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History & Physical Examination > Exam 2 - Abdominal Exam > Flashcards

Exam 2 - Abdominal Exam Flashcards

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1
Q

What’s in the Abdomen (GI) Review of Systems? (21)

A
  • Trouble swallowing, heartburn, change in appetite, nausea, vomiting, regurgitation, vomiting of blood, indigestion
  • Change in bowel habits, rectal bleeding, black tarry stools, hemorrhoids, constipation, diarrhea
  • Abdominal pain, food intolerance, excessive belching or passing of gas, jaundice, liver or gall bladder problems, hepatitis
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2
Q

What are common abdominal complaints?

A
  • Acute vs. chronic abdominal pain
  • Indigestion, nausea, vomiting, hematemesis, anorexia, early satiety
  • Dysphagia, odynophagia
  • Change in bowel function
  • Diarrhea, constipation, bloody stools
  • Jaundice
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3
Q

How do you tell if plain is flank pain or abdominal pain?

A

Many patients will confuse suprapubic or flank pain as an abdominal complaint
–Depends if the pain is anterior or posterior in nature

These complaints typically represent a urinary or renal disorders:
Suprapubic pain, dysuria, urgency, frequency, hesitancy, split stream, polyuria, nocturia, incontinence (stress, urgence, overflow), hematuria, kidney or flank pain, ureteral colic

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4
Q

What is an important aspect to assess in GI disorders?

A

How is the patient’s appetite?

Are they complaining of any of the following symptoms?
- Heartburn, excessive gas or flatus, abdominal fullness or early satiety, and anorexia.

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5
Q

What is heartburn?

A

A burning sensation in the epigastric region radiating into the throat; often associated with regurgitation

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6
Q

What is excessive gas or flatus?

A

Needing to belch or pass gas per rectum; patients often state they feel bloated

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7
Q

What is – Abdominal fullness or early satiety?

A

Being full with little intake or sooner than normal.

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8
Q

What is anorexia?

A

Lack of an appetite

Unintentional weight loss over a short or extended period of time

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9
Q

What is regurgitation?

A

– The reflux of food and stomach acid back into the mouth with a brine-like taste

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10
Q

How do you assess severity of vomitting?

A

– Ask about the amount of vomit
– Ask about the type of vomit: food, green- or yellow-colored bile, mucus, blood, coffee ground emesis (often old blood)
– Blood or coffee ground emesis is known as hematemesis

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11
Q

What is retching?

A

Retching; spasmodic movement of the chest and diaphragm like vomiting, but no stomach contents are passed

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12
Q

What is hematemesis?

A

Blood or coffee ground emesis is known as hematemesis

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13
Q

How do you qualify patient’s pain?

A

Visceral pain, parietal pain, referred pain

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14
Q

What is visceral pain?

A

Visceral pain: when hollow organs (stomach, colon) forcefully contract or become distended.

  • Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules.
  • Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)

Something is not right and they CAN’T sit still.

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15
Q

What is parietal pain?

A

Parietal pain: when there is inflammation from the hollow or solid organs that affect the parietal peritoneum.

  • Parietal pain is more severe and is usually easily localized (appendicitis)
  • Inflammation has affected the peritoneum.

Patient does NOT want to move because exertion causes more pain.

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16
Q

What is referred pain?

A

Referred pain: originates at different sites but shares innervation from the same spinal level

Examples:

  • Such as pancreatic pain in the shoulder
  • Gas pain hurts diaphragm; referred pain continues in the shoulder.
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17
Q

What do you ask to complete HPI?

A

What to ask the patient in order to complete the HPI?

Ask the patient:
– To describe the pain in their own words
– To point with one finger to the area of pain
– To rate the severity of pain, on a scale from 0 to 10
– What brings on the pain (timing)
– How often they have the pain (frequency)
– How long the pain lasts (duration)
– If the pain goes anywhere else (radiation)
– If anything aggravates the pain or relieves the pain
– If there are any symptoms associated with the pain

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18
Q

How do you ask a patient about bowel movements?

A

Ask the patient about bowel movements
1. Frequency of the bowel movements
2. Diarrhea versus constipation
3. Any pain with bowel movements?
4. Any blood (hematochezia) or black, tarry stool (melena) with the bowel movement?
5. Look for any associated signs such as jaundice
or icteric sclerae

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19
Q

What is icteric sclerae?

A

Jaundice, also known as icterus, is a yellowish pigmentation of the skin, the conjunctival membranes over the sclerae (whites of the eyes), and other mucous membranes caused by high blood bilirubin levels.

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20
Q

What is hematochezia?

A

Fresh blood in stool or with stool

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21
Q

What is melena?

A

Black, tarry stool containing partly digested blood (melena)

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22
Q

What are examples of prior medical problems related to the abdomen?

A

Prior medical problems related to the abdomen

  • Hepatitis, cirrhosis, gallbladder problems, or pancreatitis
  • Prior surgeries of the abdomen
  • Any foreign travel and occupational hazards
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23
Q

What other substances affect the GI system?

A

Any chemicals that are toxic to the liver, brain, renal, etc.; causes jaundice, etc.
-Use of tobacco, alcohol, illegal drugs, medication history
-Any hereditary disorders affecting the abdomen
in the patient’s FHx

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24
Q

What do we ask about urination? Why?

A 
–	Frequency and urgency of urination
–	Any pain with urination? 
–	Any hematuria?
–	Difficulty with urination
–	History of incontinence
–	Any flank pain?
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25
Q

Tips for examining the abdomen?

A

Check if the patient has an empty bladder.

Make patient comfortable in supine position with a pillow under the head and knees. Slide our hand under the low back to see if the patient is relaxed and lying flat on the table.

Ask the patient to keep arms at the sides or folded across the chest. When the arms above he head, the abdominal wall stretches and tightens making palpitation difficult. Move the gown to below teh nipple line and drape to the level of the symphysis pubis.

Before you begin palpation, ask the patient to point to any areas of pain so that you can examine these areas last.

Warm your hands and stethoscope. Rub together or place under hot water. Also can palpate through patients gown to absorb warmth from the body before exposing the abdomen.

Approach patient calmly and avoid any quick of unexpected movements. Watch for signs of pain and discomfort Avoid having long nails.

Distract them if necessary with conversations or questions. If they’re rightened or ticklish begin palpation with the patient’s hand under yours. After a few moments, slip your hand underneath to palpate directly.

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26
Q

What is the right order for the abdominal exam?

A

> > > Abdomen: Inspection, auscultation, palpation, percussion

Very different form the other organ systems. Why?
»> Thorax: Inspect, palpate, percuss, then auscultate

  • There are numerous special tests used during the examination of the abdomen that help define possible pathology
  • We will be understanding the exam and possible DDx by quadrants and regions
27
Q

What are the characteristics you look at during inspection of the abdominal exam? (Different from skills practical).

A

– Inspect the skin: scars, striae (stretch marks; indication of Kushing’s syndrome), vein pattern (may see a pattern where they’re using accessory veins bc of failure in another part of the body), hair distribution (alopecia), rashes, or lesions.
– Inspect the umbilicus: observe contour and location and any signs of an umbilical hernia
– Inspect the contour of the abdomen: flat, rounded, protuberant, gravid, scaphoid
– Inspect for abdominal symmetry
– Inspect for signs of peristalsis and pulsations

28
Q

What do you auscultate for in an abdominal exam?

A

Auscultation - Always auscultate before palpating or percussing the abdomen

Place the diaphragm of the stethoscope over the abdomen to hear bowel sounds (BS)
4 quadrants- RUQ, LUQ, RLQ, LLQ

Place the bell over the aorta, iliac, and femoral arteries to assess for bruits

29
Q

What is borborygmi? When won’t you hear them?

A

Borborygmi = long gurgles; typically will hear BS Q 20 minutes, unless the patient JUST ate

30
Q

Why do we palpate the abdomen light to deep?

A

Light Palpation
– Start palpating the abdomen using gentle probing with
the hands; this reassures and relaxes the patient
– Glide smoothly over all 4 quadrants
– Identify any superficial organs or masses as you palpate
– Assess guarding (indication of tenderness)

Deep palpation
– Repeat using deeper probing

Looking for MASSES and TENDERNESS.

31
Q

Where do you palpate the liver?

A

Use the left hand to support the back at the level of the 11th and 12th rib

Use the right hand to press on the abdomen inferior to the border of the liver

Continues to palpate superiorly until the liver border is felt

Ask the patient to take a deep breath

32
Q

What does it mean when patient experiences pain during liver palpitation?

A

This may illicit pain in – liver or gallbladder disease

33
Q

Why do we have patient take a deep breath during liver palpitation?

A

– It makes it easier to find the inferior border of the liver
• The diaphragm lowers during deep inspiration which forces the liver downward

34
Q

With liver palpitation, we can use the hooking technique – Who is it used on? How is it done?

A

Liver palpitation in Obese Patients:
Try the “hooking technique”
– Place both hands side by side, on the RUQ
– Press in with your fingers and move up toward the costal margin
– Ask the patient to take a deep breath
– The liver edge should be palpable under all your finger pads

35
Q

Why do we palpate the spleen if we can’t normally feel it?

A

Spleen Palpation
• The spleen should never be palpable, unless there is something wrong
– Palpate to detect a cracked spleen, hemorrhage, splenomegaly

Palpate the spleen the same way as the liver
– Left hand supports the back
– Right hand palpating the abdomen
– Generally the spleen cannot be felt by you, even with the patient performing deep inspiration

36
Q

How and where do you palpate the left kidney?

A

Left kidney
– Position yourself on the patient’s left side
– Place your right hand under the 12th rib
– Lift up, trying to displace the kidney anteriorly

– Place your left hand in the LUQ
– Ask the patient to take a deep breath

– At the peak of inspiration, press your left hand deeply into the left upper quadrant trying to “capture” the kidney between your hands

37
Q

How and where do you palpate the right kidney?

A

Right kidney
– Position yourself on the patient’s right side
– Use your left hand to lift the patient’s back while your right hand feels deeply into the RUQ
– Repeat the same steps as used to trap the left kidney

38
Q

Why do we tap the costovertebral angle of the back on left and right sides?

A

• Lightly tap (once) the costovertebral angle on each flank for kidney tenderness
– Elicits CVA tenderness in nephrolithiasis, pyelonephritis

39
Q

When does a costovertebral angle tap elicit tenderness?

A

Elicits CVA tenderness in nephrolithiasis, pyelonephritis

40
Q

What sounds are we listening for when we percuss the 4 abdominal quadrants?

A

Percuss over all four quadrants

– Listening for tympany (hollow) versus dullness (mass)

41
Q

What are indications of ascites?

A

A protuberant abdomen with bulging flanks is suspicious for ascites

42
Q

What is ascites? What causes it?

A

Fluid in the abdomen from diseases such as cancer or cirrhosis
– Due to gravity, dullness should be located along the lateral sides of the abdomen
– The anterior portion of the abdomen should be tympanic(?)

43
Q

How do we percuss the liver?

A

Percuss over the liver in both the midclavicular line and at the midsternal line

– Midclavicular percussion of dullness should be 6–12 cm; longer than this indicates an enlarged liver
– Midsternal line percussion of dullness should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver

44
Q

How do we tell if a liver is enlarged or small and cirrhotic?

A

– Midclavicular percussion of dullness should be 6–12 cm; longer than this indicates an enlarged liver!
» Enlargement indicated as a larger liver span at midclavicular line.

– Midsternal line percussion of dullness should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver
»Small, hard, or cirrhotic liver is shown by dull percussion being less than the standard 4 to 6 cm range

45
Q

What sound are we looking for when percussing the spleen?

A

Percuss the left lower anterior chest wall between lung resonance above the costal margin.
>When tympany is prominent, splenomegaly is not likely; TYMPANY IS GOOD.

46
Q

What sound indicates an enlarged spleen during percussion?

A

Dullness can indicate an enlarged spleen

47
Q

What tests are used to assess the appendix?

A 
Assessing appendicitis
–	“Rebound Tenderness”
–	“Rovsing’s sign”
–	“McBurney’s point” 
–	“Psoas sign” 
–	“Obturator sign"
48
Q

What is rebound tenderness?

A

Assessing appendicitis

Check for involuntary guarding and “Rebound Tenderness” in the RLQ

49
Q

What is Rovsing’s sign?

A

Assessing appendicitis

Check for “Rovsing’s sign” = tenderness in the RLQ while palpating LLQ

50
Q

What is McBurney’s point?

A

Assessing appendix: Pain over “McBurney’s point” = 2 inches from the ASIS on a line from umbilicus to ASIS

51
Q

What is Psoas Sign?

A

Assessing apendix: Check for “Psoas sign” = patient flexes his thigh against the examiner’s hand; pain indicates a positive sign as inflamed appendix irritates the psoas muscle

52
Q

What is obturator sign?

A

Assessing appendix: Check for “Obturator sign” = flex the patient’s thigh and rotate the leg internally at the hip; pain indicates a positive sign as inflamed appendix irritates the internal obturator muscle

53
Q

How do you assess for acute cholecystitis?

A

Assessing acute cholecystitis
– Hook fingers of right hand under right costal margin
– Ask patient to take a deep breath
– If there is a sudden stop in breath or sharp increase in tenderness, this is positive “Murphy’s sign”

54
Q

What two tests are used to assess ascites?

A

Assessing Acites: Shifting Dullness and Fluid Wave Tests

  • Percuss the abdomen for areas of tympany and dullness. Due to gravity, dullness should be located along the lateral sides of the abdomen, while the anterior portion should be tympanitic.
  • Test for shifting dullness: after mapping out the areas of tympany and dullness, have the patient roll to one side. Remap the areas of tympany and dullness. In ascites, there should be a shift due to free fluid moving with gravity.
  • Test for a fluid wave: have the patient or an assistant press hands firmly down the midline. This pressure stops the transmission of the wave through fat tissue. Now tap on one flank sharply and feel with your own hand if the wave transmits to the other side of the flank.
55
Q

How do you test for shifting dullness?

A

Test for shifting dullness: after mapping out the areas of tympany and dullness, have the patient roll to one side. Remap the areas of tympany and dullness. In ascites, there should be a shift due to free fluid moving with gravity.

56
Q

How do you test for a fluid wave?

A

Test for a fluid wave: have the patient or an assistant press hands firmly down the midline. This pressure stops the transmission of the wave through fat tissue. Now tap on one flank sharply and feel with your own hand if the wave transmits to the other side of the flank.

57
Q

EX of abdomen documentation PE

A

Documentation
Abdomen
• Flat, umbilicus midline. (+) BS x 4. Soft, nontender, without guarding or rigidity. No masses, no HSM. No CVA tenderness bilaterally. No bruits.

58
Q

Odynophagia

A

Pain with swallowing

Results in weight loss

59
Q

Dysphagia

A

Difficulty swallowing

60
Q

Pyelenonephritis

A

Infection of kidney

61
Q

Nephrolithiasis

A

Kidney stone

62
Q

Cracked spleen

A

Ruptured spleen

63
Q

Dyspepsia

A

Indigestion

History & Physical Examination (19 decks)

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