Abnormals of Abdomen

Question 1

Abdominal distention in Obesity: inspection, auscultation, percussion, palpation

Answer 1

Inspection. Uniformly rounded. Umbilicus sunken (it adheres to peritoneum, and layers of fat are superficial to it).

Auscultation. Normal bowel sounds.

Percussion. Tympany. Scattered dullness over adipose tissue.

Palpation. Normal. May be hard to feel through thick abdominal wall.

Question 2

Abdominal distention due to air or gas

Answer 2

Inspection. Single round curve.

Auscultation. Depends on cause of gas, e.g., decreased or absent bowel sounds with ileus; hyperactive with early intestinal obstruction.

Percussion. Tympany over large area.

Palpation. May have muscle spasm of abdominal wall.

Question 3

Abdominal distention from Ascites

Answer 3

Inspection. Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin; recent weight gain; increase in abdominal girth.

Auscultation. Normal bowel sounds over intestines. Diminished over ascitic fluid.

Percussion. Tympany at top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness.

Palpation. Taut skin and increased intra-abdominal pressure limit palpation.

Question 4

Abdominal distention from large ovarian cyst

Answer 4

Inspection. Curve in lower half of abdomen, midline. Everted umbilicus.

Auscultation. Normal bowel sounds over upper abdomen where intestines pushed superiorly.

Percussion. Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness.

Palpation. Transmits aortic pulsation, whereas ascites does not.

Question 5

Abdominal distention from pregnancy (Normal finding)

Answer 5

Inspection. Single curve. Umbilicus protruding. Breasts engorged.

Auscultation. Fetal heart tones. Bowel sounds diminished.

Percussion. Tympany over intestines. Dull over enlarging uterus.

Palpation. Fetal parts. Fetal movements.

Question 6

Abdominal distention from feces

Answer 6

nspection. Localized distention.

Auscultation. Normal bowel sounds.

Percussion. Tympany predominates. Scattered dullness over fecal mass.

Palpation. Plastic-like or rope-like mass with feces in intestines.

Question 7

Abdominal distention from tumor

Answer 7

Inspection. Localized distention.

Auscultation. Normal bowel sounds.

Percussion. Dull over mass if reaches up to skin surface.

Palpation. Define borders. Distinguish from enlarged organ or normally palpable structure.

Question 8

Umbilical Hernia

Answer 8

In an adult, it occurs with pregnancy, with chronic ascites, or with chronic intrathoracic pressure (e.g., asthma, chronic bronchitis).

Question 9

epigastric hernia

Answer 9

A small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing.

Question 10

Incisional hernia

Answer 10

A bulge near an old operative scar that may not show when person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver.

Question 11

Diastasis Recti

Answer 11

Diastasis recti, or a midline longitudinal ridge, is a separation of the abdominal rectus muscles. Ridge is revealed when intra-abdominal pressure is increased by raising head while supine. Occurs congenitally and as a result of pregnancy or marked obesity in which prolonged distention or a decrease in muscle tone has occurred. It is not clinically significant.

Question 12

Hypoactive bowel sounds

Answer 12

Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia.

Question 13

Hyperactive bowel sounds

Answer 13

Loud, gurgling sounds, “borborygmi,” signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus.

Question 14

Peritoneal Friction Rub

Answer 14

A rough, grating sound, like two pieces of leather rubbed together, indicates peritoneal inflammation. Occurs rarely. Usually occurs over organs with a large surface area in contact with the peritoneum.

Liver—friction rub over lower right rib cage, from abscess or metastatic tumor.

Spleen—friction rub over lower left rib cage in left anterior axillary line, from abscess, infection, or tumor.

Question 15

Arterial vascular sounds

Answer 15

a bruit indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels. Listen with the bell. Occurs with the following three conditions:

Aortic aneurysm—murmur is harsh, systolic, or continuous and accentuated with systole. Note in person with hypertension.

Renal artery stenosis—murmur is midline or toward flank, soft, low to medium pitch.

Partial occlusion of femoral arteries.

Question 16

Venous Hum (vascular sounds)

Answer 16

occurs rarely. Heard in periumbilical region. Originates from inferior vena cava. Medium pitch, continuous sound, pressure on bell may obliterate it. May have palpable thrill. Occurs with portal hypertension and cirrhotic liver.

Question 17

Enlarged Liver

Answer 17

An enlarged, smooth, and nontender liver occurs with fatty infiltration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia.

The liver feels enlarged and smooth but is tender to palpation with early heart failure, acute hepatitis, or hepatic abscess.

Question 18

Enlarged Nodular Liver

Answer 18

An enlarged and nodular liver occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilis

Question 19

Enlarged gallbladder

Answer 19

An enlarged, tender gallbladder suggests acute cholecystitis. Feel it behind the liver border as a smooth and firm mass like a sausage, although it may be difficult to palpate because of involuntary rigidity of abdominal muscles. The area is exquisitely painful to fist percussion, and inspiratory arrest (Murphy sign) is present.

An enlarged, nontender gallbladder also feels like a smooth, sausagelike mass. It occurs when the gallbladder is filled with stones, as with common bile duct obstruction.

Question 20

Enlarged Spleen

Answer 20

Because any enlargement superiorly is stopped by the diaphragm, the spleen enlarges down and to the midline. When extreme, it can extend down to the left pelvis. It retains the splenic notch on the medial edge. When splenomegaly occurs with acute infections (mononucleosis), it is moderately enlarged and soft, with rounded edges. When the result of a chronic cause, the enlargement is firm or hard, with sharp edges. An enlarged spleen is usually not tender to palpation; it is tender only if the peritoneum is also inflamed.

Question 21

Enlarged Kidney

Answer 21

Enlarged with hydronephrosis, cyst, or neoplasm. May be difficult to distinguish an enlarged kidney from an enlarged spleen because they have a similar shape. Both extend forward and down. However, the spleen may have a sharp edge, whereas the kidney never does. The spleen retains the splenic notch, whereas the kidney has no palpable notch. Percussion over the spleen is dull, whereas over the kidney it is tympanitic because of the overriding bowel.

Question 22

Aortic Aneurysm

Answer 22

Most aortic aneurysms (>95%) are located below the renal arteries and extend to the umbilicus. A focal bulging >5cm is palpable in about 80% of cases during routine physical examination and feels like a pulsating mass in the upper abdomen just to the left of midline. You will hear a bruit. Femoral pulses are present but decreased