Abdominal/Renal Exam Flashcards
Auscultation
Bowel sounds - not frequency and character in all 4 quadrants
- normal = 5-35 clicks/gurgles per minute
- abnormal = high pitched, decreased/absent
- decreased = none for 1 minute (post-surgical ileum, peritonitis)
- increased (diarrhea, early bowel obstruction)
- high pitched (early intestinal obstruction)
Vascular sounds - abdominal aorta, iliac, renal and femoral arteries
- listen for bruits (vascular obstruction)
- friction rub (inflammation of peritoneal surface of an organ)
- venous hum (increased collaterals circulation between portal and systemic venous systems)
Abdominal Exam Order
Inspect
Auscultate
Percuss
Palpate
Percussion
Tympany - majority of abdomen; caused by air-filled viscera
Dullness - flat sound without echoes, heard over solid organs; liver, spleen, fluid in peritoneum, feces
Liver: 6-12 cm at mid-clavicular line on right
Spleen: from ribs 6-10 at mid-axillary line on the left
Palpation
General:
- warm hands
- bend patient’s knees to relax abdominal muscles if needed
- examine tender areas last
Light = 1 cm in depth Moderate = 2-3 cm in depth Deep = more than 3 cm in depth
Rebound Tenderness
Pain upon removal of pressure rather than application of pressure to abdomen
Tests for peritoneal inflammation
Guarding
Voluntary or involuntary
Rigidity
Abdomen is hard, involuntary reflex
Rovsing’s Sign
Pain in RLQ during left-sided pressure
Referred rebound tenderness seen in appendicitis
McBurney’s Point
Rebound tenderness of pain 1/3 of distance from ASIS to umbilicus (of 2/3 from umbilicus to ASIS)
May suggest appendicitis/peritoneal irritation
Murphy Sign
Palpate deeply under right costal margin during inspiration
Observe pain and/or sudden stop in inspiratory effort
Acute cholecystitis or cholelithiasis
Courvoisier’s Sign
Enlarged, non-tender gallbladder secondary to pancreatic disease or cancer
Aorta
Palpate just above the umbilicus, slightly to the left of midline
Estimate the width of the aorta (normal = 2-3 cm)
Expected = pulsation in anterior-inferior direction
Unexpected = prominent lateral pulsation and more than 3 cm in diameter
Sympathetic Levels
Esophagus - T2-8 Stomach - T5-9 Liver - T6-9 Gallbladder - T6-9 Small Intestine - T9-11 Colon - T10-L2 Pancreas - T5-11 Appendix - T12
Parasympathetic Levels
Upper portion: esophagus thru transverse colon - OA, AA (vagus n.)
Lower portion: descending colon, sigmoid, rectum - S2-S4 (pelvic splanchnic n.)
Iliopsoas Muscle Test
Flex right hip against resistance
Increased abdominal pain = +
Suggests irritation of psoas m. From inflammation of appendix
Obturator Muscle Test
Flex right thigh at hip with knee bent and leg internally rotated
Right hypogastric pain = +
Suggests irritation of obturator m. From inflamed appendix
Lloyd Punch/Kidney Punch/Costovertebral Angle (CVA) Tenderness
Gently tapping costovertebral angle (area of back overlying kidney) produces pain
Suggests infection around kidney (perinephric abscess) or polynephritis, or renal stone
Heel Strike
Pain could indicate appendicitis
Abdominal Quadrants
RUQ
LUQ
RLQ
LLQ
Abdominal Regions
Right hypochondriac region Right lumbar region Right iliac region Hypogastric region Umbilical region Epigastric region Left hypochondriac region Left lumbar region Left iliac region
Test for Ascites
Fluid in peritoneal cavity
Shifting dullness test
- percussion borders of tympany and dullness supine and lateral recumbent
- normal = borders stay the same
- positive test = dullness shifts to dependent side and tympany on top side
Test for fluid wave
- tap one flank
- normal = no impulse felt on other flank
- positive test = impulse transmitted to other flank
Abdominal Wall Mass vs. Intraabdominal Mass
Patient raises head and shoulders when supine or strains down
Abdominal wall mass = remains palpable
Intraabdominal mass = no longer palpable, obscured by muscular contraction
Ventral Hernia
Lying supine, raise both head and shoulders off table
Positive test = bulge of hernia will usually appear
Documenting a Normal Abdominal Exam
Abdomen is soft, nontender, nondistended, bowel sounds heard in all 4 quadrants, no rebound, guarding, rigidity, hepatoplenomegaly, or costovertebral angle tenderness
Abd S/NT/ND/BS+ x 4, no R/G/R, HSM or CVAT
Inspection
Skin color/characteristics
- jaundice
- Grey Turner Sign - flank ecchymosis secondary to hemorrhage (hemoperitoneum, acute pancreatitis)
- Cullen Sign - ecchymosis around the umbilicus (preumbilical) secondary to hemorrhage (hemoperitoneum, acute pancreatitis, ectopic pregnancy)
- scars/striae
- dilated veins
- rashes and lesions
Contour/symmetry
- abdominal distension
- hernias/masses
Surface motion - peristalsis
Pulsations
