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Physical Diagnosis > PD Abdomen > Flashcards

PD Abdomen Flashcards

1
Q

Preparations for abdominal exam

A 
Privacy, proper draping
Expsoure of abdomen from xiphoid to symphysis pubis
Empty bladder before exam
Warm hands
Gentile touch, patience
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2
Q

Patient positioning for abdominal exam

A

Supine, relaxed
Arms at sides
Legs slightly flexed, keeping soles on table
Approach from patient’s right side

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3
Q

When are painful areas percussed and palpated?

A

Last on the exam!

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4
Q

Always think of what … underlie the area being examined?

A

Organs

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5
Q

Solid viscera

A 
Liver
Spleen
Kidneys
Adrenals
Ovaries
Uterus
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6
Q

Hollow viscera

A 
Stomach
Small bowel
Colon
Gallbladder
Bladder
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7
Q

Watch patient’s facial … throughout the exam

A

Expressions

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8
Q

Order of abdominal exam

A 
Inspection 
Auscultation
Percussion
Palpation and special maneuvers
DRE
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9
Q

Where does the kidney lie in relation to the ribs

A

Protected by 11th and 12 th ribs, and pokes out right underneath

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10
Q

RUQ

A 
Liver
Gallbladder
Duodenum
Head of pancreas
Right adrenal gland
Portion of right kidney
Hepatic flexure
Portions of ascending and transverse colon
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11
Q

RLQ

A 
Lower portion of right kidney
Cecum and appendix
Portion of ascending colon
Bladder
Right ureter
Ovary/uterus
Spermatic cord
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12
Q

LUQ

A 
Stomach 
Spleen
Body and tail of pancreas
Left adrenal gland
Splenic flexure
Portions of transverse and descending colon
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13
Q

LLQ

A 
Lower portion of left kidney
Portion of descending colon
Sigmoid colon
Left ureter
Ovary/uterus/salpinx
Spermatic cord
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14
Q

Inspection

A 
Shape/contour
Scars
Striae
Vascular patterns
Masses, hernias
Ecchymoses
Pulsations 
Peristaltic waves
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15
Q

Shape and contour of abdomen

A 
Obese
Protuberant
Distended
Flat
Scaphoid
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16
Q

Striae on abdomen

Causes

A

“Stretch marks”
Pregnancy
Obesity
Cushing’s

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17
Q

What color are striae in Cushing’s syndrome?

A

Purple from hypercortisolism

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18
Q

Ecchymoses

A

Cullen sign

Grey Turner sign

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19
Q

Cullen sign

A

Bluish discoloration/bruising around the umbilicus due to intraperitoneal bleeding

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20
Q

Causes of Cullen sign

A

Hemorrhagic pancreatitis

Ruptured ectopic pregnancy

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21
Q

Grey Turner sign

A

Ecchymoses of flanks causes by retroperitoneal bleeding

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22
Q

Causes of Grey Turner sign

A

Coagulopathies
Acute hemorrhagic pancreatitis
Ruptured AAA
Trauma

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23
Q

Hernia

A

Protrusion or projection of an organ (or part) through the wall of the cavity that normally contains it

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24
Q

Reducible hernia

A

Contents of the hernia sac are easily replaced

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25
Types of hernia
``` Congenital Umbilical Direct/indirect inguinal Incisional Ventral Sliding Incarcerated Strangulated ```
26
Incarcerated hernia
Hernia sac contents can't be reduced
27
Strangulated
Blood supply to an incarcerated hernia is compromised, contents may become gangrenous
28
Special maneuvers
Deep breath | Head lift
29
Deep breath special maneuver
Displaces abdominal contents downward and may reveal previously unseen hernias or masses
30
Head lift special maneuver
Increases intra-abdominal pressure which may also protrude hernias and /or separate the recti muscles
31
Diastasis recti | Causes
Right and left rectus muscles have separated | Often due to obesity or pregnancy
32
Is a diastasis recti a true abdominal hernia?
No, no fascial defect | No risk for incarceration or strangulation
33
Caput medusa | Causes
Dilated cutaneous veins around the umbilicus | Newborns, portal HTN, cirrhosis
34
Diaphragm or bell?
Diaphragm
35
What abdominal sounds are normal?
Clicks and gurgles
36
How many bowel sounds are normal?
3-30 per minute, irregularly spaced is normal
37
Borborygmi | Causes
Loud, prolonged gurgles associated with hyper peristalsis Diarrhea Hunger Early obstruction
38
High pitched, tinkling BS indicates...
Fluid or air under pressure and often indicative of small bowel intestinal obstruction
39
Causes of decreased bowel sounds
Adynamic ileus Obstruction Peritonitis Common post surgically
40
When can we determine that there are truly no bowel sounds?
Established only after full 5 minutes of continuous listening Auscultate all 4 quadrants to not miss any localized bowel sounds
41
Where do we listen for bruits?
``` Aorta (above umbilicus) Renal arteries (2) (sides of aorta) Iliac arteries (2) (sides of umbilicus) Femoral arteries (2) (sides of groin) ```
42
Bell or diaphragm for bruits
Bell
43
Venous hum
Soft, low systolic diastolic hum over liver, umbilical area | Indicative of increased collateral circulation between portal and systemic venous systems
44
Causes of venous hum
Cirrhosis | Portal HTN
45
Friction rub
Rare to hear in abdomen High (possibly low) pitched grating sound Vary with inspiration, may be referred from pleurae
46
Causes of friction rubs
Peritoneal irritation Peritonitis Enlarged liver Splenic infarct
47
Where do we percuss?
All four quadrants Liver Spleen Bladder
48
What is the normal percussion sound? What is it due to?
Tympany | Due to gas in GI tract
49
Dullness on percussion
Solid organ Mass/tumor Fecal matter Fluid accumulation
50
How do we determine the size of the liver?
Determine the upper and lower margins of the liver by percussion
51
How do we perform percussion for liver span?
Percussing inferiorly from lungs (resonant) and superiorly from lower abdomen (tympanic)
52
What does percussion over the liver sound like?
Dull
53
Normal liver span
6-12 cm at right mCL | 4-8 cm at midsternal line
54
What individuals have normally larger livers?
Men, taller individuals
55
Increased liver span
``` Cirrhosis Hepatomegaly Hepatitis Liver carcinoma CHF ```
56
Causes of falsely enlarged liver
``` Obesity Ascites Pleural effusion Lung consolidation Stool filled colon Mass ```
57
Where is the spleen percussed?
Posterior to left midaxillary line, percussed in several directions noting dullness 6-10th ribs
58
Most normal spleens do not traverse the...
Left anterior axillary line
59
What is heard on percussion of the spleen?
Dullness
60
What does a large area of dullness suggest?
Splenomegaly
61
What conditions can mimic splenomegaly?
Full stomach or stool filled colon
62
Where do we start palpation?
Start opposite of area of complaint | Systematic approach, all four quadrants
63
What structures do we palpate?
``` Liver edge Spleen Kidneys Bladder Masses Aorta CVA (costovertebral angle) ``` Light palpation Deep palpation
64
Light palpation
Soft, using right hand only | Pressing down about 1 cm
65
What do we identify with light palpation
Guarding Areas of tenderness Superficial masses
66
Guarding
Involuntary muscle resistance, may be due to peritoneal irritation/inflammation
67
What do we identify with deep palpation?
Delineate organ size Masses Aorta Areas of tenderness
68
Deep palpation
May use 1 or 2 hands | Press down 4-5 cm or more
69
Examples of abdominal masses
``` Tumors Hernias Aneurysms Pregnant uterus Stool Abdominal muscles Enlarged organ ```
70
Description of masses
``` Location Size Shape Consistency Tenderness Mobility Pulsatility ```
71
Consistency of masses
Hard or soft, smooth or nodular
72
Palpating liver edge
Approach from inferior aspect Left hand under patient at 11-12th ribs lifting up Right hand just below costal margin pointing toward head May also stand facing patients feet and hook fingers under costal margin
73
In a normal healthy patient, the liver should not be felt below..
The costal margin
74
If liver is felt below costal margin, how should it feel
Firm Smooth Non tender
75
Asses liver for...
Size Surface texture - smooth versus irregular / nodular Tenderness
76
Causes of hepatomegaly
``` Hepatitis Cirrhosis Liver ca, mets CLL Lymphoma Fatty infiltration of liver Portal venous HTN Hepatic vein thrombosis Passive congestion from CHF Amyloidosis Mononucleosis Hepatic abscess ```
77
Palpating the spleen
Bimanual palapation Right hand pushing into abdomen in LUQ Left hand lifting from the back
78
Position of patient for palpation of spleen
Patient supine and also right lateral decubitus
79
What should the patient do to increase the chance of palpating the spleen?
Inspiration
80
Can we feel the spleen in most patients?
Tip of spleen is barely palpable in small percentage of adults normally If you can feel it, it's enlarged
81
Causes of splenomegaly
``` Lymphoma CML, CLL Polycythemia vera Mono, viruses Hepatitis TB Cirrhosis Splenic abscess SLE Hemolytic anemia Sarcoidosis Sicle cell anemia Portal HTN Liver/abdominal malignancy Long standing CHF Amyloidosis ```
82
Are the kidneys palpable? Which kidney is more palpable?
May be barely palpable in thin individuals | Right kidney more palpable than left
83
Cause of enlarged kidneys
Hydronephrosis Polycystic kidney disease Tumor (renal cell carcinoma most common) Wilm's tumor
84
Where should we assess for renal tenderness?
CVA tenderness
85
What does CVA tenderness indicate?
Kidney infection - pyelonephritis | Musculoskeletal
86
What is the diameter of the descending aorta in most healthy individuals?
2-3 cm
87
How is the aorta assessed?
Deep palpation just left of midline in the upper abdomen Should be non tender Looking for pulsatile mass
88
What does enlargement of the aorta suggest?
Abdominal aortic aneurysm
89
What individuals are more likely to have an AAA?
Men older than 50 | Hx of atherosclerosis
90
When is the bladder palpable?
Not usually palpable unless distended with urine
91
Where are masses present with the bladder is distended?
Rounded/tense/smooth mass is palpable midline above the pubis symphysis
92
What is heard on percussion over a mass in the bladder?
Dull
93
What condition might mimic a mass in the bladder?
Ovarian cysts
94
Special maneuvers
Assessing for peritoneal signs - rebound tenderness, guarding Iliopsoas test Obturator test McNurney's sign Rovsing's sign Murphy's sign Assessing for ascites - fluid wave/shifting dullness
95
What is rebound tenderness used to detect?
Peritoneal irritation
96
Rebound tenderness
Press gently and deeply into area remote from area of patient's discomfort Rapidly withdraw hand and fingers
97
What is another name for positive rebound tenderness
Positive Blumberg sign
98
Why is there pain in rebound tenderness?
The return to position of structures that were compressed by your fingers causes a shape pain at the site of peritoneal inflammation
99
Iliopsoas test
Place hand over lower thigh and have patient raise leg while you push downward Will cause pain if iliopsoas is irritated
100
What is the iliopsoas used to detect?
Appendicitis | Iliopsoas abscess
101
Obturator test
Have patient flew leg at the hip and knee to 90 degrees Hold leg just above knee, grasp ankle Rotate leg laterally and medially Inflammation of obturator will cause pain
102
What is the obturator test used to detect?
Ruptured appendix | Pelvic abscess
103
McBurney's point
Halfway between umbilicus and anterior superior iliac spine
104
Cause of McBurney's point tenderness
Acute appendicitis
105
Rovsing's sign
Palpate patient's LLQ | If this causes pain in the RLQ
106
What is the Rovsing's sign used to detect?
Appendicitis
107
Murphy's sign
Ask patient to inspire while your fingers are held under the liver border where the gallbladder may be depressed into them Inspiration will abruptly stop when inflamed gallbladder comes into contact with fingers
108
What is Murphy's sign used to detect?
Cholecystitis
109
What kind of patients should we suspect ascites?
Protuberant abdomens or flanks that bulge in supine position
110
Conditions that produce ascites
``` Cirrhosis Alcoholic hepatitis CHF Hypoalbuminemia (nephrotic syndrome, malnutrition) Malignancy Renal failure ```
111
What are we percussing for when assessing ascites?
Areas of dullness and tympany
112
Shifting dullness
Helps to determine presence of fluid Have patient lie on one side and again percuss for tympany and dullness and mark borders Fluid will settle in dependent position
113
Fluid wave
Requires two people Have patient or other examiner place edge of hand and forearm along vertical midline of abdomen Place hands on each side of abdomen and strike one side sharply with fingertips Feel implies of a fluid wave with fingertips of the other hand Easily detected wave suggests ascites
114
What do we confirm a fluid wave with?
Ultrasound
115
DRE structures
``` Anal mucosa External sphincter Internal sphincter Rectal mucosa Transverse folds ```
116
What is another name for transverse folds?
Houston valves
117
Which transverse fold can be palpated?
Inferior fold
118
Where is the prostate gland in relation to the bladder?
Base of the urinary bladder
119
Which surface of the prostate is accessible?
Posterior surface is accessible on DRE
120
Parts of the prostate
Median sulcus | Right and left lobes
121
.... rectal wall lies adjacent to ... aspect of vagina
Anterior rectal wall lies adjacent to posterior aspect of vagina
122
How are female structures assessed?
Two fingers, but commonly performed without pelvic exam
123
Patient preparation for rectal exam
Uncomfortable/embarassing - be sensitive Explain procedure clearly and purpose Respect patient's wishes if refuses, but document Calm, slow, gentle manner leads to patient cooperation, trust, and understanding
124
Positioning for rectal exam
Supine, knees flexed Left or right lateral with knees flexed Standing, hips flexed, torso supported
125
Inspection areas rectal exam
Perianal area | Anus
126
Palpation areas rectal exam
Perianal area Sphincter/anal ring Rectal walls Prostate gland
127
Inspection perianal area
``` Smooth skin contours Lumps, growths Rashes Inflammation Excoriations ```
128
Inspection anus
Gently spread buttocks apart ``` Skin pigmentation Lesions Hemorrhoids Fissures Fistulas ```
129
What maneuver will make abnormalities of the anus more apparent?
Asking patient to bear down
130
Hemorrhoids
Veins around anus or lower rectum are swollen and inflamed
131
Risk factors for hemorrhoids
``` Constipation Pregnancy Aging Overweight/sedentary Anal intercourse ```
132
External hemorrhoids cause
Caused by increase pressure within the external hemorrhoidal veins
133
Where do external hemorrhoidal veins arise?
Arise at lower end of the anal canal near the anus, below the dentate line
134
Where do internal hemorrhoids arise?
Develop above the dentate line
135
When might an internal hemorrhoid be visible?
Not visible unless prolapsed
136
What patients usually suffer from rectal prolapse?
Mainly in elderly | Children under 6
137
Anal fissure | Symptoms
Tear in the skin of the anal canal | Usually cause pain and rectal bleeding
138
Tx anal fissure
Over 90% heal without surgery Topical creams Suppositories
139
Pilonidal cyst | Symptoms
Cyst develops along the tailbone near cleft of buttocks | May cause pain and inflammation as often become secondarily infected
140
How old are patients who get pilonidal cysts?
15-24
141
Tx for pilonidal cyst
Often need surgical resection
142
Palpation perianal area
Masses | Tenderness
143
Palpation sphincter/anal ring
Lubricate index finger Rest pad of finger against anal opening Ask patient to bear down - relaxes external anal sphincter Sphincter tone Smoothness of anal ring Tenderness Consistency of stool in vault
144
What do we need to be aware of about the patient with a DRE?
Be aware of patient's urge to defecate
145
Tenderness of anal ring causes
Fissure Fistula Abscess
146
Palpation of rectal walls
Rotate examining finger both directions to thoroughly evaluate entire anal wall ``` Masses Polyps Tenderness Nodules Irregularities ```
147
Rectal wall male
Prostate
148
Rectal wall female
Uterus Cervix Septum
149
Size of prostate
Size of walnut
150
Contour of prostate
Symmetric with median sulcus
151
Consistency of prostate
Firm and smooth, similar to the tip of nose | Assess for tenderness
152
Stool
Color Consistency Presence of pus or blood Test for occult blood
153
What substance do we use to test for occult blood?
Guiac testing
154
What color does a positive stool test turn?
Blue

Physical Diagnosis (10 decks)

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