Approach To Abdominal Complaint I

Question 1

What are the types of abdominal pain?

Answer 1

Visceral, parietal, referred pain

Question 2

Describe visceral pain

Answer 2

Caused by stimulation of the visceral pain fibers
Secondary to distention, stretching or contracting of hollow organs, stretching the capsule of solid organs or organ ischemia
Not localized
Usually felt in midline at level of structure involved

Question 3

Describe parietal (somatic) pain

Answer 3

Caused by stimulation of the somatic pain fibers
Secondary to inflammation in the parietal peritoneum
Localized

Question 4

Describe referred pain?

Answer 4

Originates within the abdominal but is felt at distant sites which are innervated at approximately the same spinal levels as the disordered structure
Ex duodenal and pancreatic pain - referred to back

Question 5

What is important to asking during the ROS?

Answer 5

Always ask discriminators and life threats (fever, chills, CP, SOA, cough)

Question 6

What are questions to ask during social history?

Answer 6

Stress, travel, well water, ingestion of undercooked meat

Question 7

What is the order of a physical exam?

Answer 7

Inspection, auscultation, percussion, palpation
Must be done in this order*
Must drape your pt*

Question 8

Describe inspection of the abdomen

Answer 8

Evaluate quadrants 
Evaluate surface (skin color, surgical scars, striae/stretch marks, dilated veins, rash, ecchymoses 
Contour of the abdomen (flat, round, scaphoid, bulges, obese, protuberant)

Question 9

Describe auscultation of bowel sounds

Answer 9

Provides important information about bowel motility
Use diaphragm to listen for bowel sounds
Use the bell to listen for bruits

Question 10

What are normal bowel sounds?

Answer 10

5-34 clicks/gurgles per min

Question 11

What are absent bowel sounds?

Answer 11

None for >2 mins

Long lasting intestinal obstruction, intestinal perforation, mesenteric ischemia

Question 12

What are decreased bowel sounds?

Answer 12

None for 1 min

Post surgical ileus, peritonitis

Question 13

What are increased bowel sounds?

Answer 13

Diarrhea, early bowel obstruction

Question 14

What are high pitched bowel sounds?

Answer 14

Sounds like tinkling (raindrops on metal)

Suggests early intestinal obstruction

Question 15

What are bruits?

Answer 15

Vascular sounds resembling a heart murmur

Result from turbulent flow, listen over the aorta or other abdominal arteries

Question 16

What is friction rub?

Answer 16

Grating sounds with respiratory variation
Inflammation of the peritoneal surface of an organ
Listen over liver and spleen

Question 17

What is a venous hum?

Answer 17

Soft humming noise
Increased collateral circulation b/w portal and systemic venous systems
Listen over epigastric and umbilical regions

Question 18

Describe percussion

Answer 18

Allows you to asses for fluid and solid filled masses, the amount of gas in abd and sizing of the liver and spleen 
Tympany predominates (because of gas in the GI tract, scattered areas of dullness is normal from fluid and feces) 
Abnormal = large dull areas from a mass or enlarged organ

Question 19

Describe palpation

Answer 19

Helpful for discerning abd tenderness, resistance, superficial organs and masses
Gently palpate in all 4 quadrants and superficially
Then deeply palpate in all 4
Always start away from the area of reported tenderness*

Question 20

Describe liver assessment

Answer 20

Mostly covered by rib cage
Assessment is difficult
Asses shape and size by percussion and palpation
Normal liver vertical span (6-12 cm in right midclavicular line)

Question 21

Describe spleen assessment

Answer 21

Normally not palpable unless enlarged

Percussion and palpation help assess splenomegaly

Question 22

Describe an increase in vertical span of the liver

Answer 22

Enlarged liver

Question 23

Describe liver vertical span decreased

Answer 23

Shrunken liver

Question 24

What are possible causes for palpating irregular edges/nodules on a liver?

Answer 24

Cancer (hepatocellular carcinoma, Mets), cirrhosis

Question 25

What are possible causes for firmness/hardness when palpating the liver?

Answer 25

Cirrhosis, hematochromatosis, amyloidosis, lymphoma

Question 26

What are possible causes for enlarged spleen (splenomegaly)?

Answer 26

Portal HTN, blood malignancies, HIV, splenic infraction, splenic hematoma, mononucleosis

Question 27

What are special tests for a fluid wave (for ascites)?

Answer 27

Normal = no impulse felt on the other flank

Ascites/positive test = impulse transmitted to the other flank

Question 28

What is McBurney’s point tenderness?

Answer 28

Best test for appendicitis

Positive test = tenderness

Question 29

What is rovsing’s sign?

Answer 29

Good test for appendicitis

Positive test = pain felt in RLQ when palpating LLQ

Question 30

What are special tests for appendicitis?

Answer 30

McBurneys, Rovsing’s sign, psoas sign and obturator sign

Question 31

What is Murphy’s sign?

Answer 31

Test for biliary colic

Positive test = sharp increase in tenderness with sudden stop in inspiratory effort

Question 32

What is Lloyds sign?

Answer 32

Pain to deep percussion in the area of the costovertebral angle
Positive test = pain in the area of the CVA with deep percussion
Implies kidney pathology (tests for kidney inflammation/distention)

Question 33

What are the peritoneal signs?

Answer 33

Guarding, rigidity, rebound tenderness

Question 34

Describe guarding

Answer 34

Voluntary - pt consciously protects the abd when its palpated
Involuntary - unconscious contraction of the abdominal wall musculature when abd is palpated

Question 35

Describe rigidity

Answer 35

Involuntary reflex contraction of the abdominal wall

Abdominal muscles are stiff, board like

Question 36

Describe rebound tenderness

Answer 36

Occurs when you push down deep into the abd and then let go quickly
Positive = more tenderness when letting go than pushing in

Question 37

Describe the process of developing a broad differential diagnosis

Answer 37

Use systemic approach

By organ system or anatomic location of pain