abdominal physical exam Flashcards
how should the patient be positioned for the exam?
lying supine on the table with arms at the side or folded across the chest and lower groin draped
what should be asked before the PE
if there is any pain so you can examine these areas LAST
What is the order of examination
IAPP
inspection, auscultation, percussion, palpation
Order of the abdomen examination
- Inspect: surface, contours, movements, skin temp, color, presense of scars or striae
- auscultate all 4 quadrants
- percuss all 4 quadrants
- lightly palpate 9 quadrants
- deeply palpate all 9 quadrants
order of examination of the liver
- estimate the size by percussing up the midclavicular line
- palpate and characterize the liver (hook the liver)
Order of examination of the spleen
- percuss for splenic enlargement along the traubes space
- palpate the splenic edge with the pt supine and in the Right lateral decubitus position
order of examination for the kidney
- fist percussion of the right and left CVA
order of examination of the urinary bladder
percuss the urinary bladder
what are you looking for on inspection of the abdomen
- color (bruises, erythema, jaundice)
- scars
- striae
- Dilated veins
- umbilicus bulging (hernia)
- rashes or ecchymoses
- contour of the abdomen
- aortic pulsation
what is indicated by pink/purple striae
cushing syndrome
what do large dilated veins of the abdomen suggest
portal hypertension due to cirrohsis (caput medusa) or inferior vena cava obstruction
what is caput medusa
large dilated veins around the umbilicus, going outwards (looks like medusa)
-from portal htn from cirrohsis
what does inferior vena cava obstruction look like
dilated veins running vertically down the stomach
what is ecchymoses of the abdominal wall from?
intraperitoneal or retroperitoneal hemorrhage
-cullens sign
grey turners sign
what is cullen’s sign?
ecchymosis around the umbilicus
what is Grey Turners Sign
ecchymosis of the flank
what can cullens sign or grey turners sign be associated with?
- acute hemorrhagic pancreatitis
- ruptured ectopic pregnancy
- abdominal trauma
- splenic rupture (MC-Mono)
- ruptured abdominal aortic aneurysm
- perforated ulcer
what are the 4 types of abdominal contours
- flat- horizontal line from costal margin to symphysis pubis
- Rounded- “convex”
- Scaphoid- concave
- protuberant- similar to rounded but greater
when is a rounded abdomen normal
in toddlers and pregnant females
when is scaphoid abdomen normally seen?
in a very thin person
when is a protuberant abdomen seen?
- obesity
- ascities
upon auscultation
what is the classification of a normoactive abdomen
5-34 clicks and gurgles per minute
upon auscultation
what is the classification of a hypoactive abdomen
<5 click/min
* heard in slowed intestinal activity (constipation, surgery, sleep)
when is the abdomen hypoactive-absent upon auscultation?
- in the ileus
- peritonitis
- late intestinal obstruction
upon auscultation
what is the classification for a hyperactive abdomen?
> 34 clicks and gurgles/min
* diarrhea, after eating, laxative use
what is indicated by high pitched and hyperactive abdomen sounds?
early intestinal obstruction
what is borborygmi
prolonged gurgles of hyperperistalsis
where do you auscultate for bruits?
aortic, renal, iliac and femoral arteries
where do you auscultate for friction rubs?
liver
spleen
abdominal mass
what may friction rub of the abdomen be present in?
- hepatoma
- liver cancer
- chlamydial or gonococcal perihepatitis
- recent liver biopsy
- splenic infarct
- pancreatic carcinoma
what is venous hum and when is it present?
rare soft humming noise
what are you percussing the abdomen for?
all 4 quadrants for distribution of tympany and dullness
what sound upon percussion dominates the abdomen
tympany (b/c gas in the GI tract)
scattered dullness due to feces and fluid
what should you note upon percussion of the GI tract
dull areas
indicates: underlying mass, enlarged organ, ascites
how many regions do you palpate?
9 regions, light and deep pressure
what is voluntary gaurding?
voluntary contraction of the abdominal wall
* with a grimace
* pt is protecting from pain
what is involuntary gaurding or rigidity?
involuntary reflex scontraction of the abdominal wall that persists despite maneuvers
indicates: peritonitis
what is involuntary gaurding aka
board like abdomen
what does persistent involuntary guarding indicate
Peritonitis
what are 3 techniques to distinguish voluntary vs involuntary
- pt bending lower extremities to make abd. muscles less tense
- pt mouth breathing with jaws wide open
- palpate after asking pt to exhale (relaxes abd. muscles)
when do you get a flat plate X-ray
Bowel perforation
what is the cough test? what is it used for?
ask the patient to cough and identify areas of pain
-used to assess for peritonitis or acute abdomen
what is rebound tenderness? what is it used to asses?
ask the patient if it hurts more w/ withdrawl or pushing in?
positive=withdrawl pain
assesses: peritonitis or acute abdomen
what are 4 ways to assess for acute abdomen or peritonitis
- cough test
- involuntary gaurding or rigidity
- rebound tenderness
- percussion tenderness
what should be assumed for female patients under 55?
that they are pregnant until proven otherwise
what is the MC for obstruction
adhesions
How to estimate the size of liver by percussion
4 steps
- right midclavicular line
- percuss upwards from the RLQ below umbilicus
- Percuss down from the nipple line
- measure the distance
what can cause a falsely decreased liver size estimate
gas in the colon in the RUQ or free air in the diaphragm
what can cause a falsey increased liver size estimate
right ham pleural effusion or pneumonia adjacent to liver
How to palpate for the liver edge?
- below the right costal margin at the midclavicular line
- ask Pt to take a deep breath
- hooking technique
what is the hooking technique?
- place both hands side by side
- press in/up with your fingers under the costal margin
- ask the pt to take a deep breath
when is the hooking technique useful?
helpful to palpate the liver especially in obsese patients
what should a normal liver edge feel like?
soft, sharp and regular with a smooth surface
what is the traube space
borders on the LEFT side
1. 6th rib
2. anterior axillary line
3. costal margin
what do you percuss the traube space for?
for the spleen
dullness to replace tympany
what is splenomegaly seen in?
Portal HTN as in:
1. cirrohsis
2. R sided HF
3. hematologic malignancies
4. HIV
5. Infiltrative disease (amyloidosis, splenicinfarct, splenic hematoma, infectious mono)
What should you assess for athletes?
mono with splenomegaly
* it could rupture during sports
How to percuss the spleen
- percuss the lowest sinterspace int he left anterior axillary line (usually tympanic)
- as pt to take a deep breath and hold
- percuss again at lowest iinterspace left anterior axillary line
what is a postive splenic percussion sign?
Castell Sign
a change in percussion note to dullness on inspiration
when should you pay extra attention to palpation of the spleen for splenogmegaly
either or both traube space dullness or a positive castell sign
Palpation technique to detect splenomegaly
- pt is supine and relaxed
- with your left hand, reach around and presss the spleen forward from the back
- with your right hand, press below the left costal margin
- ask the patient to take a deep breath to try and feel the spleen
- repeat with the pt lying on the right side with hips and knees flexed
How to asses for CVA tenderness
- place the palm of one hand over the cva area
- strike your hand with ulnar surface
- positive if pain is felt
what does a positive CVA test indicate?
Pyelonephritis
should further evaluate for fever and urinary symptoms
are kidneys usually palpable?
No unless they are markedly enlarged
what can cause unilateral enlarged kidney
- hydronephrosis
- cysts
- tumors
- kidney stokes
what can cause bilateral enlarged kineys
polycystic kidney disease
what are the three ways to test for ascities
- percussion outward from central tympany to area of dullness on supine pt
- test for shifting dullness (putting the patient one one side and mark the borders again)
- test for fluid wave
when is ascities suspected?
a protuberant abdomen with bulging flanks
How to decipher between ascites and a gas filled abdomen
ascities= fluid sinks to the bottom
gas-filled= bowels rrise
what does a distended abdomen in a pediatric pt indicate
malnutritrion
How to do a test for a fluid wave
- ask the patient to press their hands firmly down the midline of abd.
- tap one flank sharpy with your fingertips and feel the opposite flank for impulse
what are the 2 limitation of the fluid wave test?
- often negative until ascites is obvious
- sometimes positive in people without ascites
what are the 5 ssigns to test for appendicitis
- McBurney’s point tenderness
- Rosving sign
- Psoas sign
- Obturator sign
- Peritoneal sign
what is the McBurney’s Point Tenderness
- tenderness 2 inches in from R anterior superior iliac spine on a line drawn from that to the ubmilicus
How to test for the Rosving sign?
pain in the RLQ during LLQ
How to test for Psoas Sign?
- increased pain with right hip flexion against the resistance
- with pt supine, have the pt push their leg against your hand
How to test for the obrurator sign?
- increased pain with internal rotation of the R hip
- Flex the pts right thigh at the hip with the knee bent, rotate the leg internallly at the hip
How to test for the Peritoneal sign?
- gaurding, rigidity, rebound tenderness, percussion tenderness
what does Murphys sign test for?
cholecystitis
how to test for murphys sign? what is positive?
- deeply palpate in RUQ
- ask the pt to take a deep breath (forces the gallbladder toward the finger)
Postive: sharp halting in the inspiratory effort due to pain
what causes acute cholecystitis?
obstructing gallstone or bile stasis
What are the risk factors of cholelithasis? (acute cholecystitis)
Four f’s
1. fat
2. female
3. forty
4. fertile
where is acute cholecystitis pain felt?
right upper quadrant
what are the clinical symptoms of acute cholecystitis
- RUQ pain
- steady pain
- fever
- N/V
- anorexia
How to assess for a ventral hernia
- ask the patient to raise both head and shoulder off the table or raise both legs and do Valsalva
- assess for protruding hernia
where is an umbilical hernia
a protrusion through a defective umbilical ring
where is an incisional hernia
a protrusion through an operative scar
Where is an epigastric hernia found?
a small midline protrusion through a defect in th elinea alba occurs b/w the xiphoid process and the umbilicus
what is diastasis recti
separation of the two rectus abdominis muscles
*typically extending from the xiphoid to the umbilicus
*not a true hernia, is clinically begnin
when is diastasis recti most present
- pts that have been pregnant
- obesity
- chronic lung disease
abdominal wall mass vs intra-abdominal mass
in wall: remains palpable
in cavity: is obscured by musclar contraction
How to feel out a Lipoma
Press your finger down on the edge of lipoma
-tumor slips out from under your finger and is:
* well demarcated, non-reducible, usually non-tender
What is a lipoma
common, benign fatty tumor in the subcutaneous tissue
* small or large
* soft and lobulated
what does acute appendicitis pain start as
periumbilical pain
Defining characteristics of acute appendicitis
- pain worsens
- aggravated by cough
- anorexia, n/v, pain, fever
what is acute appendicitis caused by?
Fecaliths or lymphoid hyperplasia
what is fecaliths
hardened fecal matter
where is acute pancreatitis pain felt? what aggravates? what alleviates?
- radiates to the back
- aggravated: supine position
- alleviated: leaning forward with truck flexed
what are associated symptoms of acute pancreatitis?
- N/V
- abdominal distention
- fever
what lab values are elevated for acute pancreatitis? (specific)
amylase
lipase
what are physical exam findings of acute pancreatitis
epigastric tenderness
rebound tenderness
what is acute pancreatitis associated with?
high triglyceride or gallstone pancreatitis, drinking, cirrohsis
what pain is associated with acute diverticulitis
LLQ pain due to sigmoinds colon or descending colon diverticulitis
*gradual onset of cramp and then steady pain
what relieves acute diverticulitis pain
analgesia
bowel rest
antibiotics
what are associated symptoms of acute diverticulitis
- fever
- constipation or diarrhea
- n/v
- diarrhea
- elevated WBC
what are the physical exam findings of acute diverticulitis
LLQ tenderness
rebound tenderness
may have: palpable mass
what is peptic ulcers described as
gnawing
burnign
boring
aching
“hunger pain”
what percentage of pts are asymptomatic with peptic ulcer disease
20%
what are associated symptoms of peptic ulcer disease
n/v
belching
bloating
heartburn
weight loss (gastric u.)
what age group is more likely to get a gastric ulcer
> 50 yo
what age group is more likely to get duodenal ulcer?
30-60 yo
what do you need to confirm post ulcer tx
ulcer heals fully because the risk of gastric cancer increased
when is pain greater for gastric ulcer
with eating meals
when is pain relieved for duodneal ulcers
with eating meals
what bacterial infection is associated with ulcers
H. Pylori
what is the mechanism of gastric ulcers
ddecreased mucosal protection against stomach acid
what is the mechanism of duodenal uclers
inc
increased gastric acid secretion
decreased mucosal protection
what type of ulcer is associated with malignancy
gastric ulcers
what are some complications of an unhealthy GI ulcer
bleeding/anemia, perforation
what kind of pain is associasted with gastric cancer
peristent, slowly progressive
epigastric pain
what aggravates gastric cancer? what does not alleive it?
food
H. Pylori
Doesn’t relieve: antacids
what are associated symptoms of gastric cancer
anorexia, early satiety, weigh loss, sometimes bleeding
nausea
what is intestinal gastric cancer associated with?
- h. pylori
- smoked foods
- smoking
- chronic gastritis
what paraneoplastic syndromes are associated with gastric cancer
acanthosis nigricans (darkening of the skin creases)
Leser-trelat sign (sudden diffuse seborrheic keratoses)
what is associated with diffuse gastric cancer?
signet ring cells
stomach lining: “leather bottle” appearance
what is a virchow node
left supraclavicular node
-metastasizes from gastric cancer
what is krukenberg tumor
bilateral ovarian mets
-metastasizes from gastric cancer
what is a sister mary joseph nodule
Periumbilical mets
-metastasizes from gastric cancer
where is bilary tract conditions felt?
RUQ or epigastric abdominal pain
-radiates to right shoulder
characteristics of bilary colic
- intermittent, recurrent pain that resolves; rapid onsest and lasts several hours
- aggravated by large fatty meals
- associated with: anorexia, N/V
what characteristics are associated with acute cholecytsitis
- steady, persistent, aching pain with gradual onset
- often prior hx of bilary colic sx
- associated: anorexia, N/V, fever
how do you diagnose acute cholecystitis
- RUQ ultrasound
- HIDA scan
what are the clincial presentations of cholangitis
- charcot tirad (RUQ pain, jaundice, fever)
- Reynolds Pentad (charcot triad, sptic shock, altered mental status)
- obstruction due to infection of biliary tree
Cholelithasis characteristics
- cholesterol stones (4 F’s,) pima native american, cirrhosis
- Pigmented Stones: chronic hemolysis, alcoholic cirrhosis, biliary infections
- most are asymptomatic
Characteristics of Choledocholithiasis
- RUQ pain and jaundice
- gallstone in the common bile duct
diagnosis features of cholangitis
- RUQ ultrasound
- elevated bilirubin, WBC, ERCP, PTC
what is the process of chronic pancreatitis
irreversible destruction of pancrease from recurrent inflammation
what is the location chronic pancreatitis
epigastric radiating to the back and longstanding and persistent
-chronic
symptoms of chronic pancreatitis
pancreatic enzyme insufficiency, diarrhea with steatorrhea, DM
What is the process of pancreatic cancer
adenocarcinoma
describe the pain of pancreatic cancer
- RUQ, LUQ, epigastric
- steady, deep, nonspecific
- persistent pain
- progressive
aggravating factors of chronic pancreatitis
- alcohol
- medication
- frequent pancreatitis
aggravating factors of pancreatic cancer
*smoking
*chronic pancreatitis
symptoms of pancreatic cancer
- painless jaundice
- anorexia
- weigh loss
- glucose
- intolerance
what causes cirrohsis (more common now)
fatty liver disease
what can cirrohsis also cause
- scarred and contracted liver with small liver span
Reidel lobe
- elongated right lobe that is normal variation in liver shape
- may be palpable
downward displacement of liver by a low diaphragm
- as in COPD
- Liver edge palpable below costal margin but percussion reveals low upper edge and vertical span
Smooth large liver
- non tender edge with cirrohsis, hemochromatosis, amyloidosis, lymphoma
- tender edge with inflammation (hepatitis) or venous congestion (R HF)
Irregular large liver
nodular cirrhotic liver
* hepatocellular carcinoma-enlarge liver that is firm with irregular edge or surface
polycystic kidney disease
- autosomal dominat
- family hx
- abdominal flank pain
- back pain
- hematuria
- HTN
