Eval PT with abdominal complaint Flashcards
Acute Abdomen
medical jargon that refers to any acute condition within the abdomen that requires immediate medical or surgical attention
Types of Abdominal Pain
Visceral Pain (colic pain): source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. Cramping not well localized.
Parietal Pain: Caused by inflammation of the peritoneum. Steady aching pain that is usually well localized.
Referred Pain: From a distant sight. Right shoulder – gallbladder, left shoulder – spleen, back – pancreas or aorta.
RUQ pain
acute cholecystitis duodenal ulcer hepatitis congestive hepatomegaly pyelonephritis appendicitis (R) pneumonia
LUQ
ruptured spleen gastric ulcer aortic aneurysm perforated colon pyelonephritis (L) pneumonia
Between LUQ and LLQ
intestinal obstruction acute pancreatitis early appendicitis mesenteric thrombosis aortic aneurysm diverticulitis
LLQ
sigmoid diverticulitis salpingitis tubo-ovarian abscess ruptured ectopic pregnancy incarcerated hernia perforated colon crohn's disease ulcerative colitis renal/ ureteral stone
RLQ
appendicitis salpingitis tubo-ovarian abscess ruptured ectopic pregnancy renal/ ureteric stone incarcerated hernia mesenteric adenitis meckel's diverticulitis crohn's disease perforated caecum psoas abscess
Diagnostic Work Up for a Patient with Abdominal Pain/Complaint
Endoscopy Plain x-ray Colonoscopy U/A and C & S Ultrasound IVP CT Scan Pregnancy test CBC Laparoscopy LFTs MRI Amylase/lipase Electrolytes Serum gastrin Bilirubin HIDA Scan ERCP Hemocult Stool C & S / O & P / WBC
Blood in the Stool
Melena:
Black tarry stools
50-60 ml of blood in the stomach can produce melena
Above the “Ligament of Treitz” (very general rule)
Hematochezia:
Blood unchanged by passage through the gut usually at the level of the colon or lower
Blood in the bowel is a cathartic
Blood mixed with stool suggests upper colon, blood outside the stool suggests sigmoid or rectum.
Hemocult testing for occult blood
currant jelly stool in infant is what?
intussusception
DDX for GI Bleeding Is it Upper or Lower GI?
Congenital:
Telangiectasias, hemophilia, Meckel diverticulum, A-V malformations
Inflammatory/Immune:
Ulcerative colitis, Crohn’s disease, PUD
Mechanical/Trauma:
Mallory-Weiss tear, intussusception, epistaxis, anal fissure, fecal impaction
Neoplastic:
Polyps, cancer, Zollinger-Ellison syndrome
Infectious:
Dysentery syndrome, gastroenteritis, Clostridium difficile, typhoid, parasites
Metabolic/Toxic:
NSAID, Vitamin K deficiency, anticoagulants
Jaundice
Staining of tissue and body fluids with bilirubin
Signs and Symptoms:
Yellow skin
Scleral yellowing
Pruritus
Urine color – darken urine from conjugated bilirubin
Acholic feces – malodorous, gray to light colored stools
Unconjugated hyperbilirubinemia
Unconjugated bilirubin being produced at a rate exceeding the maximal rate of liver conjugation and excretion or decreased conjugation.
Etiologies Hemolysis Red cell defects – sickle cell Ineffective erythropoiesis Deficient hepatic uptake Deficient hepatic conjugation – hepatitis
Conjugated Hyperbilirubinemia
Impaired excretion of conjugated bilirubin from hepatocytes in the bile canaliculi or obstruction of biliary flow.
* Serum alkaline phosphatase is elevated out of proportion to the transaminases.
Intrahepatic cholestasis – hepatocellular disease, drugs, sepsis, primary biliary cirrhosis
Extrahepatic obstruction – gallstones, biliary carcinoma, sclerosing cholangitis, parasites, pancreatic cancer, pancreatitis
Ascites
An increase accumulation of peritoneal fluid by any one or more of several mechanisms:
Transudation of fluid from portal hypertension
Lymphatic obstruction
Decreased plasma oncotic pressure
Peritoneal inflammation – peritonitis
Four signs of free fluid (ascites)
Bulging flanks
Tympany at the top of the abdomen
Fluid wave
Shifting dullness
Ascites Differential Diagnosis
Cirrhosis (80-85%) Malignancy (10%) Congestive heart failure (3%) Tuberculous peritonitis Dialysis Nephrotic syndrome Bile or pancreatic ascites Lymphatic tear
Fluid wave
Place patient’s or assistant’s hand in midline. Tap on one flank and palpate with the other hand. An easily palpable impulse suggests ascites.
Shifting dullness
percuss the patient on their
back and then their side. Note where the sound
changes from tympany to dull and the shift of the
sound when the patient is turned to the side.
The physical examination of the abdomen and rectum includes:
Inspection Auscultation Percussion Palpation Rectal examination Special techniques
Examination of the Abdomen
- Inspection
- Auscultation
Before palpation/percussion
All 4 quadrants - Palpation
Light in 4 quadrants
Deep in 4 quadrants
Liver
Spleen
Kidneys
Aorta - Percussion all 4 quadrants
- TART exam looking for viscersomatic lesion in spine
Investigating Exam Skills 1. Bowel sounds Aorta Renal arteries 2. Palpation Rebound over area of tenderness Rovsing’s Murphy Shifting dullness Fluid wave 3. Percussion Lloyds Liver span
inspection of the abdomen
Must adequately expose the abdomen
Skin - scars, striae, superficial veins
Umbilicus – hernia, “Caput medusa”
Contour – flat, scaphoid, protuberant
Pulsations or peristalsis
Auscultation
Listen for bowel sounds before palpation and percussion.
All 4 quadrants
RLQ – best place to listen
Normal bowel sounds – high pitched “tinkle” about every 3-5 seconds.
No bowel sounds after 2 minutes – report as “absent”.
Borborygmi
Increased, hyperactive bowel sounds,
Low pitched rumbling
Hyperperistalsis
Abdominal bruits
A soft sound made by disrupted arterial flow through a narrowed artery.
- Aortic – between the umbilicus and xiphoid
- Renal artery – just lateral to the aorta
- Femoral artery – along the inguinal ligament
Proper technique for
auscultation of the
abdomen.
Listen in all 4 quadrants. Listen for bruits in the midline between the xiphoid and umbilicus. Femoral arteries B/L.
Percussion – helps evaluate the presence of:
Gaseous distention
Fluid
Solid masses
Size and location of the liver and spleen
Percussion of the Abdomen
Percuss all 4 quadrants
Best done with the patient in the supine position
Tympany:
Most common percussion note.
Presence of gas in the stomach and small bowel.
Percussion of the liver:
Percuss along the right mid-clavicular line from top to bottom.
Resonant (lungs) to dull (liver) to tympanic (intestine)
Abdominal palpation is usually divided into the following segments:
Light palpation Deep palpation Liver palpation Spleen palpation Kidney palpation Rebound palpation
Technique for light palpation
Detect tenderness and areas of muscular spasm or rigidity.
Palpate all 4 quadrants.
Use finger tips with a gentle motion.
Technique for deep palpation
Used to evaluate organ size, abnormal masses, aorta, deep pain etc.
One hand placed on top of the other.
Rebound Tenderness
Evaluate for peritoneal tenderness and inflammation.
Technique :
In the suspected area of the abdomen, *slowly, gently and deeply palpate.
Then, quickly remove the palpating hand.
If the patient experiences pain = “+ rebound tenderness”.
* Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
DDX for Peritonitis
Spontaneous bacterial peritonitis Secondary bacterial peritonitis - Appendicitis - Diverticulitis - Perforated PUD/ Perforated bowel - Cholecystitis Pancreatic ascites PID Ectopic pregnancy Fitz-Hugh-Curtis syndrome
Technique for palpation of the liver
Place left hand under the right 11th and 12th rib.
Right hand in the RUQ
Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.
Can repeat the maneuver.
Technique for palpation of the liver
“Hooking Technique”
Stand near the patient’s head .
With both hands “hook” your fingers around the lower right costal margin.
Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver.
DDX for Hepatomegaly
Hepatitis - Viral - Bacterial - Protozoal - Alcoholic - Toxic Fatty liver Cirrhosis Congestive heart failure Hepatocellular carcinoma or metastatic cancer Leukemia or lymphoma Autoimmune disease Infiltrative disease Sickle cell disease Glycogen storage disease
Liver EnzymesA General Approach
Extrahepatic: AST, ALT elevated, Alk Phos VERY elevated
Hepatic: AST/ ALT VERY elevated, alk phos moderately up
Palpation of the Spleen
Place left hand under the 11th and 12th ribs.
Place right hand in the LUQ under the costal margin.
Instruct the patient to breath deeply as the examiner gently presses inward and upward.
Repeat the maneuver for deeper palpation.
The spleen is normally not palpated in normal conditions.
DDX for Splenomegaly
Infections - Mononucleosis – EBV - Cytomegalovirus – CMV - HIV - Malaria - Histoplasmosis Leukemia/Lymphoma Extramedullary hematopoiesis CHF Polycythemia vera/thrombocytosis SLE RA – Felty’s syndrome Metastatic disease Amyloidosis
Palpation of the Aorta
Press firmly and deep in the upper abdomen with two hands.
Normal aorta is 2.5 to 3.0 cm wide.
Aortic aneurysm – pathologic dilatation of the aorta. Can be associated with a bruit.
Assessed with an ultra sound or CT scan.
Palpation of the Kidneys
“Sandwich method”
Place a hand above and below the costal margins just lateral to the midline.
Deep and gentle palpation attempt to palpate the lower pole of each kidney.
The kidneys are normally not palpated under normal conditions.
Percussion of the kidneys,
a.k.a. CVA tenderness
With a fist, gently hit the area over the costovertebral angle on each side of the spine.
Pain over a kidney may indicate an inflammatory or infectious process of the kidney.
The examiner may also place a flat hand over the CVA and strike the hand.
DDX for CVA Tenderness
Nephrolithiasis Pyelonephritis Renal cell carcinoma DJD Pneumonia – lower lobe SLE Perinephric abscess AAA Glomerulonephritis
The Rectal Examination
Position the Patient
Patient on their back – Modified Lithotomy
Lying on left side – a.k.a. – Sims’ Position
Standing, bent over the exam table
Inspection Spread the buttocks Sacrococcygeal and perianal areas Anus and rectum Note: Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors
Palpation or Digital Rectal Examination (DRE)
Inform the patient of what is going to happen.
Lubricate your gloved index finger.
Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.
Slowly insert the finger as the sphincter relaxes as far as possible.
Fecal Occult Blood Testing
Patients with a positive FOBT require a through evaluation for CRC. Colonoscopy is the study of choice. Sigmoidoscopy and air contrast barium enema are acceptable alternatives.
Documentation Example
Flat, + RLQ 4 inch surgical scar
BS x 4, neg. aortic or femoral bruits
Tympanic percussion, neg. distension, liver 9 cm
Neg. tenderness or masses to superficial and deep palpation, aorta not enlarged
Neg. hepatosplenomegaly or tenderness
Neg. CVA tenderness
Rectal: neg. external lesions, good sphincter tone, no masses or tenderness, stool for occult blood negative
Appendicitis: etiology and history
Etiology:
Obstruction of the appendiceal lumen. Fecal or foreign matter, tumors or lymphomas.
History: Pain starts peri-umbilical then shifts to the right lower quadrant. Nausea and vomiting Anorexia Fever
Appendicitis physical exam
RLQ pain and RLQ rebound tenderness
Decreased or absent bowel sounds
Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
Psoas sign – turn patient on left side and extend the right leg to check for psoas muscle inflammation.
Obturator sign – place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
Always do a rectal examination and a pelvic exam on a female.
Appendicitis Diagnostic Work Up
CBC – moderate leukocytosis with left shift.
Urine – may contain a few WBC or RBC. Helps R/O any GU condition.
Plain x-ray – rarely helpful.
Ultrasound – enlarged and thick walled appendix.
CT scan – most sensitive. 90 – 98% sensitive.
Female patient – Must do a pregnancy test to R/O ectopic pregnancy.
BMP – evaluate electrolytes and renal functions, especially if patient has been vomiting.
Acute Cholecystitis etiology and history
Etiology:
Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.
History: RUQ postprandial pain. Biliary colic pain. Pain radiating to the right shoulder. Nausea and vomiting. Anorexia Obesity Fever The 5 “f’s” – female, fat, fertile, fair, flatulent.
Acute Cholecystitis Physical Examination
RUQ pain and RUQ rebound tenderness.
Decreased or absent bowel sounds.
Abdominal distention.
* Murphy’s sign – RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
* Diagnostic Triad – RUQ pain, fever and leukocytosis.
Acute Cholecystitis Diagnostic Work Up
CBC – leukocytosis with left shift
Serum bilirubin – can be mildly elevated.
AST/ALT – can be elevated.
Ultrasound – will detect stones, thicken GB wall, dilated bile duct and fluid.
HIDA scan – radionuclide biliary scan.
CT scan
Acute Pancreatitis Etiology and history
Etiology: Alcohol use Obstruction – gallstones, cancer Hyperlipidemia Drugs and medications Infection
History: Acute onset Nausea/vomiting Pain radiating to the back Constant pain
Acute Pancreatitis Physical exam
Low grade fever
Hypotension
Decreased or absent bowel sounds
Epigastric tenderness
* Turner’s sign – discoloration around the flanks
* Cullen’s sign – discoloration around the umbilicus
D/T Hemorrhagic pancreatitis
Acute Pancreatitis Diagnostic workup
CBC Liver function tests * Amylase and lipase (most specific) Glucose & Calcium Abd film Ultrasound/CT Scan/MRI ERCP
