PD - Abdominal exam Flashcards
abd surface anatomy
- Rectus abdominis muscle
- Umbilicus
- Inguinal ligament
- Costal margins
- Linea alba
- Iliac crest
- Anterior superior iliac spine (ASIS)
- Symphysis pubis
- McBurneys Point
LUQ
Liver, left lobe Spleen Stomach Pancreas: body Left adrenal gland Left kidney: upper pole Splenic flexure Transverse colon: portion Descending colon: portion
RUQ
Liver Gallbladder Pylorus Duodenum Pancreas: head Right adrenal gland Right kidney: upper pole Hepatic flexure Ascending colon: portion Transverse colon: portion
RLQ
Right kidney: lower pole Cecum Appendix Ascending colon: portion Right ovary Right fallopian tube Right ureter Right spermatic cord Uterus, Bladder (if enlarged)
LLQ
Left kidney: lower pole Sigmoid colon Descending colon: portion Left ovary Left fallopian tube Left ureter Left spermatic cord Uterus, Bladder (if enlarged)
Epigastrium
Stomach
Pancreas
Liver (portion)
Aorta
Suprapubic area
Bladder
Uterus
Imp sx for abd disease
Pain Nausea and vomiting Change in bowel movements GI bleeding Jaundice or Icterus Abdominal distention Mass Pruritis (itching)
To characterize abd pain, note…
time acuteness location severity character radiation
Right shoulder pain
referred from acute cholecystitis or anything irritating the right hemidiphragm
Testicular pain
referred from renal colic or appendicitis
Periodic epigastric pain 1 hour after eating-
think gastric peptic ulcer
Pain 2-3 hours after eating
think duodenal peptic ulcer
Back pain
perforation of duodenal ulcer, pancreatic pain
Nocturnal pain
duodenal peptic ulcer
Postprandial pain (after eating)
part of the abdominal angina triad, which also includes anorexia and weight loss.
Tenesmus
A feeling of needing to void the bowel, but unable to defecate
Causes of vomiting
severe irritation of the peritoneum resulting from perforation of an abdominal organ;
abdominal obstruction of the bile duct, ureter, or intestine;
inflammation of intraabdominal structures
extra-abd causes: cardiac ischemia, pregnancy, central nervous system disorders, medications, and drug toxicity
cause of episodic vomiting at height of pain
obstruction
causes of persistent vomiting
toxin, central nervous system causes, metabolic causes
Green-yellow vomitous cause
biliary colic
Feculent smelling vomitus cause
intestinal obstruction
causes of nausea w/o vomiting
hepatocellular disease, pregnancy, metabolic causes
Not all abd emergencies cause vomiting, exp…
intraperitoneal bleeding
bowel movement hx
duration number of movements per day onset whether or not change was associated with a meal the type of meal one ate, characterization, constipation, weight loss, caliber of stool, other symptoms it may be associated with
acute onset changes in bowel movements may be caused by
acute infection or toxin
watery stool causes
small bowel and colon inflammation or protein-losing enteropathies
Bloody diarrhea causes
dysentery
causes of alternating diarrhea and constipation
colon cancer, diverticulitis, colitis
Floating, light colored, or foul-smelling stool
malabsorption syndrome
Stool mixed with blood and mucus
ulcerative colitis or Crohn’s colitis
Blood with stool or undigested food
inflammation of small bowel or colon
Pencil-thin stool
anal or distal rectal carcinoma
clay colored stool
obstruction of bile flow or decreased production of bile
Constipation and weight gain
hypothyroidism
Constipation and weight loss
colon cancer
Silver-colored stool
rare cancer of the ampulla of Vater in the duodenum
hematochezia
bright red blood per rectum (BRBPR)
causes: colonic tumor, diverticular disease, ulcerative colitis
melena
black, tarry stool
causes: bleeding of first section of duodenum or upper gastrointestinal tract
causes of blood mixed with stool
tumors, diverticular disease, ulcerative colitis, or hemorrhoids
jaundice
yellow discoloration of skin
suspect liver disease or possible biliary obstruction
icterus
yellow discoloration of sclera of eyes
*usu seen before jaundice
causes of jaundice/icterus
hyperbiliurubinemia Viral hepatitis Obstructive jaundice Cholangitis Liver Failure
See jaundice/icterus, ask pt about…
duration and onset, associated sx, use of recreational drugs, travel, transfusions or tatooing, urine and stool characterization, work, and any friends with similar sx
viral hepatitis
jaundice, nausea, vomiting, loss of appetite, and aversion to smoke
obstructive jaundice
slowly developing jaundice with clay-colored stool and cola-colored urine
cholangitis
jaundice with fever and chills;
may be caused by stasis of bile in duct due to gallstone or cancer of the head of pancreas
Liver Failure
jaundice abdominal distension ascites caput medusae spider telangiectasia
Abd distention
due to increased gas in the GI tract or to ascites (free intraperitoneal fluid)
increased gas –> via malabsorption, irritable colon, air swallowing
ascites –> via cirrhosis, CHF, portal HTN, neoplasia…
Possible cause of intermittent distention relieved by flatus or belching
gas related to eating
Possible cause of ascites and loss of appetite
cirrhosis, malignancy, CHF
Possible cause of ascites and SOB
CHF or decreased pulmonary capacity w/ ascites from other cause
Abd mass may be a …
neoplasm, hernia, organomegaly, stool, pregnancy or something else
Note swelling/pulsatile nature/duration/location/pain
common causes of groin or scrotum mass
inguinal hernia
hydrocele
varicocele
common causes of pulsatile mass in abd
abdominal aortic aneurism (AAA)
Common GI causes of generalized itching
diffuse skin disorder or chronic renal or hepatic disease
Common GI causes of intense itching
lymphoma, Hodgkin’s, or GI malignancies
Common GI causes of anal pruritis
fistulae, fissure, psoriasis, parasite, poor hygeine
No abdominal examination is complete without performing a …
genitourinary examination and a rectal examination!
Evaluate for color and consistency of the stool, presence of gross or occult blood, and presence of presence of masses.
for the abd exam, ______ is performed prior to _______________, in contrast to the Pulmonary and Cardiac examination
auscultation is performed prior to percussion or palpation, bc the latter can stimulate GI sounds, rendering ausculation inaccurate
order for the abd examination
- Inspection
- Auscultation
- Percussion
- Palpation
- Special Tests
inspection of abd
◦ Contour: obese, flat, or scaphoid (sucked inward)
◦ Presence of absence of visible pulsations or pulsatile mass
◦ Presence or absence of surgical scars
◦ Presence or absence of visible masses
during abd exam, examine skin for
jaundice Caput medusae (abnormal, dilated periumbilical veins) Spider telangiectasias (small patches of prominent, thin veins)
during abd exam, examine extremities for
peripheral edema
abd auscultation
technique, normal bowel sound timing?
use diaphragm of stethoscope over mid abd to listen for bowel sounds
normal bowel sounds –> every 5-10 sec
absence of bowel sounds –> no sounds within 2 mins (must auscultate this amnt of time)
borborygmi
low-pitched rumbling sounds created via hyperperistalsis
possible cause of absence of bowel sounds
paralytic ileus perhaps due to diffuse peritoneal irritation
possible cause of high-pitched, rushing bowel sounds
acute intestinal obstruction
Auscultation may be used to detect bruits. Which area would you auscultate?
auscultate over the general area of the renal arteries (bruits=result from stenosis of a renal a. or abd aorta)
percussion used to…
determine size of organs
evaluate for xs gas, fluid, solid mass
assess for peritonitis
when percussing all quadrants, ________ predominates, w/ areas of ______
when percussing all quadrants, tympany predominates, w/ areas of dullness
Sequence of percussion
- general (all quadrants)
- liver
- spleen
- percuss for shifting dullness (detects ascites)
percussion of liver
1st: start at upper border of liver in midclavicular line at level of nipple, percuss in inferior direction
chest –> resonance
liver –> dullness (upper edge)
2md: move to abd @ ~umbilicus, percuss twd head –> hyper resonance
liver –> dullness (lower edge)
normal span of liver
10cm or less
percussion of spleen
same as liver, but percuss more laterally at anterior axillary line
percussion for shifting dullness
helps detect ascites
pt supine, begin percussing laterally abd in midline, superior to umbilicus
determine where tympany changes to dullness
(area of tympany should be above area of dullness)
turn pt away from side you percussed (while maintaining your hand @ tympany-dullness interface)
ascites –> tympany/dullness interface shifts w/ pt, if fluid w/I peritoneal cavity is free to move
sequence of palpation of abd
light palpation deep palpation palpation of liver palpation of spleen palpation of kidney (often not possible) examine for peritoneal signs
light palpation
detects guarding, tenderness and areas of muscular spasm or rigidity
use flat part of hand or pads of fingers with fingers together
list from area to area instead of sliding
deep palpation
determines organ size/presence of abnormal masses
have pt breathe thru their mouth,
place flat portion of R hand on abd, place L hand over it
L hand exerts pressure, R hand appreciates any movement or mass
pressure should be gentle but steady
if pt has pain in abd, palpate that part of abd first or last?
palpate painful area of abd LAST
rigidity
involuntary muscle spasm, indicative of peritoneal irritation
may be diffuse or localized
guarding
abd wall muscle tension/contraction
may be diffuse or localized
may be voluntary (pt can control guarding and relax abd wall muscles w/ encouragement)
or involuntary (uncontrollable abd wall muscle spasm aka rigidity)
2 techniques to palpate liver
- Stand at pts R side
place L hand posteriorly between 12th rib and iliac crest.
- Place R hand on RUQ, parallel, and lateral to rectus m., below area of liver dullness.
- Ask pt to take deep breath, press inward and upward w/ R hand while L hand pulls upward.
- liver edge should be felt w/ R hand fingertips
normal edge: firm, regular, smooth - Pt laying supine.
- stand at their head and place both hands below R costal margin and the area of dullness.
- press inward and upward in a hook motion during patient inspiration –> edge of the liver should be felt.
palpation of spleen
pt laying supine, stand at R side. Place L hand in lower L rib cage, pull rib cage upward.
- also put R hand flat below L costal margin
- press inward and upward toward anterior axillary line during pt’s deep inspiration
- normally not palpable but may feel tip of an enlarged spleen
- more easily palpated in L lateral decubitus position
palpation of kidneys
often not palpable
to attempt, stand at pt’s right
- place L hand on pt’s R flank between costal margin and iliac crest
- place R hand below costal margin w/ tips pointing toward your left
- deep palpation
- lower pole of kidney should be smooth and round
move to L and repeat for pt’s L kidney
examination for peritoneal signs
rebound tenderness
perform deep palpation then abruptly remove your examining hand, causing abd contents to spring back
+ rebound tenderness –> peritoneal irritation
*not recommended if clinical suspicion is high bc painful
+ peritoneal signs (w/o testing for rebound tenderness)
bump the edge of the table to see if pain develops as the peritoneal contents are moved ever so slightly
pump the gurney up
ask the patient to cough
ask the patient if they had any pain during the car ride over as the car passed over bumps in the road
McBurney’s Point
2/3 of the distance between the umbilicus and the right anterior superior iliac spine
tenderness –> concerning for appendicitis
fluid waves
Tests for ascites
pt lying supine, ask an assistant (or the patient) to put his/her hand on the midline of the abd.
tap on one side of the patients abdomen to propagate a fluid wave. Feel for the wave on the other side of the abd.
Presence of a fluid wave indicates ascites.
Rovsing’s Sign
tests for appendicitis
push on pt’s LLQ
if pain present on OTHER side (RLQ, or at McBurney’s point) –> rosving’s sign present
obturator sign
tests for inflammation, appendicitis, peritoneal irritation
pt laying supine, flex pt’s leg at hip w/ knee bent
rotate leg internally
if inflammation next to obturator m., pain results
may be a sign of appendicitis, OR abscess of another origin irritating the obturator m.
psoas sign
tests for intra-and inflammation, appendicitis, psoas abscess
pt lying on unaffected side, passively extend affected side
presence of abd pain –> + test
murphy’s sign
acute cholecystitis (inflammed gallbladder)
pt laying supine, palpate liver head on pt’s deep inspiration - feel for gallbladder
pt stops inspiration bc/ of pain –> Murphy’s sign
