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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
Q

Types of hernia

A 
Congenital
Umbilical
Direct/indirect inguinal
Incisional
Ventral
Sliding
Incarcerated
Strangulated
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26
Q

Incarcerated hernia

A

Hernia sac contents can’t be reduced

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27
Q

Strangulated

A

Blood supply to an incarcerated hernia is compromised, contents may become gangrenous

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28
Q

Special maneuvers

A

Deep breath

Head lift

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29
Q

Deep breath special maneuver

A

Displaces abdominal contents downward and may reveal previously unseen hernias or masses

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30
Q

Head lift special maneuver

A

Increases intra-abdominal pressure which may also protrude hernias and /or separate the recti muscles

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31
Q

Diastasis recti

Causes

A

Right and left rectus muscles have separated

Often due to obesity or pregnancy

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32
Q

Is a diastasis recti a true abdominal hernia?

A

No, no fascial defect

No risk for incarceration or strangulation

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33
Q

Caput medusa

Causes

A

Dilated cutaneous veins around the umbilicus

Newborns, portal HTN, cirrhosis

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34
Q

Diaphragm or bell?

A

Diaphragm

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35
Q

What abdominal sounds are normal?

A

Clicks and gurgles

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36
Q

How many bowel sounds are normal?

A

3-30 per minute, irregularly spaced is normal

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37
Q

Borborygmi

Causes

A

Loud, prolonged gurgles associated with hyper peristalsis
Diarrhea
Hunger
Early obstruction

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38
Q

High pitched, tinkling BS indicates…

A

Fluid or air under pressure and often indicative of small bowel intestinal obstruction

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39
Q

Causes of decreased bowel sounds

A

Adynamic ileus
Obstruction
Peritonitis
Common post surgically

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40
Q

When can we determine that there are truly no bowel sounds?

A

Established only after full 5 minutes of continuous listening
Auscultate all 4 quadrants to not miss any localized bowel sounds

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41
Q

Where do we listen for bruits?

A 
Aorta (above umbilicus)
Renal arteries (2) (sides of aorta)
Iliac arteries (2) (sides of umbilicus)
Femoral arteries (2) (sides of groin)
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42
Q

Bell or diaphragm for bruits

A

Bell

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43
Q

Venous hum

A

Soft, low systolic diastolic hum over liver, umbilical area

Indicative of increased collateral circulation between portal and systemic venous systems

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44
Q

Causes of venous hum

A

Cirrhosis

Portal HTN

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45
Q

Friction rub

A

Rare to hear in abdomen
High (possibly low) pitched grating sound
Vary with inspiration, may be referred from pleurae

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46
Q

Causes of friction rubs

A

Peritoneal irritation
Peritonitis
Enlarged liver
Splenic infarct

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47
Q

Where do we percuss?

A

All four quadrants
Liver
Spleen
Bladder

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48
Q

What is the normal percussion sound? What is it due to?

A

Tympany

Due to gas in GI tract

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49
Q

Dullness on percussion

A

Solid organ
Mass/tumor
Fecal matter
Fluid accumulation

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50
Q

How do we determine the size of the liver?

A

Determine the upper and lower margins of the liver by percussion

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51
Q

How do we perform percussion for liver span?

A

Percussing inferiorly from lungs (resonant) and superiorly from lower abdomen (tympanic)

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52
Q

What does percussion over the liver sound like?

A

Dull

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53
Q

Normal liver span

A

6-12 cm at right mCL

4-8 cm at midsternal line

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54
Q

What individuals have normally larger livers?

A

Men, taller individuals

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55
Q

Increased liver span

A 
Cirrhosis
Hepatomegaly
Hepatitis
Liver carcinoma
CHF
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56
Q

Causes of falsely enlarged liver

A 
Obesity
Ascites
Pleural effusion
Lung consolidation
Stool filled colon
Mass
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57
Q

Where is the spleen percussed?

A

Posterior to left midaxillary line, percussed in several directions noting dullness
6-10th ribs

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58
Q

Most normal spleens do not traverse the…

A

Left anterior axillary line

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59
Q

What is heard on percussion of the spleen?

A

Dullness

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60
Q

What does a large area of dullness suggest?

A

Splenomegaly

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61
Q

What conditions can mimic splenomegaly?

A

Full stomach or stool filled colon

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62
Q

Where do we start palpation?

A

Start opposite of area of complaint

Systematic approach, all four quadrants

63
Q

What structures do we palpate?

A 
Liver edge
Spleen
Kidneys
Bladder
Masses
Aorta
CVA (costovertebral angle)

Light palpation
Deep palpation

64
Q

Light palpation

A

Soft, using right hand only

Pressing down about 1 cm

65
Q

What do we identify with light palpation

A

Guarding
Areas of tenderness
Superficial masses

66
Q

Guarding

A

Involuntary muscle resistance, may be due to peritoneal irritation/inflammation

67
Q

What do we identify with deep palpation?

A

Delineate organ size
Masses
Aorta
Areas of tenderness

68
Q

Deep palpation

A

May use 1 or 2 hands

Press down 4-5 cm or more

69
Q

Examples of abdominal masses

A 
Tumors
Hernias
Aneurysms
Pregnant uterus
Stool
Abdominal muscles
Enlarged organ
70
Q

Description of masses

A 
Location
Size
Shape
Consistency
Tenderness
Mobility
Pulsatility
71
Q

Consistency of masses

A

Hard or soft, smooth or nodular

72
Q

Palpating liver edge

A

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
Q

In a normal healthy patient, the liver should not be felt below..

A

The costal margin

74
Q

If liver is felt below costal margin, how should it feel

A

Firm
Smooth
Non tender

75
Q

Asses liver for…

A

Size
Surface texture - smooth versus irregular / nodular
Tenderness

76
Q

Causes of hepatomegaly

A 
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
Q

Palpating the spleen

A

Bimanual palapation
Right hand pushing into abdomen in LUQ
Left hand lifting from the back

78
Q

Position of patient for palpation of spleen

A

Patient supine and also right lateral decubitus

79
Q

What should the patient do to increase the chance of palpating the spleen?

A

Inspiration

80
Q

Can we feel the spleen in most patients?

A

Tip of spleen is barely palpable in small percentage of adults normally
If you can feel it, it’s enlarged

81
Q

Causes of splenomegaly

A 
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
Q

Are the kidneys palpable? Which kidney is more palpable?

A

May be barely palpable in thin individuals

Right kidney more palpable than left

83
Q

Cause of enlarged kidneys

A

Hydronephrosis
Polycystic kidney disease
Tumor (renal cell carcinoma most common)
Wilm’s tumor

84
Q

Where should we assess for renal tenderness?

A

CVA tenderness

85
Q

What does CVA tenderness indicate?

A

Kidney infection - pyelonephritis

Musculoskeletal

86
Q

What is the diameter of the descending aorta in most healthy individuals?

A

2-3 cm

87
Q

How is the aorta assessed?

A

Deep palpation just left of midline in the upper abdomen
Should be non tender
Looking for pulsatile mass

88
Q

What does enlargement of the aorta suggest?

A

Abdominal aortic aneurysm

89
Q

What individuals are more likely to have an AAA?

A

Men older than 50

Hx of atherosclerosis

90
Q

When is the bladder palpable?

A

Not usually palpable unless distended with urine

91
Q

Where are masses present with the bladder is distended?

A

Rounded/tense/smooth mass is palpable midline above the pubis symphysis

92
Q

What is heard on percussion over a mass in the bladder?

A

Dull

93
Q

What condition might mimic a mass in the bladder?

A

Ovarian cysts

94
Q

Special maneuvers

A

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
Q

What is rebound tenderness used to detect?

A

Peritoneal irritation

96
Q

Rebound tenderness

A

Press gently and deeply into area remote from area of patient’s discomfort
Rapidly withdraw hand and fingers

97
Q

What is another name for positive rebound tenderness

A

Positive Blumberg sign

98
Q

Why is there pain in rebound tenderness?

A

The return to position of structures that were compressed by your fingers causes a shape pain at the site of peritoneal inflammation

99
Q

Iliopsoas test

A

Place hand over lower thigh and have patient raise leg while you push downward
Will cause pain if iliopsoas is irritated

100
Q

What is the iliopsoas used to detect?

A

Appendicitis

Iliopsoas abscess

101
Q

Obturator test

A

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
Q

What is the obturator test used to detect?

A

Ruptured appendix

Pelvic abscess

103
Q

McBurney’s point

A

Halfway between umbilicus and anterior superior iliac spine

104
Q

Cause of McBurney’s point tenderness

A

Acute appendicitis

105
Q

Rovsing’s sign

A

Palpate patient’s LLQ

If this causes pain in the RLQ

106
Q

What is the Rovsing’s sign used to detect?

A

Appendicitis

107
Q

Murphy’s sign

A

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
Q

What is Murphy’s sign used to detect?

A

Cholecystitis

109
Q

What kind of patients should we suspect ascites?

A

Protuberant abdomens or flanks that bulge in supine position

110
Q

Conditions that produce ascites

A 
Cirrhosis
Alcoholic hepatitis
CHF
Hypoalbuminemia (nephrotic syndrome, malnutrition)
Malignancy
Renal failure
111
Q

What are we percussing for when assessing ascites?

A

Areas of dullness and tympany

112
Q

Shifting dullness

A

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
Q

Fluid wave

A

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
Q

What do we confirm a fluid wave with?

A

Ultrasound

115
Q

DRE structures

A 
Anal mucosa
External sphincter
Internal sphincter
Rectal mucosa
Transverse folds
116
Q

What is another name for transverse folds?

A

Houston valves

117
Q

Which transverse fold can be palpated?

A

Inferior fold

118
Q

Where is the prostate gland in relation to the bladder?

A

Base of the urinary bladder

119
Q

Which surface of the prostate is accessible?

A

Posterior surface is accessible on DRE

120
Q

Parts of the prostate

A

Median sulcus

Right and left lobes

121
Q

…. rectal wall lies adjacent to … aspect of vagina

A

Anterior rectal wall lies adjacent to posterior aspect of vagina

122
Q

How are female structures assessed?

A

Two fingers, but commonly performed without pelvic exam

123
Q

Patient preparation for rectal exam

A

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
Q

Positioning for rectal exam

A

Supine, knees flexed
Left or right lateral with knees flexed
Standing, hips flexed, torso supported

125
Q

Inspection areas rectal exam

A

Perianal area

Anus

126
Q

Palpation areas rectal exam

A

Perianal area
Sphincter/anal ring
Rectal walls
Prostate gland

127
Q

Inspection perianal area

A 
Smooth skin contours
Lumps, growths
Rashes
Inflammation
Excoriations
128
Q

Inspection anus

A

Gently spread buttocks apart

Skin pigmentation
Lesions
Hemorrhoids
Fissures
Fistulas
129
Q

What maneuver will make abnormalities of the anus more apparent?

A

Asking patient to bear down

130
Q

Hemorrhoids

A

Veins around anus or lower rectum are swollen and inflamed

131
Q

Risk factors for hemorrhoids

A 
Constipation
Pregnancy
Aging
Overweight/sedentary
Anal intercourse
132
Q

External hemorrhoids cause

A

Caused by increase pressure within the external hemorrhoidal veins

133
Q

Where do external hemorrhoidal veins arise?

A

Arise at lower end of the anal canal near the anus, below the dentate line

134
Q

Where do internal hemorrhoids arise?

A

Develop above the dentate line

135
Q

When might an internal hemorrhoid be visible?

A

Not visible unless prolapsed

136
Q

What patients usually suffer from rectal prolapse?

A

Mainly in elderly

Children under 6

137
Q

Anal fissure

Symptoms

A

Tear in the skin of the anal canal

Usually cause pain and rectal bleeding

138
Q

Tx anal fissure

A

Over 90% heal without surgery
Topical creams
Suppositories

139
Q

Pilonidal cyst

Symptoms

A

Cyst develops along the tailbone near cleft of buttocks

May cause pain and inflammation as often become secondarily infected

140
Q

How old are patients who get pilonidal cysts?

A

15-24

141
Q

Tx for pilonidal cyst

A

Often need surgical resection

142
Q

Palpation perianal area

A

Masses

Tenderness

143
Q

Palpation sphincter/anal ring

A

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
Q

What do we need to be aware of about the patient with a DRE?

A

Be aware of patient’s urge to defecate

145
Q

Tenderness of anal ring causes

A

Fissure
Fistula
Abscess

146
Q

Palpation of rectal walls

A

Rotate examining finger both directions to thoroughly evaluate entire anal wall

Masses
Polyps
Tenderness
Nodules
Irregularities
147
Q

Rectal wall male

A

Prostate

148
Q

Rectal wall female

A

Uterus
Cervix
Septum

149
Q

Size of prostate

A

Size of walnut

150
Q

Contour of prostate

A

Symmetric with median sulcus

151
Q

Consistency of prostate

A

Firm and smooth, similar to the tip of nose

Assess for tenderness

152
Q

Stool

A

Color
Consistency
Presence of pus or blood
Test for occult blood

153
Q

What substance do we use to test for occult blood?

A

Guiac testing

154
Q

What color does a positive stool test turn?

A

Blue

Physical Diagnosis (10 decks)

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