Abdominal & Rectal Examinations - Stasio Flashcards
Visceral Pain (colic pain)
- Source is usually hollow organ caused by distension or stretching (intestinal, renal, ureteral)
- Comes and goes, crescendo/decrescendo pattern
- Not well localized
Parietal Pain
- Caused by inflammation of the peritoneum
- Steady aching pain that is usually well localized
Referred Pain
- From a distant sight
- Right shoulder: gallbladder
- Left shoulder: spleen
- Back: pancreas or aorta
The physical examination of the abdomen and rectum includes:
- Inspection
- Auscultation
- Percussion
- Palpation
- Rectal examination
- Special techniques
- (Always auscultate before you palpate!)
How should you expose the abdomen for inspection?
Expose from xiphoid to pubis (Adequate exposure of the abdomen is essential)
Considerations during inspection:
- Skin - scars, striae, superficial veins
- Umbilicus - hernia, “Caput medusa”
- Contour - flat, scaphoid, protuberant
- Pulsations or peristalsis
Caput Medusae
Dilated cutaneous veins around the umbilicus, seen mainly in the newborn and in patients with cirrhosis
Auscultation of the Abdomen
–Listen for bowel sounds before palpation and percussion.
•All 4 quadrants
•RLQ – best place to listen d/t cecum
–Normal bowel sounds – high pitched “tinkle” about every 3-5 seconds.
–No bowel sounds after 2 minutes – report as “absent”.
Borborygmi – (bor-bo-rig-me)
–Increased, hyperactive bowel sounds
–Low pitched rumbling
–Hyperperistalsis
Abdominal bruits, different locations
A soft sound made by disrupted arterial flow through a narrowed artery
- Aortic – between the umbilicus and xiphoid
- Renal artery – just lateral to the aorta
- Femoral artery – along the inguinal ligament
Percussion of the Abdomen
•Helps evaluate the presence of:
–Gaseous distention
–Fluid
–Solid masses
–Size and location of the liver and spleen
•Percuss all 4 quadrants
•Best done with the patient in the supine position
Tympany
–Most common percussion note.
–Presence of gas in the stomach and small bowel.
Liver Percussion
–Percuss along the right mid-clavicular line from top to bottom.
–Resonant (lungs) to dull (liver) to tympanic (intestine)
Fluid Wave in Ascites
Fluid wave – Place patient’s or
assistant’s hand in midline. Tap on
one flank and palpate with the other
hand. An easily palpable impulse
suggests ascites.
Shifting Dullness in Ascites
Shifting dullness – percuss the patient on their
back and then their side. Note where the sound
changes from tympany to dull and the shift of the
sound when the patient is turned to the side.
Abdominal Palpation (segments)
–Light palpation
–Deep palpation
–Liver palpation
–Spleen palpation
–Kidney palpation
–Rebound palpation
Light Palpation
Detect tenderness and areas of muscular spasm or rigidity.
Palpate all 4 quadrants.
Use finger tips with a gentle motion.
Deep Palpation
Used to evaluate organ size, abnormal masses, aorta, deep pain etc.
One hand placed on top of the other.
Rebound Tenderness
–Evaluates for peritoneal tenderness and inflammation.
–Technique:
•In the suspected area of the abdomen, slowly, gently and deeply palpate.
•Then, quickly remove the palpating hand.
–If the patient experiences pain = “+ rebound tenderness”.
–Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
Palpating the Liver
Place left hand under the right 11th and 12th rib.
Right hand on the RUQ.
Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.
Can repeat the maneuver.
Liver “Hooking Technique”
Stand near the patient’s head.
With both hands “hook” your fingers around the lower right costal margin.
Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver.
Spleen Palpation
Place left hand under the 11th and 12th ribs.
Place right hand in the LUQ under the costal margin.
Instruct the patient to breath deeply as the examiner gently presses inward and upward.
Repeat the maneuver for deeper palpation.
The spleen is normally not palpated in normal conditions.
Palpation of the Aorta
Press firmly and deep in the upper abdomen with two hands.
Normal aorta is 2.5 to 3.0 cm wide.
Aortic Aneurysm
Pathologic dilatation of the aorta. Can be associated with a bruit.
Assessed with an ultra sound or CT scan.
Palpation of the Kidneys
“Sandwich method”
Place a hand above and below the costal margins just lateral to the midline.
Deep and gentle palpation attempt to palpate the lower pole of each kidney.
The kidneys are normally not palpated under normal conditions.
Percussion of the kidneys
With a fist, gently hit the area over the costovertebral angle on each side of the spine.
Pain over a kidney may indicate an inflammatory or infectious process of the kidney.
The examiner may also place a flat hand over the CVA and strike the hand.
+ CVA (costovertebral angle) Tenderness = Lloyd’s sign
Every abdominal exam should conclude with a…
…DRE (digital rectal examination)
DRE positions
Patient on their back – Modified Lithotomy
Lying on left side – a.k.a. – Sims’ Position
Standing, bent over the exam table
Rectal Inspection
Spread the buttocks
Sacrococcygeal and perianal areas
Anus and rectum
Note: Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors
Steps to the DRE
Inform the patient of what is going to happen.
Lubricate your gloved index finger.
Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.
Slowly insert the finger as the sphincter relaxes as far as possible.
Rectal examination details
During male exams, evaluate the prostate.
Rotate your hand to palpate as much of the rectal surface as possible.
Gently withdraw the glove and note the color.
of the fecal material and test for occult blood.
Note: nodules, irregularities, masses, tenderness,
induration.
Fecal Occult Blood Testing
Patients with a positive FOBT require
a through evaluation for CRC.
Colonoscopy is the study of choice.
Sigmoidoscopy and air contrast barium
enema are acceptable alternatives.
Examples of Rectal Pathology (…I’ll hold off on the pictures here)
- Anal warts (Condyloma acuminata from HPV; Condylomata lata from syphilis)
- Prolapsed internal hemorrhoid
- Rectal CA
Abdominal documentation example
–Flat, + RLQ 4 inch surgical scar
–BS x 4, neg. aortic or femoral bruits
–Tympanic percussion, neg. distension, liver 9 cm
–Neg. tenderness or masses to superficial and deep palpation, aorta not enlarged
–Neg. hepatosplenomegaly (HSM)or tenderness
–Neg. CVA tenderness
–Rectal: neg. external lesions, good sphincter tone, no masses or tenderness, stool for occult blood negative
APPENDICITIS
•Etiology
–Obstruction of the appendicular lumen. Fecal or foreign matter, tumors or lymphomas.
•History
–Pain starts peri-umbilical then shifts to the right lower quadrant.
–Nausea and vomiting
–Anorexia
–Fever
APPENDICITIS
•Physical Exam
–RLQ pain and RLQ rebound tenderness
–Decreased or absent bowel sounds
–Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
–Psoas sign – turn patient on left side and extend the right leg to check for psoas muscle inflammation.
–Obturator sign – place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
–Always do a rectal examination and a pelvic exam on a female.
APPENDICITIS WORK-UP
INCLUDES:
–CBC – moderate leukocytosis with left shift.
–Urine – may contain a few WBC or RBC. Helps R/O any GU condition.
–Plain x-ray – rarely helpful.
–Ultrasound – enlarged and thick walled appendix.
–CT scan – most sensitive. 90 – 98% sensitive.
–Female patient – Must do a pregnancy test to R/O ectopic pregnancy.
–BMP – evaluate electrolytes and renal functions, especially if patient has been vomiting.
Acute Cholecystitis
•Etiology
–Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.
•History
–RUQ postprandial pain. Biliary colic pain.
–Pain radiating to the right shoulder.
–Nausea and vomiting.
–Anexoria
–Obesity
–Fever
–The 5 “f’s” – female, fat, fertile, fair, flatulent.
Acute Cholecystitis
•Physical Examination
–RUQ pain and RUQ rebound tenderness.
–Decreased or absent bowel sounds.
–Abdominal distention.
–Diagnostic Triad – RUQ pain, fever and leukocytosis.
Murphy’s sign
RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
Cholecystitis Work-Up
–CBC – leukocytosis with left shift
–Serum bilirubin – can be mildly elevated.
–AST/ALT – can be elevated.
–Ultrasound – will detect stones, thicken GB wall, dilated bile duct and fluid.
–HIDA scan – radionuclide biliary scan.
–CT scan
