Abdominal exam Flashcards
What is the different between the GI exam and Abdominal exam?
Both can be used interchangeably but GI exam covers stomach, liver, gall bladder, pancreas, small and large bowel, rectum and anus. Abdominal exam also covers spleen, kidneys, abdominal aorta, bladder and female reproductive structures
The abdominal cavity extends from the ______ to the ______
Diaphragm to the pubis symphysis.
For exam purposes the abdomen is divided into 4 quadrants. What are the lines used to make these quadrants?
Both lines (vertical and horizontal) are drawn thru the umbilicus.
What are the 4 quadrants of the abdomen
Always from the Patient’s perspective
RUQ, LUQ, LLQ, RLQ
What is the area above the RUQ and LUQ?
The epigastric area
What is the area below the LLQ and RLQ
The suprapubic area
What is the area right around the umbilicus called
the periumbilical area
What are some of the typical GI complaints
Disorders of digestion Disorders of causing weight loss Disorders of bowel function Jaundice Abdominal pain
Anorexia is
the loss of appetite (distinguished from abdominal fullness)
Earlier satiety could mean what?
1) Gastric outlet obstruction
2) Gastric cancer
3) Hepatitis
4) Diabetic gastroparesis
What kinds of questions should you asked in a physical exam?
Open ended questions
Unintentional weight loss can be due to what possible causes?
1) Malignancy
2) Malabsorption
3) Liver disese
4) Non GI causes
- Depression
- Hyperthyroidism
- Non-GI malignancies
Difficulty swallowing is called ______
Painful swallowing is called _________
Dysphagia
Odynophagia
Heartburn without sweating could be….
An MI
What questions should you ask to a patient with Indigestion?
How it may change with posture (lying down precipitates GERD),
Does it change leaning forward?
Do certain foods or meds trigger it.
Does eating a large meal affect it?
What are some possible reasons for dysphagia (trouble swallowing)?
Mechanical - Structural (stenosis) - Cancer or mass - Obstruction (foreign body) Motor - Neurological disorder - Spasm - Scleroderma (tissue in esophagus can be less elastic)
Patients who have dysphagia, may point to different parts of their body depending on what’s wrong. What are the differences?
A patient who points to their throat usually have a transfer problem
A patient who points to their chest often have an esophageal problem
What is transfer dysphagia and what could it indicate?
When a patient attempts to swallow and that results in the aspiration of food into the nose/lungs.
It could suggest a CNS problem (stroke, neuromuscular condition)
What is achalasia?
When the espophogeal musculature does not relax enough
When it comes to mechanical dysphagia and regurgitation, bringing up more solids in relation to liquids would indicate which problems ?
More intermittent solids than liquids suggest stricture
Intermittent solids then progressing to liquids AND progressively getting worse with pain suggests esophageal cancer
What is the most common cause of painful swallowing (odynophagia)?
Pharyngitits
What are the different kinds of painful swallowing (odynophagia) and what could each mean?
1) Sharp and burning - Mucosal inflammation ( reflux esophagitis or infection)
2) Sharp and sticking - Mechanical (foreign body)
3) Squeezing/cramping - Muscular etology ( esophageal spasm or achalasia)
Blood in vomit is called
Hematemesis
What are some non- GI causes of nausea and vomiting?
1) CNS problems
2) Preggo
3) Infection
4) Meds
5) Electrolyte imbalance
What is regurgitation
Bringing up gastric contents without nausea or vomiting
What condition may cause vomiting with fecal like material?
A small bowel blockage or fistula
What may cause vomiting with bright red blood?
Acute esophageal or upper GI bleed
What may cause vomiting with coffee ground material?
Suggests partially digested blood
Prolonged vomiting will cause ______
Fluid and electrolyte imbalance (loss of Na, K, Cl)
How do you treat the electrolyte loss due to prolonged vomiting?
Pedialyte, plasmalyte or IV
What can cause excessive belching or flatus?
Aerophagia (swallowing of air)
What are some causes of constipation?
1) Low fiber diet
2) IBS
3) Non-GI problems (CNS, spinal injury, MS)
4) Drugs (opiates, anticholinergics, antacids
5) Hyopthryroidism
6) Mechanical obstruction (cancer narrowing lumen)
7) Volvulus/Diverticulitis
8) Fecal obstruction
IBS has _____ but not _____ ________ with constipation
Mucus
bloody alternates
What is the difference btwn Inflammatory Bowel disease (Ulcerative Colitis) and Crohn’s disease
IBD - soft watery diarrhea with blood
Crohn’s - small, soft, watery diarrhea w/o blood
What would you find with Colon Cancer
Usually older than 55, it alternates btwn diarrhea and constipation (diarrhea around obstruction) and blood streaked.
What is Melena (what’s it caused by)
Black tarry stools. It means that blood has passed thru the digestive tract. It suggests an Upper GI problem
Red bloody stools suggests what
That it is a lower GI problem (colon, rectum, anus)
What can cause a positive fecal occult blood test?
The Ingestion of Iron
What may jaundice be accompanied by?
Pain or severe itching
If you see jaundice, what should you look for
Hepatic disease, an enlarged liver, history of ETOH or drug abuse, hepatitis or cirrhosis.
Jaundice causes elevated _______
bilirubin in the blood
What may urine and stools look like in a jaundiced patient?
Urine - tea like (dark)
Stool - light yellow or gray
If a patient has abdominal pain you should palpate that area _____
last
What are three types of abdominal pain?
1) Visceral
2) Parietal or somatic
3) Referred
What are some examples of abdominal visceral pain?
Forceful contraction or distention of intestine, biliary tree (obstruction, gallstone). Stretching of the liver capsule.
How is abdominal visceral pain described?
Usually not localized. Often described as ‘cramping, achy, burning or gnawing’. It can crescendo and decrescendo and be related to intestinal peristalsis
What may abdominal visceral pain be accompanied by
1) Nausea/vomiting
2) Sweating
3) Pallor
4) Restlessness
Where does abdominal parietal pain arise from?
the parietal peritoneum
What is the parietal peritoneum?
Its the part of the peritoneum that lines the abdominal and pelvic cavities
The kidneys are retroperitoneal. What does that mean?
That they protrude into the peritoneal cavity but are not encased by it.
What does the mesentery do?
Suspends the organs in the abdominal cavity. It also acts as a conduit for blood vessels, nerves, lympatics
How is abdominal parietal pain described?
A steady aching severe pain (generally worse than visceral). Well localized over the structure with no relief. Aggravated by moving/coughing
You walk into the patient’s room. How can you tell if he has visceral or parietal pain?
If he is writhing around it’s probably visceral (trying to get to a place where it hurts less). If its parietal he’s probably laying still (doesn’t want to move)
A patient with acute appendicitis will have what kind of pain?
It will start off as visceral and then get localized to a specific parietal pain in the RLQ.
What is referred pain?
Pain that radiates from an original site to a distant site.
Where may referred pain present?
Can be superficial or deep as well as localized. Generally the pain radiates along the same spinal level as the affected structure
Referred pain is classic for _______ pain
nerve
What are some examples of when you may have referred pain?
1) MI - pain travels down arm
2) Ulcer - may radiate to mid back
3) Gall bladder disease - may radiate to shoulder blade
4) Renal stone - may refer to scrotum or testicle
What is the order of assessment for the physical exam of the abdomen
1) Inspection
2) AUSCULTATION
3) Palpation
4) Percussion
5) Special tests
It’s recommended that before the abdominal exam, the patient’s bladder is ______
empty
Why is it important that when performing the abdominal exam, the patients hand’s are not behind his head
Because it can tighten the abdominal muscularture
Why is it important to auscultate the abdomen before you palpate/percuss it?
Because palpation and percussion can alter bowel sounds and may produce sounds no present naturally
What are ways that you can use to describe the abdominal contour ?
1) Scaphoid - caved in
2) Flat
3) rounded - small distention
4) protuberant - slightly overweight
5) Obese
What quadrants would you find an enlarged liver and spleen?
Liver - RUQ
Spleen - LUQ
What can visible peristalsis be an early sign of?
An early sign of obstruction
T/F Aortic pulsations may be a normal sign?
True - especially in thin people
What may be the cause of a ridge found in the midline of the abdomen?
The separation of the two rectus abdominis muscles. It’s called ‘diastasis recti’ and can be best seen when the patient lifts his head and shoulders off a flat surface
What is Ascites?
Free fluid collection in the abdomen. It generally can be seen with the patient lying flat, it will be seen as a protuberance at the flanks
T/F when listening for bowel sounds, you should push your stethoscope head fairly hard into their abdomen
False
How long should you listen to the abdomen for bowel sounds.
2 minutes
What are the different ways to describe the frequency of bowel sounds
Hypoactive - Less than 5 sounds/minute
Normative - Btwn 5 and 35 sounds/minute
Hyperactive - More than 35 sounds/minute
Absent - No sounds for 2 minutes
A bruit in the abdominal aorta could be an indication of what?
An aortic aneurysm.
How do you find the renal, iliac and femoral arteries
Renal - starting at the aorta, midline btwn the nipples and umbilicus, move 2-3 finger breadths to either side to find the renal arteries
Iliac - On the same vertical plane of the renal arteries, Go one finger breadth below. umbilicus (R & L)
Femoral - over the groins
What are some reasons for hypoactive, hyperactive and absent bowel sounds
Hypoactive - Paralytic ileus (bowel segment stops working) and early peritonitis
Hyperactive - Diarrhea or early obstruction
Absent - complete obstruction
How does solid/liquid/gas in the abdominal area affect the sounds on percussion
Gas - produces tympanic tones
Liquid - produces dullness
Solid - produces even more dullness
Gas and fluid together will produce a lower pitched tympanic note
What quadrant would you percuss the gastric bubble?
the LUQ
What quadrant would you percuss the splenic flexure? What sound would you hear if normal?
the LUQ, you would hear a lower pitched tympanic note since you’ll find both gas and liquid
When palpating the abdomen, you should start by pressing ______ and then if no pain, palpate ______
soft, harder
What part of your hand would you want to use to palpate the abdomen?
The flat palmer side.
If the patient continues to have muscular resistance in the abdominal exam, what may you do to try and have him relax?
Ask patient to take a deep breath and let it out.
Have patient flex hips and knees.
What may muscular rigidity not being done by the patient indicate?
It implies peritoneal irritation.
When palpating deep, which part should you start in?
The quadrant just after the area of pain (if any)
What is the advantage of using the 2 handed technique in palpating deep in the abdomen?
It improves sensitivity
What is the preferred way to be in relation to the patient when conducting the abdominal exam?
Be on the right side of the patient
What are 4 ways that abdominal masses can be characterized as?
1) Physiologic (pregnant uterus)
2) Neoplastic ( tumors, firm and nodular)
3) Vascular (aortic aneurysm)
4) Inflammatory (mass felt with diverticulitis)
Why would you test for rebound tenderness?
To determine the presence of peritoneal inflammation
How would you test for rebound tenderness?
Go to area of pain and use 1-2 fingers to gently then more firmly push into the patient’s abdomen. Then abruptly let go. If this produces a greater pain it is positive for rebound tenderness.
The _______ liver is a ________ finding
non-palpable … normal
How would you percuss the liver in an abdominal exam.
Begin right below the umbilicus in the MC line and percuss up. This will determine the lower border. Percuss over the ribs in the MCL and you should hear resonance. To find the upper border percuss down the MCL until resonance of lung is replaced by the dullness of the lungs
When measuring the span of the upper and lower borders of the liver what should be the normal distance btwn borders?
6-12 cm… men greater than women
The normal size liver may be palpable up to ______ below the costal margin in the MCL?
3 cm
In a normal person, where does the spleen lie?
Between the left 10th rib
T/F a normal spleen is non palpable?
True
When palpating for an enlarged spleen which direction should you palpate?
From the RLQ to the LUQ
What is the test to assess Ascities (and how is it done)
Succission splash or Fluid wave (ballotment). Assistant place ulnar aspects of hands on abdomen from head to tail. Place one hand on opposite side of lateral aspect of abdominal cavity. Other hand taps other side of flak. If fluid is present you’ll feel a shifting fluid wave
How do you test for CVA, Costovertebral Angle Tenderness?
Place heel of your fist over the midback at costovertebral angle (over kidneys). Firmly strike your fist with other hand. If there is tenderness, its a positive CVA
What are the four tests for appendicitis?
1) Psoas sign
2) Obturator sign
3) Rovsing’s sign
4) McBurney’s Point Tenderness
How do you test for appendicitis thru the Psoas sign?
Patient lies on left side. Examiner takes right leg and passively extends it (standing back side of patient pull leg toward you). while simultaneously applying counter force to the patient’s hip. If pt. reports abdominal pain, it’s a positive psoas sign
How do you test for appendicitis thru the Obturator sign?
Patient lies supine. Flex patient’s right hip and knee externally. Passively internally rotate hip and if there is pain, its’ a positive obturator sign
How do you test for appendicitis thru the Rovsing’s sign?
Test for rebound tenderness (but indirect rebound tenderness). Push into LLQ at the place where the appendix would be in right. If tenderness in the RLQ it is a positive rovsing’s sign
How do you test for appendicitis thru the McBurney’s Point tenderness?
Find the imaginary point 1 1/2 to 2 inches from the anterior superior iliac spine moving in a straight line to the umbilicus. If there is tenderness it’s suggestive of appendicitis.
What are the 2 reasons to not do a Digital rectal exam in a complete abdominal exam?
1) Patient doesn’t have a rectum
2) The examiner doesn’t have any digits.
