Chapter 15: Abdomen Flashcards
Physical exam component: abdomen
Inspect the abdomen.
Skin characteristics, venous return patterns, symmetry, surface motion
Inspect abdominal muscles as patient raises head.
Masses, hernia, separation of muscles
Auscultate with stethoscope.
Bowel sounds (use diaphragm); bruits over aortic, renal, iliac, femoral arteries (use bell)
Percuss the abdomen.
Tone in all four quadrants (or nine regions); liver borders to estimate span; splenic dullness in left midaxillary line; gastric air bubble
Lightly palpate in all quadrants or regions.
Muscular resistance, tenderness, masses
Deeply palpate.
Bulges and masses around the umbilicus and umbilical ring; liver border in right costal margin; gallbladder below liver margin at lateral border of the rectus muscle; spleen in left costal margin; right/left kidneys; aortic pulsation in midline; other masses
With patient sitting, percuss the left and right costovertebral angles for kidney tenderness.
Abd HPI
Abdominal pain
Onset and duration, character, associated symptoms, relationship factors, stool characteristics, urine characteristics, medications
Indigestion
Character, location, relationship factors, onset, relieving factors, medications
Nausea
Associated with vomiting, precipitation stimuli, menses, medication
Vomiting
Character, relationship factors, medications
Diarrhea
Character, associated symptoms, relationship factors, travel history/ill contacts, medications
Constipation
Character, pattern, diet, medications
Fecal incontinence
Character, associated symptoms, relationship factors, medications
Jaundice
Onset and duration, color of stools/urine, associated symptoms, exposures, medications
Dysuria
Character, location, associated factors, relationship to sex, hydration status
Urinary frequency
Character, associated factors, medications
Urinary incontinence
Character, associated factors, medications
Hematuria
Character, associated factors, medications
abd PMH
GI disorders; hepatitis/cirrhosis; abdominal/urinary tract surgery/injury; UTIs; major illnesses; blood transfusions; immunizations; colorectal/related cancers; STIs
FMH abd
Colorectal cancer/syndromes; gallbladder disease; kidney disease; malabsorption syndrome; Hirschsprung disease; Mediterranen fever
PMH/SMH abd
Nutrition; LMP; alcohol; stress factors; exposure to infectious diseases; trauma; illicit drugs; tobacco
HPI infants and children
Infants
Gestational age/birth weight; meconium stool; jaundice; gastroesophageal reflux; vomitng; diarrhea; colic; steatorrhea; weight loss; failure to grow; abdominal enlargement
Children
Constipation; dietary habits; abdominal pain; psychosocial stressors
HPI preg
Urinary symptoms; abdominal pain; fetal movement; contractions
Older adult HPI abd
Urinary symptoms, bowel changes, dietary habits
Physical exam: inspection
Abdominal landmarks
Surface characteristics
-Seated position at patient’s right side
-Skin; venous return; lesions and scars; tautness and striae
Contour
Contour, symmetry, surface motion
Movement
-Patient’s head resting on table
-Respiration versus costal movement; rippling; aortic pulsations
Physical exam: auscultation
Before percussion and palpation
Frequency and character
-Clicks and gurgles that occur irregularly; range from 5 to 35 sounds/min
Sound types
-Loud prolonged gurgles=borborygmi
-Increased bowel sounds=gastroenteritis, intestinal obstruction, hunger
-High-pitched tinkling=intestinal fluid/air under pressure (obstruction)
-Decreased bowel sounds=peritonitis and paralytic ileus
-Decreased bowel sounds=peritonitis and paralytic ileus
-Absent bowel sounds=abdominal pain/rigidity; surgical emergency
-High-pitched with respiration=friction rub
-Harsh/musical intermittent sound=bruit
-Soft, low-pitched, continuous=venous hum
Physical Exam: Percussion
Used to assess
-Size and density of organs
-Presence of fluid (ascites)
-Presence of air (gastric distention)
-Presence of fluid-filled or solid masses
Liver span
-6 to 12 cm (2.5 to 4.5 inches)
Spleen
Gastric bubble
Kidneys
-Tenderness
Physical Exam: Palpation
Light palpation
Avoid areas with previously identified problems.
Moderate palpation
Moderate pressure before deep palpation
Deep palpation
-Necessary to thoroughly delineate abdominal organs and to detect less obvious masses
-Bimanual technique
Masses
Location, size, shape, consistency, tenderness, pulsation, mobility, movement with respiration
Umbilical ring
Free of bulges, protrusion nodules, granulation
Also palpate the liver, spleen, kidneys, aorta, urinary
bladder
Palpating the liverA, Fingers are extended, with tips on right midclavicular line below the level of liver dullness and pointing toward the headB, Alternative method for liver palpation with the fingers parallel to the costal margin
Physical Exam: Additional Procedures
Percussion for ascites
-Dullness/resonance, shifting dullness, fluid wave
-Testing for fluid wave: Strike one side of the abdomen sharply with the fingertips. Feel for the impulse of a fluid wave with the other hand
Pain
Watch patient’s face while assessing.
Rebound tenderness
Performed at end of examination
-Press deeply and gently into the abdomen-Then rapidly withdraw the hands and fingers
Iliopsoas muscle test
Possible appendicitis
Obturator muscle test
Possible ruptured appendix or pelvic abscess
Ballottement
Assesses organ or mass
Physical Exam: Infants, Children, and Adolescents
Inspect
Shape, contour, movement, pulsations, peristalsis, umbilical cord, protrusion
Auscultate
-Bowel sounds in chest and abdomen (diaphragmatic hernia)
-Bruits or hums should not be heard
Percuss
-More tympany expected
Palpate
-Detectable spleen tip common
-Liver
Adolescents: pregnancy and ovarian torsion
Infant supine
Toddler: parents lap
Preg physical exam
Nausea, vomiting, constipation, hemorrhoids
Uterine size, fetal growth, fetal position, fetal well-being monitoring, uterine contractions
Older adults physical exam
Thinner, softer abdominal wall
Rounded abdominal contour
Decreased intestinal mobility
Obstruction
GI cancers
Altered pain perception
Abnormalities of Alimentary Tract
Acute diarrhea
Three or more watery stools per day
Gastroesophageal reflux disease
Backward flow of gastric contents, which are typically
acidic, into the esophagus
Irritable bowel syndrome
Functional chronic GI disorder with symptoms of pain and change in stooling pattern
Hiatal hernia with esophagitis
Part of the stomach passes through the esophageal hiatus in the diaphragm into the chest cavity.
Duodenal ulcer
Chronic circumscribed break in the duodenal mucosa that scars with healing
Crohn disease
-Chronic inflammatory disorder that can affect any part of the gastrointestinal tract, producing ulceration, fibrosis, and malabsorption.
-Terminal ileum and colon are most common sites.
Ulcerative colitis
Chronic inflammatory disorder of the colon and rectum that produces mucosal friability and areas of ulceration
Stomach cancer
-Malignancy that arises from epithelial cells of the mucous membrane
Diverticular disease
-Small bulges or saclike outpouchings (diverticula) through colonic muscle in the intestine
Colon cancer
-May involve the rectum, sigmoid, proximal, and descending colon
Abnormalities of Hepatobiliary System
Hepatitis
Inflammatory process characterized by diffuse or patchy hepatocellular necrosis
Cirrhosis
Diffuse hepatic process characterized by fibrosis and alteration of normal liver architecture into structurally abnormal nodules
Primary hepatocellular cancer
Frequently due to cirrhosis, approximately 20 to 30 years after liver injury or disease onset
Cholelithiasis
Stone formation in the gallbladder occurs when certain substances reach a high concentration in bile and produce crystals.
Cholecystitis
Inflammatory process of the gallbladder most commonly due to obstruction of the cystic duct from cholelithiasis; may be either acute or chronic
Nonalcoholic fatty liver disease (NAFLD)
Spectrum of hepatic disorders not associated with excessive alcohol intake, ranging from steatosis to cirrhosis and hepatocellular carcinoma
Abnormalities of Pancreas
Acute pancreatitis
Acute inflammatory process in which release of pancreatic enzymes results in pancreatic glandular autodigestion
Chronic pancreatitis
Chronic inflammatory process of the pancreas, characterized by irreversible morphologic changes resulting in atrophy, fibrosis, and pancreatic calcifications
Abnormalities of Spleen
Spleen laceration/rupture
-Most commonly injured organ in abdominal trauma because of its anatomic location
-Mechanism of injury can be either blunt or penetrating but is more often blunt (e.g., from motor vehicle accidents)
Abnormalities of Kidney
Acute glomerulonephritis
Inflammation of the capillary loops of the renal glomeruli
Hydronephrosis
Dilation of the renal pelvis and calyces due to an obstruction of urine flow anywhere from the urethral meatus to the kidneys
Pyelonephritis
Infection of the kidney and renal pelvis
Renal abscess
Localized infection within the medulla or cortex of the kidney
Renal calculi
Stones formed in the pelvis of the kidney from a physiochemical process associated with obstruction and infections in the urinary tract
Abnormalities in Infants
Necrotizing enterocolitis
Inflammatory disease of the gastrointestinal mucosa associated with prematurity and gut immaturity
Meconium ileus
Distal intestinal obstruction caused by thick inspissated impacted meconium in the lower intestine
Associated with cystic fibrosis
Biliary atresia
-Congenital obstruction or absence of some or all of the bile duct system resulting in bile flow obstruction
-Most have complete absence of the entire extrahepatic biliary tree
Hirschsprung disease (congenital aganglionic megacolon)
Primary absence of parasympathetic ganglion cells in a segment of the colon that interrupts intestinal motility
Pyloric stenosis
Hypertrophy of the circular muscle of the pylorus leading to obstruction of the pyloric sphincter
Intussusception
Prolapse, or telescoping, of one segment of intestine into another causing intestinal obstruction
Meckel diverticulum
Outpouching of the ileum that varies in size from a small appendiceal process to a segment of bowel several inches long, often in the proximity of the ileocecal valve
Abnormalities in Children (Cont.)
Neuroblastoma
Solid malignancy of embryonal origin in the peripheral sympathetic nervous system
Wilms tumor (nephroblastoma)
-Most common intraabdominal tumor of childhood; usually appears at 2 to 3 years of age
-Avoid repeated palpation
Hemolytic uremic syndrome (HUS)
-Triad of microangiopathic hemolytic anemia, thrombocytopenia, and uremia
-Usually caused by Escherichia coli 0157
Abnormalities in Older Adults
Fecal incontinence
-Inability to control bowel movements leading to leakage of stool
-Associated with three major causes: Fecal impaction, Underlying disease, Neurogenic disorders
