Lecture 5.1: Abdomen (6% of final)

Question 1

To speak intelligently about the abdomen in your note and to other providers requires that we be fluent with what?

Answer 1

Abdominal regions

Question 2

What is the surface designation of:
1) Liver/gallbladder
2) Appendix
3) Stomach
4) Pancreas
5) Sigmoid colon
6) Bladder/ uterus

Answer 2

1) Liver/gallbladder = RUQ
2) Appendix = RLQ
3) Stomach = epigastric
4) Pancreas = LUQ/epigastric
5) Sigmoid colon = LLQ
6) Bladder/uterus = suprapubic

Question 3

What should you ask about the red flag of pain in the abdomen?

Answer 3

-7 attributes, per usual. But location is particularly important. (See slide 6 to see why)
-Timing will certainly apply, as will radiation and character.
-Ask about associated symptoms, and provoking factors
-There is no excepted portion of the HPI, but the above will directly help you to differentiate many of the different abdominal etiologies.

Question 4

What questions about associated symptoms and provoking factors of pain in the abdomen should be asked?

Answer 4

1) N/V/D. If yes to nausea or vomiting, are either one bloody? If yes to diarrhea, how often? More than 5 times a day?
2) Is the pain worse with eating? Do they totally lose their appetite? Are they afraid to eat?
3) When was your last bowel movement? And was it normal – no diarrhea, constipation or blood?

Question 5

What are the 3 types of abdominal pain? Describe each

Answer 5

1) Visceral pain occurs when hollow organs contract, are distended or stretched
2) Parietal pain comes from inflammation of the peritoneum. Is usually more severe.
3) Referred pain is felt from distant sites that are innervated at the same spinal level as the effected organ. Ex. Pancreatic or gallbladder pain that radiates to the back.

Question 6

1) Colicky (comes and goes) pain located in the RUQ that radiates to the back is often ____________
2) Constant burning and stabbing pain in the LUQ/epigastrium that cuts to the back is often ______________
3) Colicky aching pain in the flank that radiates to the groin is often __________________

Answer 6

1) gallbladder
2) pancreatitis
3) renal/ureteral calculus

Question 7

1) Pain that begins at the umbilicus and localizes later to the RLQ, becoming more intense, is often ______________.
2) Unilateral lower quadrant pain that is tearing and increasing in intensity can be __________________
3) Suprapubic pain with burning dysuria and frequency is often ______________.

Answer 7

1) appendicitis
2) ectopic pregnancy
3) cystitis

Question 8

1) Left lower quadrant pain with bloody stools in the elderly is often ______________
2) Burning pain in the epigastrium without radiation is often ________________ and sometimes ________________

Answer 8

1) diverticulitis
2) gastritis and sometimes MI (watch out)

Question 9

1) Difficulty swallowing, painful swallowing can indicate what two things?
2) Vomiting blood is indicative of what?
3) “Coffee ground consistency” of vomitus is often what?

Answer 9

1) GERD, Cancer
2) Cancer, esophageal varices, Malory Weis tear
3) Digested blood

Question 10

1) Define hematochezia
2) Dark-tarry stool (melena) is often what? What part of the GI is this?

Answer 10

1) Blood in stool
2) Slow and chronic bleed; probably will be lower GI, but occasionally slow “upper GI”

Question 11

1) Bright red blood on TP is often what?
2) Bright red blood filling the toilet can be what two things?

Answer 11

1) Hemorrhoids
2) Inflammatory bowel disease, cancer

Question 12

1) What can jaundice indicate?
2) What can recurrent diarrhea indicate?

Answer 12

1) Liver dysfunction
2) Inflammatory bowel disease, irritable bowel syndrome, c. difficile, malabsorption, medicines (antibiotics)

Question 13

1) What can recurrent vomiting indicate?
2) What can recurrent constipation indicate?

Answer 13

1) Ulcer, gastritis, GERD
2) Irritable bowel syndrome, hypothyroid, anticholinergic meds

Question 14

1) Dark stool can indicate what?
2) What about pencil thin stool?
3) What about gray and soft stools?

Answer 14

1) Lower GI bleed
2) Colon cancer
3) Pancreatic cancer

Question 15

1) What can bloody urine indicate?
2) What 3 things can dark urine indicate?
3) What can pain with fever, chills, sweats, shakes indicate?

Answer 15

1) Bladder cancer
2) Renal disease, hematuria, rhabdomyolysis
3) Infectious process: Pyelonephritis, appy, intraabdominal abscess, possible perforation

Question 16

List 10 red flags for the abdominal region

Answer 16

1) Pain (many different kinds can be red flags)
2) Difficulty swallowing, painful swallowing
3) Vomiting blood
4) Blood in the stool (hematochezia)
5) Jaundice
6) Recurrent vomiting, diarrhea, or constipation
7) Change in stool consistency or color
8) Bloody urine
9) Dark urine
10) Pain with fever, chills, sweats, shakes

Question 17

When are hep a, hep b, and hep c vaccines given?

Answer 17

1) Hep A: all kids at one year
2) Hep B: in infancy (multiple shots)
3) Hep C: no vaccine

Question 18

1) Risk factors for Hep C are what?
2) How is it transmitted?

Answer 18

1) Chiefly IV drug use, and sometimes sharing intranasal devices for sniffing
2) It’s blood borne; very low risk for sexual transmission

Question 19

Start screening for colonoscopy at age _________, then every _______ years in patients with no risk factors

Answer 19

50; 10

Question 20

What are the risk factors for abdominal aortic aneurysm?

Answer 20

Male, over 65, a smoker
*and having 1st degree relative with hx of AAA repair

Question 21

1) What can you do to loosen a pts abdominal muscles and ease palpation
2) What can you do if the pt is especially ticklish?
3) If you want to surreptitiously elicit a pain response, what should you do?

Answer 21

1) Have them bend at the knees
2) Have them put their hand under yours
3) Use “deep auscultation” with your stethoscope.

Question 22

1) How do you inadvertently check for peritoneal pain?
2) Warm your _________ and _______________ before exam if either is very cold
3) Expose what’s ___________for no longer than ___________

Answer 22

1) You can hip check the bed to see if movement worsens pain
2) hands and stethoscope
3) necessary; necessary

Question 23

What should you visually inspect on the abdomen? (6 things)

Answer 23

1) Is there distress: are they writhing or completely still?
2) Do you see striae?
3) Masses or pulsations, caput medusa
4) Surgical scars!
5) Contour: protuberant, scaphoid, distended
6) Discoloration: Grey Turner’s or Cullen’s sign

Question 24

How should you auscultate the abdomen? What should you listen for and where?

Answer 24

1) Listen to all four quadrants and make sure you hear bowel sounds in each
2) Listen for bruits (with the bell)

Question 25

Abdomen auscultation:
1) High-pitched sounds occur in _________ and __________
2) Absent sounds or hypo-active sounds are ___________.

Answer 25

1) ileus and obstruction
2) abnormal

Question 26

Percussion:
1) If abdomen is diffusely is tympanitic, think of ____________ or ______________
2) An abdomen that is _________ to percussion throughout indicates constipation

Answer 26

1) intestinal obstruction or paralytic ileus
2) dull

Question 27

1) Local dullness can indicate what 4 things?
2) It is _____[normal/ abnormal]_______ to sometimes pick up tympany over the gastric air bubble

Answer 27

1) pregnant uterus, tumor, large liver or spleen
2) normal

Question 28

What places should you be sure to percuss?

Answer 28

1) Liver, spleen
2) Over bladder for dullness or tympany

Question 29

When you begin with light palpation, how should you do it and what should you watch or note?

Answer 29

-Palpate with a flat hand, lightly in all 4 quadrants
-Watch the patients face for wincing
-Note any masses, induration, tenderness

Question 30

1) If you find tenderness, you must note what? What is this?
2) What does this indicate?

Answer 30

1) Whether there is rebound pain: pain that occurs as you release pressure on the abdomen
2) Indicates a more serious peritoneal inflammation and may indicate need for surgery

Question 31

1) If patient is flexing abd. muscles, this is called what?
2) What are the two types and how are they differentiated? What does one suggest?

Answer 31

1) “Guarding”
2) Voluntary guarding may be overcome with tricks, involuntary guarding will persist and suggests peritoneal inflammation

Question 32

What are 3 tips to overcome voluntary guarding?

Answer 32

1) Have the patient “blow out”
2) Have them breathe with jaws wide open
3) Distract them some way!

Question 33

1) Define guarding
2) What must guarding be in order to count?

Answer 33

1) A voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted.
2) Severe

Question 34

1) Define rigidity. What causes it?
2) Define rebound tenderness
3) How do you assess rebound tenderness? When is the maneuver positive? What should you then do?

Answer 34

1) An involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations.
2) Rebound tenderness refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand.
3) Ask the patient “Which hurts more, when I press or let go?” Press down with your fingers firmly and slowly, then withdraw your hand quickly.
-The maneuver is positive if withdrawal produces pain.
-Percuss gently to check for percussion tenderness.

Question 35

What are the 3 signs of peritonitis?

Answer 35

1) Guarding
2) Rigidity
3) Rebound tenderness

Question 36

1) What do the 3 signs of peritonitis say about its likelihood?
2) What causes peritonitis?
3) Give 4 examples of these causes

Answer 36

1) Double the likelihood of peritonitis
2) Disease that has spread to inflame the peritoneum
3) Appendicitis (esp. if ruptured), advanced cholecystitis, perforated bowel wall, abscess

Question 37

1) What does deep palpation help feel for?
2) What should you palpate a second time?

Answer 37

1) Liver, kidneys, splenomegaly and deep masses
2) All 4 quadrants a second time, now that you know patient is not in intense pain

Question 38

1) What should you palpate for when looking for hepatomegaly and splenomegaly?
2) How do you do it?

Answer 38

1) Palpate costal margins for hepatomegaly and splenomegaly
2) Gently push in and deep to the costal margin from inferior
-Palpate for boarders of these organs

Question 39

1) How should you palpate the spleen?
2) When is the spleen too big?
3) Splenomegaly is 8 times more likely if spleen is ___________

Answer 39

1) Have the patient take a deep breath, then palpate
2) If you can feel the spleen, it’s too big
3) palpable

Question 40

1) How do you palpate the kidneys?
2) What is different than palpating the spleen?

Answer 40

1) In a similar maneuver to spleen palpation
2) You will not be as close to the costal border

Question 41

1) What part of the circulatory system should you palpate?
2) What should you screen for in every risky patient? Why?

Answer 41

1) The aorta
2) Screen for AAA; save a life

Question 42

1) An abdominal mass greater than 3 cm with pulsation indicates what?
2) Sensitivity of examiners goes up as the size of what goes up?
3) Sensitivity also goes up if the examiner has done what?
4) DO NOT PALPATE A LARGE __________________ MASS!

Answer 42

1) AAA
2) AAA goes up
3) Practiced lots. . .
4) PULSATILE

Question 43

Describe the CVA tenderness special technique:
1) What is it sensitive to?
2) What could it also be?
3) When should you do it?

Answer 43

1) Test is sensitive to pyelonephritis if associated with fever and dysuria
2) Musculoskeletal (So it’s not always specific)
3) When already behind pt

Question 44

How do you check for appendicitis?

Answer 44

-Draw a line from the ASIS to umbilicus
-Find the midpoint
-Two inches inferior to this spans the diameter of McBurney Point
-Palpate McBurney Point for local tenderness

Question 45

1) What sign should you check for for appendicitis? How do you perform this maneuver?
2) What should you assess for pain for appendicitis? What should you also check for at this time?

Answer 45

1) Check Rovsing sign; palpate deeply and evenly in the LLQ and quickly let go
2) Assess for pain in the right lower quadrant; also check for referred rebound pain

Question 46

What is the Psoas sign for appendicitis?

Answer 46

-Have patient flex Right hip against your resistance on the R thigh
-This flexes the psoas, suggesting irritation of psoas in response to appendix inflammation

Question 47

1) How do you check the Obturator sign for appendicitis?
2) What is a positive obturator sign and what is it secondary to?
3) Is it high or low sensitivity?

Answer 47

1) Flex patient’s right leg at hip and with knee bent, rotate leg internally
2) Right hypogastric pain; secondary to inflamed muscle
3) Very low sensitivity.

Question 48

Appendicitis is:
1) _________ as likely with RLQ tenderness, Rosving sign and psoas sign!
2) __________times more likely in McBurney point tenderness!
3) What other appendicitis tests/ checks are there?

Answer 48

1) Twice
2) Three
3) You can perform the “kangaroo test” and the “heel check” in practice

Question 49

How do you assess for cholecystitis? (i.e. what test?)

Answer 49

Assess Murphy sign:
-Palpate under R costal margin as the patient inspires
-Greatly increased tenderness with inspiratory effort
triples likelihood of cholecystitis
-Look for arrested breathing

(“IF the test can go ‘wrong’ it will go ‘wrong’” = Murphy’s law)

Question 50

What is a retired abdominal test?

Answer 50

1) Ascites (not done much anymore)
-Protuberant abdomen with bulging flanks
-Check for fluid wave or shifting dullness
-Putting their hands in the middle stops transmission of waves through fat. . . but not water