Chapter 15: Abdomen

Question 1

Physical exam component: abdomen

Answer 1

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.

Question 2

Abd HPI

Answer 2

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

Question 3

abd PMH

Answer 3

GI disorders; hepatitis/cirrhosis; abdominal/urinary tract surgery/injury; UTIs; major illnesses; blood transfusions; immunizations; colorectal/related cancers; STIs

Question 4

FMH abd

Answer 4

Colorectal cancer/syndromes; gallbladder disease; kidney disease; malabsorption syndrome; Hirschsprung disease; Mediterranen fever

Question 5

PMH/SMH abd

Answer 5

Nutrition; LMP; alcohol; stress factors; exposure to infectious diseases; trauma; illicit drugs; tobacco

Question 6

HPI infants and children

Answer 6

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

Question 7

HPI preg

Answer 7

Urinary symptoms; abdominal pain; fetal movement; contractions

Question 8

Older adult HPI abd

Answer 8

Urinary symptoms, bowel changes, dietary habits

Question 9

Physical exam: inspection

Answer 9

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

Question 10

Physical exam: auscultation

Answer 10

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

Question 11

Physical Exam: Percussion

Answer 11

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

Question 12

Physical Exam: Palpation

Answer 12

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

Question 13

Physical Exam: Additional Procedures

Answer 13

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

Question 14

Physical Exam: Infants, Children, and Adolescents

Answer 14

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

Question 15

Preg physical exam

Answer 15

Nausea, vomiting, constipation, hemorrhoids

Uterine size, fetal growth, fetal position, fetal well-being monitoring, uterine contractions

Question 16

Older adults physical exam

Answer 16

Thinner, softer abdominal wall

Rounded abdominal contour

Decreased intestinal mobility

Obstruction

GI cancers

Altered pain perception

Question 17

Abnormalities of Alimentary Tract

Answer 17

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

Question 18

Abnormalities of Hepatobiliary System

Answer 18

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

Question 19

Abnormalities of Pancreas

Answer 19

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

Question 20

Abnormalities of Spleen

Answer 20

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)

Question 21

Abnormalities of Kidney

Answer 21

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

Question 22

Abnormalities in Infants

Answer 22

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

Question 23

Abnormalities in Children (Cont.)

Answer 23

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

Question 24

Abnormalities in Older Adults

Answer 24

Fecal incontinence
-Inability to control bowel movements leading to leakage of stool
-Associated with three major causes: Fecal impaction, Underlying disease, Neurogenic disorders

Question 25

Borborygmi sounds are:

Low-pitched crackle sounds
High-pitched tinkling sounds
Loud prolonged gurgles
High-pitched sounds heard in association with respirations

Answer 25

ANS: C

Rationale: Loud prolonged gurgles are called borborygmi sounds.

Question 26

The most pronounced functional change of the gastrointestinal (GI) tract in older adults is:

Decreased hydrochloric acid production
Increased motility
Decreased bile absorption
Decreased motility

Answer 26

ANS: D

Rationale: A decrease in motility of the gastrointestinal tract is the most pronounced GI change in older adults.

Question 27

Relaxation or incompetence of the lower esophageal sphincter causes:

Peptic ulcer disease
Hiatal hernia
Crohn disease
Gastroesophageal reflux disease

Answer 27

ANS: D

Rationale: Backward flow of gastric contents, which are typically acidic, into the esophagus is gastroesophageal reflux disease. It is caused by relaxation or incompetence of the lower esophageal sphincter.