Abdominal Exam Lecture-Dobbs (exam 2) Flashcards
What is diarrhea?
Diarrhea= loose, watery stools (bowel movements). You havediarrheaif you have loose stools three or more times in one day. Acutediarrheaisdiarrheathat lasts a short time. MAKE sure you define what the Pt means by diarrhea
What is considered normal for the Pt? figure out their normal bowel habits
What is constipation?
fewer than 3 stools per week.
ROS- GI
Abdominal pain
Appetite changes
Weight changes
Reflux/belching
Nausea/vomiting
Hematemesis=throwing up blood
Changes in stool frequency/consistency
Frequency of bowel movements
History of laxative use
History of upper GI, Barium enema, colonoscopy
(notes: With weight changes: are they up or down? Are they intentional or unintentional? Do your clothes fit differently
-be careful with the overuse of ex lax!!! It becomes a rebound issue to the point where they NEED a laxative in order to poop
Reflux/beltching=
Vomiting- ask about color, digested or undigested food (achalasia), how many episodes per day, per hour. Is this Pt getting dehydrated or malhourished
-ask the Pt if they have a hx of upper GI issues, Barium enema when was last colonoscopy
Nausea: this nausea that you’re having, how often does this occur? Does it interfere with your daily life? Is this allowing you to go about your daily life?
Stool Changes:
Melena=
**upper GI bleeding (dark sticky feces containing partly digested blood.)
Order for abdominal exam:
-inspect (make sure abdomen is revealed)
-auscultate
-
Hematochezia=
pronunciation= hematokeeezia
- indicates lower GI bleed
- blood that is mixed into the stool (some red, but NOT bright red), may be coming from a polyps, or somewhere in the colon
Steatorrhea=
- *indicates malabsorption
- fatty stool that is greasy and floats= indicates malabsorption. (can be seen with pancreatitis, cholestasis, ***cystic fibrosis) KNOW
BRBPR=
external/internal hemorroids, fissure
ROS- GI
Jaundice Hepatitis Cholecystitis Diverticulitis Polyps Hemorrhoids (Ask the Pt if they have any hx of cholecystitis: do they still have their gallbladder? )
ROS- GU
Frequency of urination Polyuria Nocturia Dysuria Hematuria Urgency Hesitancy Force of stream History of infections History of stones (Increased urinary frequency and urgency DM? UTI? Polyuria= DM Nocturia: prostate issues, or Dysuria= painful or dificult urination– could be UTI
Hematuria= stone, cystitis, CANCER
Urgency:
Hesitancy: do you have any trouble initiating urination (possible BPH)
-have you noticed a weak stream or any changes with that? (Ddx: BPH)
)
whay are knees up (flexed) in abdominal exam?
-in order to relax the abdomen
Chief Complaint: abdominal pain
Onset
Location
Duration
Character- is it sharp(ex: bowel perf., triple A) or dull (ex: IBS, constipation) or crampy or colicky
Associated symptoms- (changes in weight, fever, diarrhea, referred pain, vomiting, changes in appetite, stool, reproductive questions, and cardiac/respiratory hx (referred pain)
Aggravating factors- coughing, movement, with eating, certain foods etc
Relieving factors- postional, meds (quantity and type of med), relief after bowel movement?
Timing- (is it worse in the morning, at night? Post meals. Etc)
Severity-
(my notes: CC of abdominal pain:
-Onset: suddenly or gradually, when DID IT START
Acute abdomen= URGENT pain
-gradual onset of abdominal pain over last 3 weeks DDx:
VS
-acute onset of abdominal pain ddx: appendicitis, pancreatitis, gallstone,
-crampy pain= IBS, gas
-colicky pain= comes and goes in waves, intermittent pain. Usually comes when something is stuck in a tube (ie cholelithiasis, constipation, nephrolithiasis, diverticulitis,
-ask about stools AND urination
-ask about last menstrual cycle and R/O pregnancy, ectopic pregnancies
-if a Pt has fever= infection, peritonitis etc
-
Dysuria=
=*painful urination
(Pts may present with painful burning urination
-the urethra is longer in males and more protective
Pt presents with “burining” while urination, UA comes back clean, denies bleeding in urine. Then pelvic exam reveals HSV (herpes). MUST r/o STD or STI prior to assuming it’s a UTI
Ask is the pain on the inside or outside
Hematuria associated with UTI: is usually not assoc. with dripping blood
)
Hematuria=
might be bright red, or slightly red,
associated with UTI, herpes simplex etc
Chyluria=
whiteish, purulent urine that stems from a parasite infection (rare)
Getting started:
-Pt position for abdominal exam
-Adequate exposure
Supine position
Knees flexed
Use gloves if there are open lesions
Make the Patient Comfortable
Adequate coverage
Empty bladder
Warm hands and short nails
The ticklish patient
ORDER MATTERS !!
inspect, auscultate, percuss, then palpate an abdomen.
Inspection: abdomen exam
-Expose the abdomen completely from the xiphoid to the symphysis pubis
-Observe from several positions:
Foot of the bed
Tangentially (with and without your penlight)
Superiorly
color (list ex’s)
Cyanosis
Hyperemic= something that is more red (HYPER-red)
Erythematous- erythema with redness/swelling
Jaundice
Shiny
Taut
Venous patterns- ie caput medusa
Shape, Symmetry, & Contour
- Flat
- Scaphoid
- Rounded- ie extra visceral fat that’s evenly rounded
- Protuberant- think about toddlers
- Distended (generalized or localized)
- Symmetry
- Bulges
Lesions (can be from?)
Scars from old wounds or surgeries
Striae
Fistulae
Open wounds
Umbilicus
Innies
Outies
Everted
Hernias
**Bruising-
Cullen’s sign=
Cullen’s sign is superficial edema and bruising in the subcutaneous fatty tissue around the umbilicus. It is named for gynecologist Thomas Stephen Cullen (1869–1953), who first described the sign in ruptured ectopic pregnancy
Diastasis Recti=
separation of the muscles along the midline of the abdomen, typically as seen in women during and after pregnancy or (as a congenital anomaly) in newborn babies.
Ventral hernia=
A ventral (abdominal) hernia refers to any protrusion of intestine or other tissue through a weakness or gap in the abdominal wall.
GSW/ Stab wounds:
A penetrating injury from a bullet shot from a gun. At very close range, the wound may have gunpowder deposits and the skin burn marks. GSWs can crush, penetrate, stretch, cavitate, or fracture body structures.
Pt with cyanotic abdomen: (RED FLAGS)
indicates serious hypoxia
Ausculation=
=This is the first touch
–Manipulation before auscultation may stir up bowel sounds that are not representative
- Five minutes of auscultation is necessary to declare that a patient has no audible bowel sounds
- BS in all four quadrants
Note character and frequency Hyperactive Hypoactive High-pitched Low- pitched
Hyperemia on an abdomen may indicate/..
cellulitis or abscess
Scaphoid abdomen=
Definition: The anterior abdominal wall is sunken and presents a concave rather than a convex contour. Comment: Scaphoid abdomen can be observed in diseases such as congenital diaphragmatic hernia (since the abdominal contents can be in the thorax).
Where is the incision for a cholecystectomy?
Open method cholecystectomy
An incision will be made. The incision may slant under your ribs on the right side of your abdomen. Or it may be made in the upper part of your abdomen. Your gallbladder is removed.
Appendectomy scar location?
acute pain in right lower quadrant
Ausculation:
-Borborygmi?
= stomach is growling
Auscultation:
-Hepatic venous hum?
indicates portal HTN
Auscultation:
-Bruits?
Aorta
Renal
Iliac
Femoral
(listen with the bell)
Name that Location… Cholecystitis Appendicitis Diverticulitis Cystitis Pyelonephritis Irritable bowel syndrome Hemorrhoids –external and internal GERD
?
Murphy’s sign?
?
Know inside and out and upside down:
Tables 17-2 and 17-3
?
Describe that pain…Cholecystitis Appendicitis Diverticulitis Cystitis Pyelonephritis Irritable bowel syndrome Hemorrhoids –external and internal GERD
?
Abdominal Exam of Infants and Children
Inspection- protuberant belly until around 5-6 Auscultation Bowel sounds Renal bruits- renal artery stenosis Percussion- may be more tympanic Palpation Light then deeper Liver- just below costal margin in infants and toddlers
Costovertebral Angle Percussion for Tenderness:
-tenderness is associated with ____ problems
- Gently percuss with your fist or hand in the costovertebral angle
- **associated with kidney problems, most commonly pyelonephritis
Further evaluation of Ascites:
-shifting _____
dullness
- fluid wave (not as reliable)
- Puddle sign (no longer recommended)
List ex special tests for Appendicitis: (list 4)
Rebound tenderness
McBurney’s point
Iliopsoas test
+Psoas sign
Obturator test
Rovsing sign
(Rebound tenderness trying to discern if there (Mcburney’s point is in the right lower quadrant) push down slowly, then you let the pressure off quickly and htat should let off some shaking (does it hurt when I push down , or when I let the pressure off? )
-the pain is more localized in that area= appendicitis
Psoas sign: have Pt lying supine, on their right side (this is a specific test for appendicitis) flexion at the hip and extension of the knee) and if this exacerbates pain in the RLQ this supports appendicitis dx
- Obturator: knee flexed, hip flexed, and
- Rovsing sign: do it on the left lower quadrant (same steps as rebound tenderness) and it causes pain on the right (in the right lower quadrant)
- If you get + rebound tenderness over mcburney’s )
