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Patient Assessment > abdominal physical exam > Flashcards

abdominal physical exam Flashcards

1
Q

how should the patient be positioned for the exam?

A

lying supine on the table with arms at the side or folded across the chest and lower groin draped

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2
Q

what should be asked before the PE

A

if there is any pain so you can examine these areas LAST

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3
Q

What is the order of examination

A

IAPP
inspection, auscultation, percussion, palpation

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4
Q

Order of the abdomen examination

A
  1. Inspect: surface, contours, movements, skin temp, color, presense of scars or striae
  2. auscultate all 4 quadrants
  3. percuss all 4 quadrants
  4. lightly palpate 9 quadrants
  5. deeply palpate all 9 quadrants
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5
Q

order of examination of the liver

A
  1. estimate the size by percussing up the midclavicular line
  2. palpate and characterize the liver (hook the liver)
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6
Q

Order of examination of the spleen

A
  1. percuss for splenic enlargement along the traubes space
  2. palpate the splenic edge with the pt supine and in the Right lateral decubitus position
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7
Q

order of examination for the kidney

A
  1. fist percussion of the right and left CVA
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8
Q

order of examination of the urinary bladder

A

percuss the urinary bladder

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9
Q

what are you looking for on inspection of the abdomen

A
  1. color (bruises, erythema, jaundice)
  2. scars
  3. striae
  4. Dilated veins
  5. umbilicus bulging (hernia)
  6. rashes or ecchymoses
  7. contour of the abdomen
  8. aortic pulsation
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10
Q

what is indicated by pink/purple striae

A

cushing syndrome

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11
Q

what do large dilated veins of the abdomen suggest

A

portal hypertension due to cirrohsis (caput medusa) or inferior vena cava obstruction

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12
Q

what is caput medusa

A

large dilated veins around the umbilicus, going outwards (looks like medusa)
-from portal htn from cirrohsis

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13
Q

what does inferior vena cava obstruction look like

A

dilated veins running vertically down the stomach

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14
Q

what is ecchymoses of the abdominal wall from?

A

intraperitoneal or retroperitoneal hemorrhage
-cullens sign
grey turners sign

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15
Q

what is cullen’s sign?

A

ecchymosis around the umbilicus

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16
Q

what is Grey Turners Sign

A

ecchymosis of the flank

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17
Q

what can cullens sign or grey turners sign be associated with?

A
  1. acute hemorrhagic pancreatitis
  2. ruptured ectopic pregnancy
  3. abdominal trauma
  4. splenic rupture (MC-Mono)
  5. ruptured abdominal aortic aneurysm
  6. perforated ulcer
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18
Q

what are the 4 types of abdominal contours

A
  1. flat- horizontal line from costal margin to symphysis pubis
  2. Rounded- “convex”
  3. Scaphoid- concave
  4. protuberant- similar to rounded but greater
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19
Q

when is a rounded abdomen normal

A

in toddlers and pregnant females

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20
Q

when is scaphoid abdomen normally seen?

A

in a very thin person

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21
Q

when is a protuberant abdomen seen?

A
  • obesity
  • ascities
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22
Q

upon auscultation

what is the classification of a normoactive abdomen

A

5-34 clicks and gurgles per minute

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23
Q

upon auscultation

what is the classification of a hypoactive abdomen

A

<5 click/min
* heard in slowed intestinal activity (constipation, surgery, sleep)

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24
Q

when is the abdomen hypoactive-absent upon auscultation?

A
  • in the ileus
  • peritonitis
  • late intestinal obstruction
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25
Q

upon auscultation

what is the classification for a hyperactive abdomen?

A

> 34 clicks and gurgles/min
* diarrhea, after eating, laxative use

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26
Q

what is indicated by high pitched and hyperactive abdomen sounds?

A

early intestinal obstruction

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27
Q

what is borborygmi

A

prolonged gurgles of hyperperistalsis

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28
Q

where do you auscultate for bruits?

A

aortic, renal, iliac and femoral arteries

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29
Q

where do you auscultate for friction rubs?

A

liver
spleen
abdominal mass

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30
Q

what may friction rub of the abdomen be present in?

A
  • hepatoma
  • liver cancer
  • chlamydial or gonococcal perihepatitis
  • recent liver biopsy
  • splenic infarct
  • pancreatic carcinoma
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31
Q

what is venous hum and when is it present?

A

rare soft humming noise

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32
Q

what are you percussing the abdomen for?

A

all 4 quadrants for distribution of tympany and dullness

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33
Q

what sound upon percussion dominates the abdomen

A

tympany (b/c gas in the GI tract)
scattered dullness due to feces and fluid

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34
Q

what should you note upon percussion of the GI tract

A

dull areas
indicates: underlying mass, enlarged organ, ascites

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35
Q

how many regions do you palpate?

A

9 regions, light and deep pressure

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36
Q

what is voluntary gaurding?

A

voluntary contraction of the abdominal wall
* with a grimace
* pt is protecting from pain

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37
Q

what is involuntary gaurding or rigidity?

A

involuntary reflex scontraction of the abdominal wall that persists despite maneuvers
indicates: peritonitis

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38
Q

what is involuntary gaurding aka

A

board like abdomen

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39
Q

what does persistent involuntary guarding indicate

A

Peritonitis

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40
Q

what are 3 techniques to distinguish voluntary vs involuntary

A
  1. pt bending lower extremities to make abd. muscles less tense
  2. pt mouth breathing with jaws wide open
  3. palpate after asking pt to exhale (relaxes abd. muscles)
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41
Q

when do you get a flat plate X-ray

A

Bowel perforation

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42
Q

what is the cough test? what is it used for?

A

ask the patient to cough and identify areas of pain
-used to assess for peritonitis or acute abdomen

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43
Q

what is rebound tenderness? what is it used to asses?

A

ask the patient if it hurts more w/ withdrawl or pushing in?
positive=withdrawl pain
assesses: peritonitis or acute abdomen

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44
Q

what are 4 ways to assess for acute abdomen or peritonitis

A
  1. cough test
  2. involuntary gaurding or rigidity
  3. rebound tenderness
  4. percussion tenderness
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45
Q

what should be assumed for female patients under 55?

A

that they are pregnant until proven otherwise

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46
Q

what is the MC for obstruction

A

adhesions

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47
Q

How to estimate the size of liver by percussion

4 steps

A
  • right midclavicular line
  • percuss upwards from the RLQ below umbilicus
  • Percuss down from the nipple line
  • measure the distance
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48
Q

what can cause a falsely decreased liver size estimate

A

gas in the colon in the RUQ or free air in the diaphragm

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49
Q

what can cause a falsey increased liver size estimate

A

right ham pleural effusion or pneumonia adjacent to liver

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50
Q
A
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51
Q

How to palpate for the liver edge?

A
  • below the right costal margin at the midclavicular line
  • ask Pt to take a deep breath
  • hooking technique
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52
Q

what is the hooking technique?

A
  • place both hands side by side
  • press in/up with your fingers under the costal margin
  • ask the pt to take a deep breath
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53
Q

when is the hooking technique useful?

A

helpful to palpate the liver especially in obsese patients

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54
Q

what should a normal liver edge feel like?

A

soft, sharp and regular with a smooth surface

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55
Q

what is the traube space

A

borders on the LEFT side
1. 6th rib
2. anterior axillary line
3. costal margin

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56
Q

what do you percuss the traube space for?

A

for the spleen
dullness to replace tympany

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57
Q

what is splenomegaly seen in?

A

Portal HTN as in:
1. cirrohsis
2. R sided HF
3. hematologic malignancies
4. HIV
5. Infiltrative disease (amyloidosis, splenicinfarct, splenic hematoma, infectious mono)

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58
Q

What should you assess for athletes?

A

mono with splenomegaly
* it could rupture during sports

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59
Q

How to percuss the spleen

A
  1. percuss the lowest sinterspace int he left anterior axillary line (usually tympanic)
  2. as pt to take a deep breath and hold
  3. percuss again at lowest iinterspace left anterior axillary line
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60
Q

what is a postive splenic percussion sign?

A

Castell Sign
a change in percussion note to dullness on inspiration

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61
Q

when should you pay extra attention to palpation of the spleen for splenogmegaly

A

either or both traube space dullness or a positive castell sign

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62
Q

Palpation technique to detect splenomegaly

A
  1. pt is supine and relaxed
  2. with your left hand, reach around and presss the spleen forward from the back
  3. with your right hand, press below the left costal margin
  4. ask the patient to take a deep breath to try and feel the spleen
  5. repeat with the pt lying on the right side with hips and knees flexed
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63
Q

How to asses for CVA tenderness

A
  1. place the palm of one hand over the cva area
  2. strike your hand with ulnar surface
  3. positive if pain is felt
64
Q

what does a positive CVA test indicate?

A

Pyelonephritis

should further evaluate for fever and urinary symptoms

65
Q

are kidneys usually palpable?

A

No unless they are markedly enlarged

66
Q

what can cause unilateral enlarged kidney

A
  1. hydronephrosis
  2. cysts
  3. tumors
  4. kidney stokes
67
Q

what can cause bilateral enlarged kineys

A

polycystic kidney disease

68
Q

what are the three ways to test for ascities

A
  1. percussion outward from central tympany to area of dullness on supine pt
  2. test for shifting dullness (putting the patient one one side and mark the borders again)
  3. test for fluid wave
69
Q

when is ascities suspected?

A

a protuberant abdomen with bulging flanks

70
Q

How to decipher between ascites and a gas filled abdomen

A

ascities= fluid sinks to the bottom
gas-filled= bowels rrise

71
Q

what does a distended abdomen in a pediatric pt indicate

A

malnutritrion

72
Q

How to do a test for a fluid wave

A
  1. ask the patient to press their hands firmly down the midline of abd.
  2. tap one flank sharpy with your fingertips and feel the opposite flank for impulse
73
Q

what are the 2 limitation of the fluid wave test?

A
  1. often negative until ascites is obvious
  2. sometimes positive in people without ascites
74
Q

what are the 5 ssigns to test for appendicitis

A
  1. McBurney’s point tenderness
  2. Rosving sign
  3. Psoas sign
  4. Obturator sign
  5. Peritoneal sign
75
Q

what is the McBurney’s Point Tenderness

A
  • tenderness 2 inches in from R anterior superior iliac spine on a line drawn from that to the ubmilicus
76
Q

How to test for the Rosving sign?

A

pain in the RLQ during LLQ

77
Q

How to test for Psoas Sign?

A
  • increased pain with right hip flexion against the resistance
  • with pt supine, have the pt push their leg against your hand
78
Q

How to test for the obrurator sign?

A
  • 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
79
Q

How to test for the Peritoneal sign?

A
  • gaurding, rigidity, rebound tenderness, percussion tenderness
80
Q

what does Murphys sign test for?

A

cholecystitis

81
Q

how to test for murphys sign? what is positive?

A
  • 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
82
Q

what causes acute cholecystitis?

A

obstructing gallstone or bile stasis

83
Q

What are the risk factors of cholelithasis? (acute cholecystitis)

A

Four f’s
1. fat
2. female
3. forty
4. fertile

84
Q

where is acute cholecystitis pain felt?

A

right upper quadrant

85
Q

what are the clinical symptoms of acute cholecystitis

A
  • RUQ pain
  • steady pain
  • fever
  • N/V
  • anorexia
86
Q

How to assess for a ventral hernia

A
  • ask the patient to raise both head and shoulder off the table or raise both legs and do Valsalva
  • assess for protruding hernia
87
Q

where is an umbilical hernia

A

a protrusion through a defective umbilical ring

88
Q

where is an incisional hernia

A

a protrusion through an operative scar

89
Q
A
90
Q

Where is an epigastric hernia found?

A

a small midline protrusion through a defect in th elinea alba occurs b/w the xiphoid process and the umbilicus

91
Q

what is diastasis recti

A

separation of the two rectus abdominis muscles
*typically extending from the xiphoid to the umbilicus
*not a true hernia, is clinically begnin

92
Q

when is diastasis recti most present

A
  • pts that have been pregnant
  • obesity
  • chronic lung disease
93
Q

abdominal wall mass vs intra-abdominal mass

A

in wall: remains palpable
in cavity: is obscured by musclar contraction

94
Q

How to feel out a Lipoma

A

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

94
Q

What is a lipoma

A

common, benign fatty tumor in the subcutaneous tissue
* small or large
* soft and lobulated

95
Q

what does acute appendicitis pain start as

A

periumbilical pain

96
Q

Defining characteristics of acute appendicitis

A
  • pain worsens
  • aggravated by cough
    • anorexia, n/v, pain, fever
97
Q

what is acute appendicitis caused by?

A

Fecaliths or lymphoid hyperplasia

98
Q

what is fecaliths

A

hardened fecal matter

99
Q

where is acute pancreatitis pain felt? what aggravates? what alleviates?

A
  • radiates to the back
  • aggravated: supine position
  • alleviated: leaning forward with truck flexed
100
Q

what are associated symptoms of acute pancreatitis?

A
  • N/V
  • abdominal distention
  • fever
101
Q

what lab values are elevated for acute pancreatitis? (specific)

A

amylase
lipase

102
Q

what are physical exam findings of acute pancreatitis

A

epigastric tenderness
rebound tenderness

103
Q

what is acute pancreatitis associated with?

A

high triglyceride or gallstone pancreatitis, drinking, cirrohsis

104
Q

what pain is associated with acute diverticulitis

A

LLQ pain due to sigmoinds colon or descending colon diverticulitis
*gradual onset of cramp and then steady pain

105
Q

what relieves acute diverticulitis pain

A

analgesia
bowel rest
antibiotics

106
Q

what are associated symptoms of acute diverticulitis

A
  • fever
  • constipation or diarrhea
  • n/v
  • diarrhea
  • elevated WBC
107
Q

what are the physical exam findings of acute diverticulitis

A

LLQ tenderness
rebound tenderness
may have: palpable mass

108
Q

what is peptic ulcers described as

A

gnawing
burnign
boring
aching
“hunger pain”

109
Q

what percentage of pts are asymptomatic with peptic ulcer disease

A

20%

110
Q

what are associated symptoms of peptic ulcer disease

A

n/v
belching
bloating
heartburn
weight loss (gastric u.)

111
Q

what age group is more likely to get a gastric ulcer

A

> 50 yo

112
Q

what age group is more likely to get duodenal ulcer?

A

30-60 yo

113
Q

what do you need to confirm post ulcer tx

A

ulcer heals fully because the risk of gastric cancer increased

114
Q

when is pain greater for gastric ulcer

A

with eating meals

115
Q

when is pain relieved for duodneal ulcers

A

with eating meals

116
Q

what bacterial infection is associated with ulcers

A

H. Pylori

117
Q

what is the mechanism of gastric ulcers

A

ddecreased mucosal protection against stomach acid

118
Q

what is the mechanism of duodenal uclers

inc

A

increased gastric acid secretion
decreased mucosal protection

119
Q

what type of ulcer is associated with malignancy

A

gastric ulcers

120
Q

what are some complications of an unhealthy GI ulcer

A

bleeding/anemia, perforation

121
Q
A
122
Q

what kind of pain is associasted with gastric cancer

A

peristent, slowly progressive
epigastric pain

123
Q

what aggravates gastric cancer? what does not alleive it?

A

food
H. Pylori
Doesn’t relieve: antacids

124
Q

what are associated symptoms of gastric cancer

A

anorexia, early satiety, weigh loss, sometimes bleeding
nausea

125
Q

what is intestinal gastric cancer associated with?

A
  • h. pylori
  • smoked foods
  • smoking
  • chronic gastritis
126
Q

what paraneoplastic syndromes are associated with gastric cancer

A

acanthosis nigricans (darkening of the skin creases)
Leser-trelat sign (sudden diffuse seborrheic keratoses)

127
Q

what is associated with diffuse gastric cancer?

A

signet ring cells
stomach lining: “leather bottle” appearance

128
Q

what is a virchow node

A

left supraclavicular node
-metastasizes from gastric cancer

129
Q

what is krukenberg tumor

A

bilateral ovarian mets
-metastasizes from gastric cancer

130
Q

what is a sister mary joseph nodule

A

Periumbilical mets
-metastasizes from gastric cancer

131
Q

where is bilary tract conditions felt?

A

RUQ or epigastric abdominal pain
-radiates to right shoulder

132
Q

characteristics of bilary colic

A
  • intermittent, recurrent pain that resolves; rapid onsest and lasts several hours
  • aggravated by large fatty meals
  • associated with: anorexia, N/V
133
Q

what characteristics are associated with acute cholecytsitis

A
  • steady, persistent, aching pain with gradual onset
  • often prior hx of bilary colic sx
  • associated: anorexia, N/V, fever
134
Q

how do you diagnose acute cholecystitis

A
  • RUQ ultrasound
  • HIDA scan
135
Q

what are the clincial presentations of cholangitis

A
  • charcot tirad (RUQ pain, jaundice, fever)
  • Reynolds Pentad (charcot triad, sptic shock, altered mental status)
  • obstruction due to infection of biliary tree
135
Q
A
136
Q

Cholelithasis characteristics

A
  • cholesterol stones (4 F’s,) pima native american, cirrhosis
  • Pigmented Stones: chronic hemolysis, alcoholic cirrhosis, biliary infections
  • most are asymptomatic
137
Q

Characteristics of Choledocholithiasis

A
  • RUQ pain and jaundice
  • gallstone in the common bile duct
138
Q

diagnosis features of cholangitis

A
  • RUQ ultrasound
  • elevated bilirubin, WBC, ERCP, PTC
139
Q

what is the process of chronic pancreatitis

A

irreversible destruction of pancrease from recurrent inflammation

140
Q

what is the location chronic pancreatitis

A

epigastric radiating to the back and longstanding and persistent
-chronic

141
Q

symptoms of chronic pancreatitis

A

pancreatic enzyme insufficiency, diarrhea with steatorrhea, DM

142
Q

What is the process of pancreatic cancer

A

adenocarcinoma

143
Q

describe the pain of pancreatic cancer

A
  • RUQ, LUQ, epigastric
  • steady, deep, nonspecific
  • persistent pain
  • progressive
144
Q

aggravating factors of chronic pancreatitis

A
  • alcohol
  • medication
  • frequent pancreatitis
145
Q

aggravating factors of pancreatic cancer

A

*smoking
*chronic pancreatitis

146
Q

symptoms of pancreatic cancer

A
  • painless jaundice
  • anorexia
  • weigh loss
  • glucose
  • intolerance
147
Q

what causes cirrohsis (more common now)

A

fatty liver disease

148
Q

what can cirrohsis also cause

A
  • scarred and contracted liver with small liver span
149
Q

Reidel lobe

A
  • elongated right lobe that is normal variation in liver shape
  • may be palpable
150
Q

downward displacement of liver by a low diaphragm

A
  • as in COPD
  • Liver edge palpable below costal margin but percussion reveals low upper edge and vertical span
151
Q

Smooth large liver

A
  • non tender edge with cirrohsis, hemochromatosis, amyloidosis, lymphoma
  • tender edge with inflammation (hepatitis) or venous congestion (R HF)
152
Q

Irregular large liver

A

nodular cirrhotic liver
* hepatocellular carcinoma-enlarge liver that is firm with irregular edge or surface

153
Q
A
154
Q

polycystic kidney disease

A
  • autosomal dominat
  • family hx
  • abdominal flank pain
  • back pain
  • hematuria
  • HTN

Patient Assessment (20 decks)

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