11th/12th rib & press up
- right hand on the top and press down while pt. breathes
- assess nodules, tenderness, irregularities, firmness
or hooking technique
- stand and pull up the costal margin
Abd. Palpation
Hepatomegaly
gallbladder
Hepatomegaly
- find hepatitis, cirrhosis, AFLD, amyloidosis, lymphoma, mets, HCC
Gallbladder
- a healthy gallbladder is not palpable
- deeply palpate at the liver margin
- Courvosier’s Sign ; a palpable gallbladder = pathologic
- if the GB is palpable but nontender = common bile duct (malginancy)
- if GB is palpable and tender = cholecystitis
Acute Cholecystitis
inflammation of the GB : usually do to obstruction from a gallstone
- sudden onset
- with RUQ pain: can radiate to teh right scapula
- Tenderness to palpate RUQ
- tender, palpabe GB possible
- + Murphys
Murphy’s Sign
- deep breath in and you palpate liver marign at GB: if they hault inspiration: + sign due to pain
Palpation: Spleen
reasons for spleenomegaly
- left hand under, right hand over and press while pt. takes a deep breathe
- & repeat with pt. on side
Spleenomegaly: (shouldnt feel spleen but if you do…)
- infection (mono, HIV)
- leukemia
- splenic tumor
- portal HTN
- lymphoma
- METS
Palpation: Kidneys
CVA tenderness test
pyelonephritis
CVA Tenderness
- sit up and strike CVA : if pain + test
Pyleonephritis
- inflammation of the kidney due to infection
- flank/back pain
- ill appearing and cva tenderness on exam
Palpation: Bladder
non palpable unless…
- distended with urine (will feel smooth and round)
- will sound lower in percussion than surrounding areas
- can be due to obstruction or medications too
Palpation: Aorta
- to left of midline: palpate for pulsations
for adults 50+ assess aortic width
- place hands on either side of aorta and press inwards until you feel the puslations
- determin direction (should be anterior!) : if its lateral: think AAA
- normal width : < 3cm wide = AAA
Abdomnial Ascites
when do you see it
Shifting Dullness Test
Ascites fluid Wave
Fluid Accumulation in the peritoneal cavity
due to….
- heart failure
- cirrhosis
- IVC obstruction
- hepativ vein obstruction
on exam: see protuberant abdomen with bulging flanks when laying
Shifting Dullness Test
- pt. lays and you percuss 6 directions from the belly button and mark the boarders of tympany to dullness
- fluid follows gravity: will go the dependent parts
then ask them to lay on their sides
- the dullness in a pt. with ascites will shift to the dependent side (towards midline)
AScites Fluid Wave
- pt. lays supine : arm in middle to press edges at midline
- tap on their sides to elicit a wave through the fluid to your hand at midline
- if you feel the wave = +
