Ch 17 Flashcards
What should you note and draw their location, confucration and relative size. It may alert you to possibility of internal adhesions.
scars
What quadrant has theliver and gallbladderpylorus, duodenum, head of pancrease, right adrenal gland, portion of right idney, hepatic flexure of colon, portions of ascending and tranverse colon.
right upper quadrant
What quadrant has the lower pole of right kidney, cecum and appendix, portion of ascending colon, bladder (if distended), ovary and salpinx, uterus (if enlarged) right spermatic cord, right ureter.
Right lower quadrant
What quadrant has the left lobe of the liver, spleen, stomach, body of pancrease, left adrenal gland, portion of left kidney, splenic flexure of colon, portions of tranverse and descending colon
Left upper quadrant
What quadrant has the lower pole of left kidney, sigmoid colon, portion of descending colon, bladder (if distended) ovary and salpinx, uterus (if enlarged), left spermatic cord, left ureter?
left lower quadrant
When you have a patient with abdominal distention and their bowel sounds are hypoactive and the patient uses diuretics, what should you be thinking?
hypokalemia or steroids
what are the 7 landmarks of the abdomen?
xiphoid process, costal margin, umbilicus, poupart ligament, superior margin of os pubis, anterosuperior iliac spine
After how long should you be worried about not hearing bowel sounds?
5 minutes
What is a musical note of higher pitch than resonance and where is it located?
tympany; located over air-filled viscera
What pitch lies between tympany and resonance and where is it located?
hypperesonance; lies at base of left lung
What is a sustained note of moderate pitch and where is it find?
resonance, over lung tissue and sometimes over the abdomen
What is a short, high-pitched note with little resonance and where is it found?
dullness, over solid organs adjacent to air filled structures
What are the two ways you should report liver size?
liver span and the extent of liver projection below the costal margin (use landmarks)
When using light palpation of the abdomen what is the farthest you should press in?
1 cm
How do you palpate a ticklish patient?
ask them to perform self-palpation or touching a different part of their body simultaneously.
What icons the acronym for the causes of constipation?
constipated
Name three causes of constipation
neoplasms, obstruction, stricture of colon
What are commonly mistaken for masses when palpating?
kidney, fecal mass (cecum), uterus, aorta, sacral promontory, fecal mass (sigmoid), bladder
Where should your fingers rest when palpating the liver?
right midclavicular line
How can you differentiate between enlarged spleen or enlarged left kidney?
Percussion will be dull over spleen (also a palpable notch), percussion over enlarged kidney will be resonant.
Can you typically palpate the left kidney? How do you feel it then?
NOpe; you capture it
Can you palpate AAA’s?
yes
Should you be able to palpate a healthy urinary bladder?
no
what is a pathological increase in fluid in the peritoneal cavity
an ascite
If you see a protuberant abdomen or bulging flank when lying supine what should you suspect?
ascite
If you have shiftin dullness then you have a (blank)
ascite
What is the most sensitive test for ascites? What is the most specific test?
flank dullness and bulging flanksFluid wave
The farther pain is from the umbilicus the more likely the cause is (blank).
organic
a sudden dramatic change from mild even vague abdominal pain could be a sign of what?
etopic pregnancy so ask about sexual history.
Where will a patient feel pain in appendicitus? What are the symptoms?
right lower quadrant RLQ pain the originates periumbilical pain and pain before vomitting
What are the symptoms of appendicitus in children?
vominting, reobound tenderness, rectal tenderness, and RLQ (but less helpful than in adults)
MANTRALS, PAS, and Ohmann are scores for what?
appendicitus
When is hepatomegaly present?
when liver is more than 3 cm below the right costal margin
Infants of mothers with poorly controlled diabetes or with gestational diabetes will have what?
enlarged liver
How do you palpate an infant’s abdomen/
thumb and forefinger
Can a person be constipated with diarehea?
yes
How long is the alimentary tract?
27 feet long
What digests, absorbs water and nutrients, excretes waste and is under control of ANS?
alimentary tract
What is posterior to the trachea in mediastinum and enters stomach through diaphragm at cardiac orifice?
esophagus
What has the fundus, body and pylorus, has pepsin to digest proteins and gastric lipase to emulsify fat?
stomach
What has the duodenum (duedenal papilla drains bile and pancreatic ducts), jejunum, ileum (ileocecal valve prevents backflow), contains digestive enzymes and absorbs nutrients?
small intestine
What has:- cecum: appendix at the base- ascending colon to hepatic flexure- transverse colon to splenic flexure- descending colon to pelvic rim- sigmoid colon terminates at the anus- absorbs water and excretes waste- contains live bacteria that performs further decomposition
large intestine
What is:- below diaphragm; above gallbladder, R kidney, and R hepatic flexure of colon- 4 lobules further divided into lobules- each lobule contains portal vein, hepatic artery, bile duct- hepatic artery and portal vein carries blood to the liver- three hepatic veins carry blood away from the liver to the IVC
liver
How many lobes does the liver have?
4
what has these Functions- metabolizes carbohydrates, fats, and proteins- detoxification- produces antibodies, prothrombin, fibrinogen, coagulation factors- conjugates steroids into hormones- synthesizes bile
liver
What has this:- located on inferior liver surface- concentrates and stores bile- secretes bile into the duodenum in response to cholecystokinin from cystic duct into common bile duct
gallbladder
What has this:- located below and behind the stomach, pancreatic head rests on duodenum- exocrine glands: acinar cells secrete digestive enzymes into pancreatic duct- endocrine glands: islet cells secrete insulin and glucagon
pancrease
What has this:- located below diaphragm and above left kidney- White pulp (lymphoid tissue) filters blood and produces lymphocytes and monocytes- Red pulp stores blood and releases as needed
spleen
What has this:- Filters blood 125mL/min in males, 110mL/min in females- Reabsorbs electrolytes, glucose, water, proteins- Secretes renin, erythropoietin , prostaglandins, active vit D
kidneys, ureter, bladder
Which kidney is higher?
the left
abdominal aorta lies left or right of midline?
left
What does this describerectus abdominis anteriorly- external oblique muscles laterally- linea alba: midline tendon from xiphoid process to pubic symphysis- inguinal ligaments from anterior superior iliac spines
musculature and connective tissue
What is this:- Abdominal aorta lies left of midline- Iliac arteries branch at level of umbilicus
vasculature
When is the GI tract fully developed in infants?
years 2-3
Who is this- abdominal muscles stretch and rectus abdominis muscles can separate- can develop striae or linea nigra- can develop gastric reflux and constipation due to dysmotility- gallbladder has decreased emptying, can lead to gallstone formation in 2nd and 3rd trimesters- kidneys enlarge and ureters dilate, can have urinary stasis and pyelonephritis- bladder has increased sensitivity and compression, can have micro hematuria from deepening and widening of the trigone- appendix can be displaced upward and laterally- after delivery, the uterus involutes to size of 20-week pregnancy and continues to decrease in size- pelvic floor regains tone 6-7 weeks postpartum
pregnant women
Who is this?- altered motility due to changes in neurons and collagen, reduced circulation- epithelial atrophy leading to decreased secretion of digestive enzymes and protective mucus- bacterial flora can decrease in activity- liver size decreases after age 50
old people
When asking about abdominal pain in HPI what are some special things you should ask?
Ask about abdominal pain, Indigestion, vomiting, diarrea, constipation, fecal incontinence, jaundice, dysuria, urinary frequency and incontinence, hematuria(mensens, stool characteristcs, bowel movmemnts, food, urine)
What should you ask for PMH?
- GI diseases: PUD, polyps, IBD, IBS, pancreatitis, etc.- Hepatitis or cirrhosis- Abdominal injuries or surgeries- Major illnesses- Blood transfusions- Hepatitis immunization status- Colorectal, breast, ovarian, endometrial cancers
What should you ask in family history?
- colorectal cancer, FAP, HNPCC- gallbladder disease- kidney disease- malabsorption syndrome- Hirschsprung disease
What should you ask in personal and social history?
- nutrition- last menstrual period- alcohol intake- major physical and psychological stressors- infectious, occupational, environmental exposures- trauma- recreational or IV drug use- tobacco use
What should you ask specifically for infants?
- gestational age and weight, weight gain- meconium stool within 24 hours?- Jaundice- Vomiting- Diarrhea
What should you ask about children?
- toilet training- psychosocial stressors
What should you ask pregnant women?
- urinary symptoms- weeks of gestation- fetal movement- contractions
What should you ask older adults?
- urinary symptoms- bowel habits- diet
For an abdominal exam, how should the patient lay?
supine with pillow under head and knees (drape if necessary)
When inspecting the patient what should you look for?
contour while patient is sitting and with deep breathdirection of venous returnumbilicus for herniascars/brusing/skin colorbreathing while supine
When looking at contour what will children look like, and what will thin adults look like?
rounded, scaphoid
What is the normal venous return?Portal HTN?IVC obstruction?
upward from umbilicus, downward below the umbilicus-concentric flow away from umbilicus-upward flow over entire abdomen
Peristalisis may show (blank) and pulsations may indicate (blank)
ripplingAAA
YOu should always do auscultation when?
BEFORE percussion and palpation
Bowel sounds:Increase sounds?High pitched tinkling?Decreased sounds?Absent?
increased motilitiyobstructionparalysis or peritonitisafter 5 minutes surgical emergency
What do friction rubs indicate?
inflammation
WHere should you listen for bruits?
aorta, renal arteries, iliac arteries
Use bell over (blank) for venous hum indicating collateral circulation
epigastrium
To percuss the liver where will you start and how will you do it?
- start over R midclavicular line and percuss downward from tympany to dullness is upper border- start in the RLQ and percuss upward, from resonant to dullness is lower border- normal span is 6-12cm
What is the normal span of liver?
6-12 cm
How do you percuss the spleen?
- start over L midaxillary line and percuss downward from tympany to dullness- normal span is dullness over 6th to 10th ribs- OR: percuss over lowest intercostal space in L midaxillary line, should remain tympanic during deep breath
How will you percuss the gastric bubble?
- Low-pitch tympany in L lower rib cage or L epigastrium
How will you percuss the kidneys?
- while sitting strike CVA with ulnar side of your fist
What are the 3 types of palpation?
light, moderate, deep
Why do you palpate the umbilical ring?
for defects and protrusions
how do you palpate the liver?
you sandwich it with your L hand on back under ribs and R on abdomen over liver PRESS DEEPLY and UPWARD. Patient takes deep breath.. (scratch test too)
How do you palpate the gallbladder?
- palpate lateral to rectus abdominis and lower liver edge, GB should not be palpable- note any tenderness on inspiration
How do you palpate the left kidney? Same for right kidney
- stand at patient’s right side, place L hand over CVA and lift upward- place R hand below L costal margin and press deeply, have patient take deep breath- OR: same technique while standing at patient’s left side; after patient exhales, slowly release fingers and may feel kidneys slip between fingers
How do you palpate the aorta?
palpate deeply left of midline for pulsation
How do you palpate the bladder?
- distended bladder may feel tense, smooth, and round on palpation- can percuss out borders
What is this called and when do you use it?- while patient supine, percuss border of tympany (bowel floats toward the umbilicus) and of dullness- repeat while patient lies on side, area of tympany should shift to dependent side
shiftin dullness and for assessing ascites
What is this called and when do you use it?- while patient supine, have patient place edge of their hand vertically over midline- strike one side of abdomen with your fingers while feeling for fluid wave or thrill on other side
fluid wave
What is this called and what is it for?- patient lies supine and raise R leg while you press against R thigh- OR: patient lies on L side and raise R leg while you press against R thigh- OR: patient lies on L side and extends R leg backwards
Iliopsoas Muscle Test: elicits pain with appendicitis
What is this called and what is it for?- patient lies supine- rotate R leg laterally and medially while flexing hip and knee 90 degrees
Obturator Muscle Test: elicits pain with appendicitis
What is ballottement used for?
to assess an organ or mass
When dealing with (blank) • Inspection- note shape, contour, movement, pulsations- distension: masses or organomegaly- scaphoid: diaphragmatic hernia- umbilical stump: inspect for infection, hernia, normally separates by 2 weeks old• Auscultation and Percussion- renal bruits may indicate renal artery stenosis or renal arteriovenous fistula- may have increased tympany from swallowed air• Palpation- spleen can be palpated 1-2cm below costal margin for first few weeks of life- liver edge can be palpated 1-3cm below costal margin in infants and toddlers- masses: pyloric stenosis (olive shaped), intussusception (sausage shaped), Hirschsprung disease (midline suprapubic mass), neuroblastoma, Wilms tumor, lymphoma- note rigidity or irritation
children/infants/ adolescents (asess for pregnancy)
Who does this describe:- history: may complain of nausea, vomiting, constipation, hemorrhoids- uterine changes discusses in Chapter - diminished bowel sounds- striae and linea nigra
pregnant women
Who does this describe:- history: constipation is common, bloating, risks and signs of colon cancer- contour may be rounded with muscle tone loss- be aware of any joint pain and flexibility- COPD may displace liver downward- Liver size decreases after age 50- Can have atypical pain findings
older adults
