Advanced Abdominal Exam Flashcards
Peritonitis
Inflammation of the peritoneum that results in intense abdominal pain and a board-like abdomen to palpation.
Rebound tenderness
Peritoneal inflammation causes increased pain when the examiner takes away his/her hand abruptly from the abdomen compared to the initial pressing down on the abdomen
Percussion tenderness of the liver, spleen or kidney
Gentle fist percussion using the heel of the hand on the ribs over the liver, spleen or kidney may elicit pain generally caused by stretching or inflammation of the capsule surrounding the organ
Traube’s Space
Traube’s space is defined superiorly by the left 6th rib, inferiorly by the left costal margin, and laterally by the left anterior axillary line.
If dullness is noted upon percussion of Traube’s space, this finding is suggestive of splenomegaly and should be confirmed with palpation for an enlarged spleen.
Hypoactive bowel sound
May be normal or suggest an ileus (obstruction of the intestine due to paralysis of the intestinal muscles.)
Hyperactive bowel sounds
May be normal or suggest an inflammatory or infectious process in the intestines.
High pitched, tinkling bowel sounds
Suggestive of small bowel obstruction
Tympany of the abdomen
Indicates that there is gas in loops of bowel or in the peritoneal space itself.
Shifting dullness on percussion of the abdomen (especially supine vs lateral decubitus)
Suggests fluid in the abdomen (ascites).
Rigidity on palpation of the abdomen
Points toward peritoneal inflammation due to a perforation or rupture of an intraabdominal organ such as stomach, gallbladder, small bowel or colon.
If contraction of the rectus abdominus on palpation is voluntary, it is ____. If it is involuntary, it is ____.
If contraction of the rectus abdominus on palpation is voluntary, it is guarding. If it is involuntary, it is rigidity.
Midline abdominal bruit
Suggests abdominal aortic narrowing or stenosis
Suprapubic abdominal bruit
Suggests iliac artery narrowing or stenosis
Lateral umbilical bruit
Suggests renal artery narrowing or stenosis
Costovertebral angle tenderness
If tenderness is elicited with palpation in the costovertebral angle, it can indicate inflammation in the kidney (pyelonephritis)
Umbilical hernia
A protrusion through a defective umbilical ring is most common in infants but also occurs in adults. In infants, it usually closes spontaneously within 1–2 yrs
May be seen more clearly while the patient is standing.
Inguinal hernia
Presence is noted best in the male patient standing up. The examiner’s finger invaginates the most dependent part of the scrotum to insert the finger in the canal laterally and cephalad.
Ask the patient to cough or strain. A small hernia causes an impulse felt on the fingertip. A larger hernia feels as if there is a mass in the canal.
Caput Medusa
Sign of portal hypertension. Indicates chronic portal vein obstruction. It is a dilatation of the paraumbilical vein that gives the appearance of a rosette around the umbilicus.
When inferior epigastric veins are visible over the abdomen, ___ should be suspected.
When inferior epigastric veins are visible over the abdomen, IVC obstruction should be suspected.
McBurney’s Point
Lies one-third of the distance between the between the anterior superior iliac spine and the umbilicus and is located over where the appendix comes off the base of the cecum.
The pain of acute appendicitis is commonly located at McBurney’s Point.
Rovsing’s Sign
When pressing in on the left lower quadrant elicits pain in the right lower quadrant.
This is an indication of a possible appendicitis.
Rectal tenderness
May indicate a thrombosed hemorrhoid, anal fissure, inflammatory bowel disease, infectious colitis, appendicitis, ischemic colitis, ulcerated rectal cancer or inflamed prostate.
Psoas sign
It is performed by having the patient lie on his/her left side and extending the right leg at the hip to stretch the psoas muscle. If significant pain results, this is a positive psoas sign.
May support the diagnosis of appendicitis, or irritation of any inflamed organ proximal to the psoas.
Obturator sign
It is performed by flexing the patient’s right thigh at the hip with the knee bent and then rotating the leg internally which stretches the obturator muscle. If significant pain results, this is a positive obturator sign.
May support the diagnosis of appendicitis, or inflammation of any pelvic sturcture.
Normal frequency of bowel sounds
Bowels sounds should occur a few times over the course of a minute. Listen for 15 seconds or so in each of the four quadrants. Appreciate whether they seem normal, increased or decreased.
If you think they are decreased, really spend a few minutes listening, and check how the patient is feeling. If bowel sounds are absent and the patient doesn’t feel poorly, it is probably fine. However, if there is severe pain, then suspicion of paralytic ileus is warranted.
When a patient presents for abdominal examination with abdominal pain, you should start the exam . . .
. . . by looking everywhere ELSE on the abdomen.
If you start with the painful site, the patient may guard, which will interfere with the exam. So, counterintuitively, you really want to examine the affected area last.
The integrity of the sacral nerves that innervate the bladder can be tested by assessing . . .
The integrity of the sacral nerves that innervate the bladder can be tested by assessing perirectal and perineal sensation in the S2, S3, and S4 dermatomes
Presentation of peptic ulcer and dyspepsia
Epigastric pain, may radiate straight to the back. Variable in quality. Intermittent timing, may happen for several weeks, disappear, and reappear months later. More likely to occur at night than other GI pain.
Food and antacids may bring relief (more likely for duodenal ulcers, less likely for gatric ulcers). Often accompanied by vomiting, belching, nausea, bloating, heartburn.
May be gnawing or burning (dyspepsia); may also be boring, aching, or hungerlike. No symptoms in up to 20%.
Dyspepsia
aka indigestion
Term that describes post-prandial discomfort or pain in the upper abdomen.
Presentation of gastric cancer
>90% due to adenocarcinoma. Pain often in cardia and GE junction.
Pain is persistent, slowly progressive; duration of pain is typically shorter than in peptic ulcer. Not relieved by food or antacids. Associated with anorexia, nausea, early satiety, weight loss, and bleeding (could be hematemesis or melena)
Types of visceral pain
Presentation of an umbilical hernia
A protrusion through a defective umbilical ring is most common in infants but also occurs in adults. In infants, it usually closes spontaneously within 1–2 yrs.
Presentation of an epigastric hernia
A small defect, through which a large hernia has passed, has a greater risk for complications than a large defect.
Summary of all hernia sites
Presentation of a Lipoma
Common, benign, fatty tumors usually in the subcutaneous tissues almost anywhere in the body, including the abdominal wall. Small or large, they are usually soft and often lobulated. Press your finger down on the edge of a lipoma. The tumor typically slips out from under your finger and is well demarcated, nonreducible, and usually nontender.
Lipomas may occur anywhere on the body, and are often localized to the sub-dermal fat. In the abdomen, another prominent source is the greater omentum.
What is this umbilical finding?
Sister Mary Joseph nodule
Metastatic cancer to the umbilicus
Shifting dullness in ascites
Tympanic boundary shifts when moving from supine to lateral decubitus position.
Signs of hemorrhagic pancreatitis
Retroperitoneal blood seeping through abdominal wall
Classic referred pain locations
Memorize these! They will be on boards!
Phrenic and just infra-phrenic pain
Kehr’s sign
Fat stranding on CT
Stranding seen in fat on CT. Indicates inflammation
