Approach to Abdominal Exam 1 Flashcards
What are 3 types of abdominal pain?
visceral pain
parietal pain
referred pain
What is the difference between visceral and parietal pain?
visceral is stretching of organs (more generalized) while parietal is more sharp & localized pain
What causes visceral pain and where is it felt?
stimulation of visceral pain fibers secondary to distension/stretch of organs
felt in midline @ level of structure involved
What causes parietal pain and where is it felt?
stimulation of somatic pain fibers secondary to inflammation in parietal peritoneum
constant & more severe pain
Referred pain
originates w/ abdomen but felt @ distant sites that are innervated @ same spinal levels as disordered structure (often felt in back)
Examples of referred pain
duodenal & pancreatic pain referred to back
biliary tree (gall bladder) referred to R shoulder
What is most important in CC/HPI for ab pain?
LOCATION
Aggravating/alleviating factors
What discriminators are important in ROS every time?
fever, chills, CP, SOA, cough
What should be asked in a focused ROS for ab pain?
GI (nausea, vomit, diarrhea)
GU (dysuria, polyuria, etc)
GYN (vaginal bleeding, pregnancy)
PMH specific for ab complaint
hepatitis liver problems cancer chronic pain constipation
PSH specific for ab complaint
abdominal (cholecystectomy or appendectomy)
gynecologic
Important meds/allergies for ab complaint
blood thinners (GI bleed?)
NSAIDS
narcotics
steroids
Why would you not want to give narcotics to pt w/ ab pain?
narcotics will mask the pain
narcotics slow down bowel (can lead to constipation)
PE for ab complaint
inspection
auscultation
percussion
palpation
What must you do in PE for ab complaint?
must DRAPE pt
Important landmarks for inspection
Xiphoid process
Costal margins
Umbilic
ASIS
What is important about inspection during ab PE?
approach inspection via quadrants (cross @ umbilicus)
RUQ
liver, gallbladder
stomach, SB & LB
RLQ
appendix, ovary
LLQ
colon, ovary
LUQ
stomach
spleen
Epigastric area
pancreas
What do you look for on inspection?
surface: skin color, surgical scars, rash, ecchymoses
contour of abdomen: bulges, obese, flat, round
Why is auscultation important in ab exam?
provides info about bowel motility
How do you auscultate during ab exam?
place diaphragm on abdomen to listen for sounds
use bell to listen for bruits
What are abnormal bowel sounds & what pathology are they associated with?
absent (none for >2 min, intestinal obstruction, intestinal perforation, mesenteric ischemia)
decreased (none for 1 min, post surgical or peritonitis)
increased (diarrhea, obstruction)
What do high pitched bowel sounds indicate?
early intestinal obstruction
What are bruits on abdomen associated with?
vascular obstruction
What do friction rub sounds indicate?
inflammation of peritoneal surface of organ (over liver & spleen)
What do venous hums indicate?
increased collateral circulation btwn portal & systemic venous systems
Why do you percuss abdomen in PE?
assess for fluid & solid-filled masses, amt gas in abdomen, sizing of liver & spleen
Why would tympany predominate in abdomen?
due to gas in GI tract, scattered areas of dullness is normal from fluid & feces
What is important about palpation in ab PE?
need to gently palpate & then deeply palpate in all 4 quadrants
always start away from tender area
Assessment of liver
mostly covered by rib cage on R side
assess shape & size by percussion & palpation
Assessment of spleen
normally not palpable unless enlarged
use percussion & palpation to assess for splenomegaly
Describe liver palpation
L hand behind pt supporting 11 & 12 ribs
push L hand upward
R hand on pt R abdomen
press in & cephalad w/ R hand
ask pt to take deep breath
feel liver edge as comes down to meet R hand
Describe spleen palpation
w/ L hand, reach over pt & grab posterior aspect of LUQ
w/ R hand below L costal margin, press posteriorly
ask pt to take deep breath in
try to feel edge as comes down to meet L hand
How do you test for ascites?
Shifting dullness test
abnormal is dullness shifts to dependent side & tympany to top side
McBurney’s point tenderness
positive is tenderness
highest sensitivity & specificity to diagnose appendicitis
Rovsing’s sign
for appendicitis
positive is pain felt in RLQ
Psoas sign
for appendicitis
positive test if increased ab pain
Obturator sign
for appendicitis
positive test is R hypograstic pain
Murphy’s sign
for biliary colic
positive test is sharp increase in tenderness w/ sudden stop in inspiratory effort
Llyod’s sign
sign for kidney inflammation/distension
positive test is pain in area of CVA w/ deep precussion
implies kidney pathology
What are signs of peritoneal inflammation?
guarding
rigidity
rebound tenderness
What are the 2 types of guarding?
voluntary-pt pushes hand away when push on abdomen
involuntary-when muscles push hands away when abdomen is palpated
If pt has RUQ, what HPI questions may you want to ask?
alcohol
diet
fever
What is working DDX for RUQ pt?
gall bladder
What do the diagnostic results show in case #1?
gall stones on ultrasound
What is the assessment for case #1?
cholelithiasis
What is abnormal on labs of case #2 and what does it indicate?
increased lipase
acute pancreatitis
What must you always consider with RLQ pain?
appendicitis
What would kidney stone show on ultrasound?
fluid backup in kidney due to obstruction
What labs must you always order?
urine analysis, CBC, lipases
How would someone w/ acute appendicitis present?
gastroenterocitis
pain localized to RLQ (parietal periteoneum around appendix is inflammed)
How would someone w/ acute cholecystitis present?
R shoulder pain
RUQ pain
more likely if obese & female & family history
