Exam V: Abdominal Flow Flashcards
Referred Pain: Ureter and Kidney
Kidney is band like effect of pain
Ureter innervation causes the pain to feel like it can range from the back to the labium majora
Costovertebral Angle
Where 12th rib meets vertebral column = kidney location
Entering Patient Room
- Introduce yourself; be clear you are a medical student
- Tell them Dr. _____ will be in afterwards
- Wash hands
- Ask permission to do exam
- Ask patient if they have anymore questions
- Thank the patient
Examination of Abdomen
Usually have a sheet over hips and legs area EVEN WHEN WEARING PANTS/SHORTS
Simple way to show respect
Stand on right side of supine patient!!!! *** = for consistency purposes!
Liver is close and spleen is farther away
Make sure pants are pulled down to ASIS
General Contours of Abdomen
Flat
Scaphoid- little body fat and muscles make shovel appearance
Distended/Protuberant
Abdominal Wall Hernias
Peritoneum – primarily soft and smooth providing lubrication and protection
Fascia holds bodily organs inside, or hernia occurs
- Semilunar= spagalia
- Incisional hernia from weakness of tissues in that location
- Femoral canal: where vessels and nerves that exit and go into the leg; can herniate
- Epigastric hernia
- Umbilical hernia
Assess for hernias and rectus diathesis
Have them flex head at waist (semi sit up) with shoulders lifted and that will cause intra-abdominal pressure to visualize hernias if present
Anterior abdominal can become weak especially during weight gain = hernias
Ridge – see the bulge/rectus diathesis = not a hernia; needs weight loss and exercise
Normal Bowel Sounds
Clicks and gurgles
Borborygmus: Rumbling of the large bowel
Frequency of Bowel Sounds
Should not be used for counting, only used for distinguishing sounds in sick patients
Hypoactive: ileus, peritonitis (must auscultate for 2 minutes)
Normoactive: 5 to 34 per minute
Hyperactive: diarrhea, early obstruction
Pathology of Bowel Sounds
Borborygmi: absence with ileus (paralyzed bowel), and increases with obstruction
High-pitched tinkling: intestinal air and fluid under high pressure in a dilated bowel
Bowel separates solid, liquid, and gases, so if mixed = abnormal
Rushes of high-pitched sounds concurrently with cramping: obstruction
Venous Hum
Rare
Systolic and diastolic
Indicates increased collateral circulation between portal and systemic venous systems
Hepatic cirrhosis
Friction Ribs
Rare
Grating which occurs with respirations
Indicate inflammation of peritoneal surfaces
Tumors, infection, abscess, splenic infarct
Percussion of Abdomen
Assess resonance
Dullness: increased with mass, organomegaly
Tympanic: predominates, gastric bubble
Hyperresonant: obstruction
Can use percussion to find where the liver is located; intestines (less solid), kidneys, etc. are underneath
Bladder height CANNOT be percussed because in pelvis, unless patient has had gradual enlargement of bladder or full with incontinence
Therefore if you can palpate the bladder, this is ABNORMAL
Palpation of Abdomen
Use distraction
Watch facial expression for grimace
Flex hips and knees if abdomen is tense
Light palpation (think skin and sub Q tissues) = 0ne hand using finger pads for tenderness, masses Deep palpation (think abdominal organs) = two hands, one on top the other
Deep Palpation
Tenderness
Masses
Hepatomegaly/masses: begin in the RLQ and work cephalad to the right costal margin and use rolling hand technique
Kidney- won’t feel kidneys unless issue
Uterine height: not palpable, unless pregnant or fibroids; gestational age can be determined by height of uterus
Bladder distension
Size of the aorta- Feel aorta pulsation to approximate size; enlarged = far more palpable than normal aorta
Splenomegaly
Begin at the umbilicus and work diagonally to the left costal margin
May use posterior lift
Spleen is behind the stomach and above the left kidney
The fingers must press more firmly
Left hand under patients ribs and push up to right hand =get better impression of spleen
Enlarged spleen is only time is it palpable
Acute Abdominal Pain
Guarding
Rigidity
Rebound
Ask patient which hurts more:
1. Pushing in: push in slowly but deeply OR
2. Letting go: suddenly lift hand from depressed position
Should be a significant difference
Ascites
Fluid Wave
Patient is supine
Place lateral hands down the abdomen centrally (inhibits transmission through adipose)
Tap one side and feel for transmission in opposite hand
Special tests for those with liver failure
By reducing the proteins made by liver, then fluid leaks into the intra-abdominal wall
Someone holds skin while someone else palpates the right and left sides
If fluid accumulation then easily movable from side to side = severe liver failure, but not much movement probably just ate too much
Murphy’s Sign
Murphy’s sign = cholecystitis related
After determining tenderness in right upper quadrant, could be pancreas, 2nd portion of duodenum, stomach, etc., but only one thing moves when you breathe and that is the liver
Hand on abdomen and find most tender spot (locate patient’s problem) and patient will tell you point of max pain, then do not move hand while patient takes deep breath
If more pain = gallbladder is issue because moves with liver when not supposed to
Lloyd’s Punch
Lloyd’s punch is associated kidney issues
Kidney stones, extra water, or infection/purulent exudate
Patient faced away from you
If tender in that place = identified problem
Hit your own hand pretty hard = shouldn’t hurt patient unless kidney is inflamed = Lloyd’s punch
Abdominal exam is not complete unless Lloyd’s punch!!!!
If patient cannot sit upright have them roll onto their side = no excuse for not doing this test
