Approach To Abdominal Complaint I Flashcards
What are the types of abdominal pain?
Visceral, parietal, referred pain
Describe visceral pain
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
Describe parietal (somatic) pain
Caused by stimulation of the somatic pain fibers
Secondary to inflammation in the parietal peritoneum
Localized
Describe referred pain?
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
What is important to asking during the ROS?
Always ask discriminators and life threats (fever, chills, CP, SOA, cough)
What are questions to ask during social history?
Stress, travel, well water, ingestion of undercooked meat
What is the order of a physical exam?
Inspection, auscultation, percussion, palpation
Must be done in this order*
Must drape your pt*
Describe inspection of the abdomen
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)
Describe auscultation of bowel sounds
Provides important information about bowel motility
Use diaphragm to listen for bowel sounds
Use the bell to listen for bruits
What are normal bowel sounds?
5-34 clicks/gurgles per min
What are absent bowel sounds?
None for >2 mins
Long lasting intestinal obstruction, intestinal perforation, mesenteric ischemia
What are decreased bowel sounds?
None for 1 min
Post surgical ileus, peritonitis
What are increased bowel sounds?
Diarrhea, early bowel obstruction
What are high pitched bowel sounds?
Sounds like tinkling (raindrops on metal)
Suggests early intestinal obstruction
What are bruits?
Vascular sounds resembling a heart murmur
Result from turbulent flow, listen over the aorta or other abdominal arteries
What is friction rub?
Grating sounds with respiratory variation
Inflammation of the peritoneal surface of an organ
Listen over liver and spleen
What is a venous hum?
Soft humming noise
Increased collateral circulation b/w portal and systemic venous systems
Listen over epigastric and umbilical regions
Describe percussion
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
Describe palpation
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*
Describe liver assessment
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)
Describe spleen assessment
Normally not palpable unless enlarged
Percussion and palpation help assess splenomegaly
Describe an increase in vertical span of the liver
Enlarged liver
Describe liver vertical span decreased
Shrunken liver
What are possible causes for palpating irregular edges/nodules on a liver?
Cancer (hepatocellular carcinoma, Mets), cirrhosis
What are possible causes for firmness/hardness when palpating the liver?
Cirrhosis, hematochromatosis, amyloidosis, lymphoma
What are possible causes for enlarged spleen (splenomegaly)?
Portal HTN, blood malignancies, HIV, splenic infraction, splenic hematoma, mononucleosis
What are special tests for a fluid wave (for ascites)?
Normal = no impulse felt on the other flank
Ascites/positive test = impulse transmitted to the other flank
What is McBurney’s point tenderness?
Best test for appendicitis
Positive test = tenderness
What is rovsing’s sign?
Good test for appendicitis
Positive test = pain felt in RLQ when palpating LLQ
What are special tests for appendicitis?
McBurneys, Rovsing’s sign, psoas sign and obturator sign
What is Murphy’s sign?
Test for biliary colic
Positive test = sharp increase in tenderness with sudden stop in inspiratory effort
What is Lloyds sign?
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)
What are the peritoneal signs?
Guarding, rigidity, rebound tenderness
Describe guarding
Voluntary - pt consciously protects the abd when its palpated
Involuntary - unconscious contraction of the abdominal wall musculature when abd is palpated
Describe rigidity
Involuntary reflex contraction of the abdominal wall
Abdominal muscles are stiff, board like
Describe rebound tenderness
Occurs when you push down deep into the abd and then let go quickly
Positive = more tenderness when letting go than pushing in
Describe the process of developing a broad differential diagnosis
Use systemic approach
By organ system or anatomic location of pain
