L6 Abdominal Exam Flashcards
What is the order of examination?
Inspection, auscultation, percussion and palpation
What is the main concern when a patient has a hernia?
Incarcerations or strangulations
Umbilical hernia
Herniation of abdominal contents through a defective umbilical ring
Spontaneously resolves between 1-2
Incisional hernia
Herniation of abdominal contents through a previous incision site
Diastasis recti
Laxity of the linea alba that leads to separation of the rectus abdominis muscles and the abdominal contents form a midline ridge
When is diastasis recti most obvious?
When the patient flexes the neck by “lifting their head up”
Ascites
Accumulation of fluid in the peritoneal cavity, usually secondary to cirrhosis
See bulging flanks
Peristalsis
Visible waves of movement seen beneath the skin
When do you see peristaltic waves?
Intestinal obstruction (seen in thin people)
When do you see increased pulsation?
Abdominal aortic aneurysm
What skin markings do you look for?
Color, rashes/lesions, scars, striae, dilated veins
When can ecchymosis be seen?
Intraperitoneal or retroperitoneal hemorrhage
When are pink-purple striae seen?
Cushings
What do prominent veins suggest?
Portal hypertension from cirrhosis
Caput medusa
When portal hypertension promotes collateral venous circulation radiating from the umbilicus to the abdominal wall
Abnormal auscultation sounds
High-pitched tinkling, hyperactive or hypoactive
Normal auscultation sounds
Clicks, gurgles, borboygmi
Borborygmi
Prolonged gurgles of hyperperistalsis, “stomach growling”
What is associated with high-pitched tinkling bowel sounds?
Intestinal obstruction interrupting the normal flow of contents
The sound is from intestinal fluid and air under tension in a dilated bowel
What are reasons for hyperactive bowel sounds?
Diarrhea (gastroenteritis) or early peritonitis
What are reasons for hypoactive bowel sounds?
Ileus (little to no bowel activity), peritonitis (may be hyperactive at first but lessens due to progressively severe inflammation and my progress to ileus)
What does percussing tympani suggest?
This predominates because of gas in the GI tract
What does percussing dullness suggest?
Underlying mass, enlarged organs or scattered areas of fluid/feces
Distended abdomen that is tympanic throughout
Intestinal obstruction or paralytic ileus
Protuberant abdomen with bulging flanks and dullness
Evaluate for ascites (free fluid sinks to dependent part of abdominal cavity where gas-filled loops of bowel float to the top)
Where do you measure the vertical span of the liver?
Midclavicular line (6-12 cm)
What happens when the spleen enlarges?
It expands anteriorly, downward and medially
When can fullness be percussed in the bladder?
Over 400-600 mL
When is the bladder tender?
Cystitis (UTI)
When is the bladder distended?
Urethral stricture, prostatic hyperplasia, neurogenic bladder
What is the purpose of light palpation?
Elicits abdominal tenderness, assesses for muscular resistance and identifies superficial masses and organs
What is guarding?
Voluntary contraction of the abdominal wall muscles with palpation (can diminish when patient is distracted)
If present, then it’s a peritoneal sign
What is rigidity/stiffness?
Involuntary reflex contraction of the abdominal wall muscles and persists
If present, it is a peritoneal sign
What is the purpose of deep palpation?
Delineate pain, identifies masses and organs, inspiration moves liver and spleen inferiorly
Reasons for abdominal masses seen on deep palpation
Physiologic: pregnant uterus Inflammatory: diverticulitis Vascular: aortic aneurysm Neoplastic: colon cancer Obstructive: distended bladder or dilated loop of bowel
Acute cholecystitis
Inflammation of the gallbladder
RUQ pain that may radiate to right scapular area
+ Murphy’s sign
Acute pancreatitis
Acute inflammation of the pancreas
Epigastric pain that may radiate to the back
Acute appendicitis
Acute inflammation of the appendix
Pain classically begins near umbilicus then migrates to RLQ
+ Psoas, obturator or Rovsing’s sign
Acute diverticulitis
Acute inflammation of a colonic diverticulum (sac like mucosal outpouching)
LLQ pain
Seen more commonly in sigmoid colon
Acute pyelonephritis
Infectious inflammatory process involving kidney
+ costovertebral angle tenderness (CVAT)
Nephrolithiasis
Stones that may lodge throughout urinary tract
Acute, severe, colicky flank pain that radiates down to groin
What makes you suspicious for liver disease?
Firmness or hardness of liver, bluntness or rounding of its edge and surface irregularity
Reasons for kidney enlargement
Hydronephrosis, cysts/tumors, polycystic kidney disease
When do you suspect aortic aneurysm?
Diameter over 3 cm
What does positive rebound tenderness indicate?
Appendicitis or peritoneal sign (intraperitoneal infection or friction)
What is Rovsing’s Sign?
Press in LLQ and pain in RLQ is positive sign
What are the peritoneal signs?
Guarding, rigidity and rebound tenderness
