Exam of Abdomen

Question 1

dysphagia

Answer 1

difficulty swallowing

Question 2

hematemesis

Answer 2

throwing up blood

Question 3

melena

Answer 3

dark stool

Question 4

visceral pain

Answer 4

colic pain- source of usually hollow organ caused by distension or stretching. comes and goes, crescendo pattern. not well localized (ANS)
ex. cholic = gas in babies

Question 5

parietal pain

Answer 5

caused by inflammation of peritoneum. steady aching pain that is usually well localized

Question 6

referred pain

Answer 6

pain from a distant sight
right shoulder = gallbladder
left shoulder = spleen
back = pancreas or aorta
lateral side = kidney pain
loin to groin = ureteral pain

Question 7

examination of abdomen

Answer 7

1- inspection
2- auscultation 
3- percussion
4- palpation
rectal examination (no abdominal exam is complete without this!)
special techniques

Question 8

most important thing to exposing abdomen

Answer 8

must go from xiphoid to pubis symphysis

Question 9

caput medusa

Answer 9

varicosities around the umbilicus

Question 10

three anastamoses

Answer 10

rectal varicies (hemorroids)
esophageal varicies
umbilical varicies

Question 11

abdominal striae

Answer 11

stretch marks

Question 12

auscultation

Answer 12

all 4 quadrants

• RLQ is best place to hear: transition of cecum
• bowel sounds tell us that peristalsis is occurring (every 3-5 seconds)
• no bowel sounds = ileus

Question 13

ileus

Answer 13

no bowel sounds, most commonly due to post-abdominal surgery

Question 14

borborygmi

Answer 14

Increased, hyperactive bowel sounds,
Low pitched rumbling
Hyperperistalsis
“stomach growling”

Question 15

abdominal bruits

Answer 15

A soft sound made by disrupted arterial flow through a narrowed artery.
– turbulent arterial flow causing a soft “hissing sound”
- Aortic – between the umbilicus and xiphoid (bifurcation occurs at the umbilicus of iliac)
- Renal artery – just lateral to the aorta
- Femoral artery – along the inguinal ligament

Question 16

percussion

Answer 16

should get tympanic sound: presence of gas in stomach and small bowels
--> can do this at MCL
resonant = lungs
dull = liver
tympany = stomach/small bowels

liver is normally < 10 cm

Question 17

fluid wave

Answer 17

–> way to test for ascites
tap on one side, a wave will move across to the other side
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.

Question 18

shifting dulness

Answer 18

–> way to test for ascites
if patient is laying on back, dullness will be percussed at the fluid level, the fluid will shift from supine position to when patient is laying on their side
- tympany will be palpated where the organs lie

Question 19

palpation of abdomen

Answer 19

1. Light palpation (work towards point of tenderness, using one hand)
2. Deep palpation (use one hand on top of other, top hand is the pushing hand, bottom hand is palpating hand)
3. Liver palpation (right hand in the RUQ, place one hand under right 11th/12th rib, instruct patient to breath deeply, can feel liver on inhalation)
4. Spleen palpation (place left hand under the 11th/12th ribs, place right hand in the LUQ under the costal margin- not normally palpable)
5. Kidney palpation (sandwich method above and below the costal margins- not normally palpable)
6. Rebound palpation

Question 20

rebound tenderness

Answer 20

• start away from point of tenderness
• indicated peritoneal tenderness, irritation and inflammation: “peritonitis”
• if it is painful on the rebound “+ rebound tenderness”

Question 21

Rovsing’s sign

Answer 21

• referred rebound tenderness
• press on the LLQ and release, positive if pain in the RLQ
• indicates appendicitis

Question 22

aorta palpation

Answer 22

• press firmly in upper abdomen

palpate for aortic aneurysm - dilation of the aorta, can be asscoiated with a bruit - need to listen first!

Question 23

CVA tenderness

Answer 23

percussion of kidneys - costovertebral angle tenderness indicate Lloyd’s sign

Question 24

positions of DRE

Answer 24

patient on back: modified lithotomy
**lying on left side : Sim’s position (female)
**standing: bend over the exam table (male- easier access to prostate gland)
DRE: inspection, palpation

Question 25

rectal examination: inspection

Answer 25

spread buttocks
look at sacroccygeal (common place for absess) and perianal areas
look at anus and rectum

Question 26

DRE

Answer 26

• palpation: put finger on external sphincter, have them relax muscles under the finger, roll finger into rectum, put finger into the knuckle slowly.
• Once inside, rotate finger 180 degrees both ways to look for masses
• in male, can feel prostates: size of walnut
• use stool collected for fecal occult blood testing (positive test turns blue when reacting to iron)

Question 27

anal warts

Answer 27

condyloma acuminate = caused by HPV

condylomata lata = caused by syphilis

Question 28

appendicitis:

Answer 28

due to obstruction of appendicular lumen. fecal or foreign matter, tumors or lymphomas

hx: pain starts peri-umbilical then shifts to the right lower quadrant
- nausea, vomiting, anorexia, fever

Rovsing’s sign, (reffered rebound tenderness, press on LLQ, pain referred to RLQ)
psoas sign,
obturator sign

must always do a pelvic exam on a woman with abdominal pain - must do pregnancy test

Question 29

what is most sensitive test for appendicitis?

Answer 29

CT scan

Question 30

Acute Cholecystitis

Answer 30

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.
Anexoria
Obesity
Fever
The 5 “f’s” – female, fat, fertile, fair, flatulent. 

Murphy’s Sign: RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder

Diagnostic Triad : RUQ pain, fever and leukocytosis

Question 31

physical exam of acute cholecystitis

Answer 31

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.

Question 32

Diagnostic Work up of Acute Cholecystitis

Answer 32

CBC: leukocytosis with left shift
can have midly elevated serum bilirubin
AST/ALT can be elevated
ultrasound will detect stones

Question 33

Murphy’s sign

Answer 33

done as part of liver palpation

• the examiner places their finger tips just below the liver edge and as the patient inhales, the examiner presses inward on the liver.
• pain during inspiration causing the patient to stop inhaling is suggestive of an acutely inflamed gallbladder