ICS-Abdominal Exam

Question 1

Why is it technically easier to herniate through the lower abdomen than the upper abdomen?

Answer 1

In the lower abdomen, the fascia from the transversus abdominalis goes above the muscle instead of beneath it as it does in the upper abdomen.

Question 2

On you abdominal exam, what is a good landmark when you are assessing vascular symptoms? Where do you need to look for bruits and friction rubs?

Answer 2

The umbilicus is the landmark of the bifurcation of the abdominal aorta

Question 3

What makes a person with appendicitis experience RLQ pain after generalized visceral pain?

Answer 3

The inflamed appendix either bursts or inflames to irritate the peritoneum, causing peritonitis AFTER visceral pain.

Question 4

Indicate the organ visceral pain that is referred to each area below.

Answer 4

*

Question 5

What is the sequence of the abdominal exam?

Answer 5

General appearance, vital signs, inspect, auscultate, percuss, palpate & special tests.

Question 6

What do you look for on inspection of the patient?

Answer 6

1) Examine the sclera for icterus 2) General appearance (quiet or writhing) 3) Contour of the abdomen (flat, rounded, protuberant, scaphoid, bulges) 4) Skin coloration, scars, striae, ecchymoses, lesions 5) Pulsations

Question 7

What kind of pain does a patient have if they are writhing in the bed?

Answer 7

Visceral

Question 8

What kind of pain does a patient have if they are lying as still as possible?

Answer 8

Peritoneal

Question 9

What is a scaphoid appearance?

Answer 9

Wasting or dying

Question 10

What is your diagnosis?

Answer 10

The pancreas is a retroperitoneal organ. Severe pancreatitis will cause retroperitoneal bleeding and show Cullen’s sign (blood in front) and Turner’s sign (blood in back). Rupture of AAA or kidney will also cause this because they are retroperitoneal.

Question 11

What is your diagnosis?

Answer 11

Budd-Chiari syndrome. This is due to liver outflow obstruction by a tumor.

Question 12

This patient had recanalization of the veins in his abdominal wall. What is that called?

Answer 12

Caput Medusa.

Question 13

A 76 year old man presents with back pain. BP is 140/85. He has a pulsatile, nontender abdominal mass. What is your diagnosis?

Answer 13

Aneurism of the AAA into the posterior peritoneal sac.

Question 14

What abdominal changes do you need to be aware of as you examine a pregnant patient?

Answer 14

Week 12, uterus becomes abdominal organ; Week 20, at umbilicus; Week 34-36, at costal margin; Week 38-40, head engages pelvis

Question 15

A pregnant woman presents in shock. How do you position her when you examine her?

Answer 15

On her left side, this relieves pressure on the vena cava.

Question 16

What are you looking for on auscultation of the abdomen?

Answer 16

Bowel sounds in all four quadrants assessing presence, pitch and bruits.

Question 17

What are you looking for on percussion of the abdomen?

Answer 17

Tympany (distended bowel), dullness (mass), shifting dullness (ascites) in all four quadrants. You also tap out the size of organs via percussion.

Question 18

What are you looking for on palpation of the abdomen?

Answer 18

Start with superficial palpation, deep palpation, liver, spleen, kidneys, aorta and any masses. Make sure to watch the patient’s face as you do this! Finally, assess rebound tenderness.

Question 19

What sign helps you assess for cholecystitis?

Answer 19

Murphey’s sign. You have them take a deep breath in to push the liver down. Then you push your finger into their right costal margin and assess for pain.

Question 20

Why do most patients with cholescystitis present with back or flank pain instead of anterior abdominal pain?

Answer 20

It sits further back on the liver and is shielded from the anterior abdominal wall.

Question 21

How do you assess for hernias?

Answer 21

Palpate the groin and then have them valsalva to see if anything protrudes through weak spaces in the abdomen. Also ask the patient if they have any bulges?

Question 22

Rovsing sign

Answer 22

Assessing for rebound tenderness in the RLQ

Question 23

What kind of appendicitis can you miss because they don’t have rebound tenderness?

Answer 23

Retrocecal appendicitis.

Question 24

What is this called when you are assessing a patient for appendicitis?

Answer 24

Psoas sign. Stretching the iliopsoas indicates pain in the retroperitoneum.

Question 25

What is this called?

Answer 25

Obturator sign. Flexing the hip and internally rotating the leg puts pressure on the obturator and femoral space. This will help you assess for hernias in this region.