Approach to Abdominal Exam 1 Flashcards by Natalie Tupper

What are 3 types of abdominal pain?

visceral pain
parietal pain
referred pain

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What is the difference between visceral and parietal pain?

visceral is stretching of organs (more generalized) while parietal is more sharp & localized pain

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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

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What causes parietal pain and where is it felt?

stimulation of somatic pain fibers secondary to inflammation in parietal peritoneum

constant & more severe pain

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Referred pain

originates w/ abdomen but felt @ distant sites that are innervated @ same spinal levels as disordered structure (often felt in back)

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Examples of referred pain

duodenal & pancreatic pain referred to back

biliary tree (gall bladder) referred to R shoulder

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What is most important in CC/HPI for ab pain?

LOCATION

Aggravating/alleviating factors

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What discriminators are important in ROS every time?

fever, chills, CP, SOA, cough

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What should be asked in a focused ROS for ab pain?

GI (nausea, vomit, diarrhea)
GU (dysuria, polyuria, etc)
GYN (vaginal bleeding, pregnancy)

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PMH specific for ab complaint

hepatitis
liver problems
cancer
chronic pain
constipation

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PSH specific for ab complaint

abdominal (cholecystectomy or appendectomy)

gynecologic

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Important meds/allergies for ab complaint

blood thinners (GI bleed?)
NSAIDS
narcotics
steroids

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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)

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PE for ab complaint

inspection
auscultation
percussion
palpation

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What must you do in PE for ab complaint?

must DRAPE pt

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Important landmarks for inspection

Xiphoid process
Costal margins
Umbilic
ASIS

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What is important about inspection during ab PE?

approach inspection via quadrants (cross @ umbilicus)

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RUQ

liver, gallbladder

stomach, SB & LB

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RLQ

appendix, ovary

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LLQ

colon, ovary

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LUQ

stomach

spleen

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Epigastric area

pancreas

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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