Phys Di - Abdominal Exam Flashcards
What to keep in mind when females c/o abdominal pain
- can arise from gynecological problem
- PID
- ectopic pregnancy
- torsion of ovary
- ovarian cyst
- so always consider pelvic exam
wavelike/”colicky” pain
- pain that comes on in a wave, hits a hard peak, then goes down
- typically a sign of the body trying to push something out
- i.e: constipation, ureteral calculi, obstruction of bowel, gallstone
what to consider with continuous or constant abdominal pain
- infection
- abcess
- cyst
- diverticulitits
- IBD
- mesenteric adenitits
What to consider w/ stabbing, searing, boring abdominal pain
- pancreatitis
- PUD
- cholangitis
ripping pain is characteristic of?
-rupturing AAA
out of proportion pain to physical findings is characteristic of what?
- mesenteric ischemia
- IBS
HPI for for abdominal exam
big 8 always works
additional things to consider in GI HPI
- relation to menstrual cycle
- relation to BM
- stool characteristic details
- ALWAYS find out about blood
- remember blood can be black
- constipation is VERY subjective
- pts often won’t offer info on fetal incontinence so ask
melena
black, tarry stool; indicates GI bleed is NOT from colon depending on transit time
hematochezia
bloody stool, passing of blood from rectum w/ or w/o stool
steatorrhea
oily, greasy stool, sign of malabsorption
suprapubic
area of abdomen just above pubis
hematuria
bloody urine
tenesmus
rectal “dry heave”
proctalgia fugax
rectal spasm
oliguria
small amout of urine
chyluria
milky urine
urolithiasis
stones in urinary tract
borborygmi
audible rumbling sound of digestion
post-prandial
after meals
BRBPR
bright red blood per rectum
NABS
normal active bowel sounds
PUD
peptic ulcer dz
family hx for GI
- **colon CA
- any abdominal CA
- IBD
- IBS
- GERD, gastric ulcer
- celiac dz
social hx for GI
- smoking
- ETOH
- eating habits
- stress level
- caffeine
- fiber
- sexual contact
GI ROS
- abdominal pain
- n/v/d
- hematemesis
- indigestion
- belching/flatulence
- appetite change
- food intolerance
- jaundice
- hx of hepatitis
- constipation
- BM change or frequency
- steatorrhea
- melena
- hematochezia
- hemorrhoids
- hx of laxative use
- hx of colon polys/colonoscopy
what is something you ALWAYS ask about in GI work up?
colon CA
when should one start getting colonoscopys?
50 unless fam hx then 40
what is the order of PE for GI?
- inspection
- auscultation
- percussion
- palpation
- special tests
general summary of what to look at during inspection
- contour (round, flat, protuberant)
- symmetry
- masses
- surface features (striae, lesions, masses, visable pulsations/peristalsis)
general summary of what to look at during auscultation
- verify bowel sounds in 4 quadrants
- describe bowel sounds as normoactive, high-pitched, tinkling, rumbling, hyper or hypo active or absent
- listen for bruits
what do you focus on during percussion of the abdomen?
difference in sounds
general summary of what to look at during palpation
- light: feel for any superficial masses, if soft, rigid, guarding and aortic pulsation
- deep: feel for stool, deep tenderness, organs, masses, McBurney’s, Rovsings, rebound last
locations of the abdomen (other than the normal RUQ, LUQ etc)
- costal margins
- suprapubic
- inguinal
- ASIS
- peri-umbilical
- flank
- epigastric
- generalized
skin/eye inspection during GI PE
- jaundice
- scleral icterus
- pallor
- skin turgor
- nail clubbing
- spider nevi
abdomen inspection
- contour, distention
- symmetry
- masses
- scars
- have patient lift head, crunch
- purple striae (Cushing’s)
- dilated vein
Why do you have the patient lift head/”crunch” during the abdomen inspection?
to assess if the pain is deep or within the muscular abdominal wall
skin turgor
- “pinch test”
- check it if evaluating a pt who is severely dehydrated (n/v/d)
striae
- purple colored stretch marks
- sign of Cushing’s if >1cm
- caused by high cortisol levels
gray turner sign
- retroperitoneal hemorrhage
- can be sign of acute pancreatitis
- on side**
cullen sign
- sign of retroperitoneal hemorrhage
- blood diffuses from retroperitoeum to the subQ tissue of abdomen
- around umbilicus**
diastiasis recti
- “reverse 6-pack”
- men may say they have hernia
- common in younger women after pregnancy
auscultation of all 4 quadrants
-auscultate for bowel sounds using diaphragm
borborygmi
normal sounds of peristalsis / “stomach growling”
absence of bowel sounds on ausultation
- intra-abdominal catastrophe, ileus, complete obstruction
- cannot determine they are actually absent unless you listen for full 5 min
high pitched tinkling sounds on auscultation
partial bowel obstruction or stricture of bowel
liver scratch test
- use bell
- pretty worthless in clinical setting
- used to determine liver size by auscultation of scratching sound over abdomen
what is the technique of the liver scratch test
- place bell just below xyphoid
- scratch up from RLQ at mid-clavicular line
- sudden increase of sound is where inf. liver edge begins
- document if inf liver edge is below costal margin (enlarged)
- an enlarged liver will extend beyond the right costal margin
- in nl test: sound changes AT right costal margin
what do you percuss for in the RUQ?
- liver size
- dullness heard when percussing over solid organ
- really only able to percuss if liver is enlarged, palpating is better
What do you percuss in the LUQ aka Traube space
- the gastric bubble
- if NOT tympanic, possible enlarged spleen or mass?
- should NOT be dull
What do you percuss for in the suprapubic area?
- enlarged or distended bladder
- would be dull
what is a normal finding on percussion of abdomen?
nl to have different areas of flat tones and tympanic throughout
palpation on PE of abdomen
- for tenderness
- for masses
- for organomegaly
- light vs deep
- for rebound tenderness (LAST)
- keep fingernails trimmed
- bimanual technique
what to do if pt is extremely ticklish
put their hand on yours
what is the normal finding on palpation?
-soft to touch, non-tender (meaning no pain elicited w/ palpation)
how would you document nl findings upon palpation?
“abdomen is soft and non tender to palpation w/ no guarding, rebounding, masses or organomegaly noted”
If tenderness is present upon palpation of the abdomen, what do you need to pay attention to?
- where? which quadrant? localized or diffuse?
- how bad? mild, moderate, severe?
abnl findings on palpation of abdomen
- guarding
- rebounding/rebound tenderness
- rigidity
guarding
involuntary contraction of anterior abdominal muscles, usually a sign of peritoneal irritation or inflammation
rebounding/rebounding tenderness
also a sign of peritoneal irritation or inflammation
rigidity
sign of severe issue, involuntary muscle contraction
what could be a cause of suprapubic tenderness?
- cystitis
- also, pelvic structures could normally be tender on palpation of RLQ and LLQ
how should you accurately assess for hernias?
-examine w/ pt standing +/- valsalva
what to document if abdominal wall hernia is found
- size
- if it easily reduced
- overlying skin changes (indication of strangulation or incarceration )
When do you palpate/percuss the kidneys?
after auscultating the posterior chest and before laying the pt down
what could tenderness to first percussion of the CVA suggest?
- renal inflammation
- pyelonephritis
- stones
- so be gentle, kidney inflammation causes bad pain
technique for palpation of masses
- use 2 hands
- have pt lift head
- if floating, use ballottement technique
when palpating for masses, what all do you need to determine?
- size
- shape
- tenderness
- location
- consistency
- mobility
- is it midline and pulsatile?
what could be confused for a mass in the LLQ?
poop
murphy’s sign
- deeply palpate RUQ
- ask pt to take deep breath
- if breath is abruptly stopped d/t pain, consider GB dz (positive murphy’s)
liver edge
- where measured
- how to describe
- measured in right mid-clavicular line
- described by # of finger breadths it extends below costal margin
- nl finding could be: liver edge not palpable or no hepatomegaly
what is the preferred method of examination of the liver?
liver hooking technique
what to palpate at LUQ?
spleen
when is it possible to palpate the spleen?
never, unless there is a pathologic enlargement
how to palpate for spleen
- deeply palpate at LUQ at costal margin
- have pt take deep breath (enlarged spleen may come forward)
- can also apply posterior pressure to flank
- nl: no spleen palpated
how do document nl spleen palpation
- no splenomegaly present
- no splenomegaly noted on palpation of the LUQ
structures at RLQ
- appendix
- ileocecal valve
- distal ileum
tenderness at McBurney’s point indicates what?
appendicitis
in what other conditions might the RLQ be tender?
- IBD
- IBS
where is McBurney’s point?
1/3 of the way between the ASIS and umbilicus
what often causes LLQ tenderness?
- diverticulitis
- colitis
Rovsing’s sign
if deep palpation of LLQ produces referred pain in RLQ
what is rovsing’s sign a sign of?
acute appendicitis
what are the special tests for appendicitis?
- psoas sign: flex hip against resistance and look for pain in RLQ
- obturator sign: internally rotate right rip
- heel jar test: “jar” heel w/ hand
what are the special tests for ascites?
- shifting dullness: fluid moves as you move the patient to side
- fluid wave
What would a note look for for PE of abdomen
The abdomen is soft and non-distended with normal contour, withtout visible scars, masses,, acites, or striae present. Normoactive bowel sounds in all 4 quadrants w/ no bruits (aortic, renal iliac, femoral) noted. The abdomen is non tender to palpation w/ no guarding, rebounding, masses, hepatosplenomegaly or CVA tenderness noted. The aortic pulse has normal width. No pelvic or suprapubic tenderness present
what to consider with rectal exam
- protect pts privacy, use drape
- chaparone
- lay pt on side
- use lube
- have guiac or hemoccult card ready before you begin
how to position patient for rectal exam
left lateral decubitis
what to inspect for during rectal exam
- skin abnormalities (perianal candidiasis, condyloma)
- external hemorrhoids, thrombosed?
- fissure
- prolapse
- neoplastic lesions
- polyps
- fistula (Crohn’s)
- abscess
What to palpate for in rectal exam
- masses/polyps
- prostate if applicable
- collect stool if hemoccult is needed
- internal hemorrhoids
- sphincter tone
technique of rectal exam
- use lube
- apply gentle pressure w/ pad of finger onto anal opening
- insert finger to examine entire canal
- should be painless if pt is relaxed
- ask pt to bare down or squeeze if need to check sphincter tone
what causes visceral abdominal pain
- noxious stimuli to visceral organs
- ischemia, stretch, distention, inflammtion
how is visceral abdominal paint described?
- many words used
- belly ache, stomach ache, cramping, gnawing, burning, etc.
- does NOT get worse by moving around
- brain has difficult localizing the pain
- happens early in dz (appendicitis)
what is the cause of parietal (somatic) pain
-carried by somatic nerves and enters the spinal cord unilaterally
afferent receptors on the parietal surface
description of parietal/somatic pain
- sharply localized
- peritoneal pain/peritonitis
- easier to localize b/c it is unilaterally innervated
What is the differential if pain is in the RUQ
- biliary dz
- hepatitis
- renal colic
- diverticulitis
Differential if pain is in the epigastric region
- MI
- PUD
- panreatitis
- biliary dz
differential if pain is in LUQ
- splenic injury
- renal colic
- diverticulitis
differential if pain is in RLQ
- appendicitis
- ovarian dz
- PID
- ruptured ectopic preg
differential if pain is in the LLQ
- ovarian dz
- PID
- ruptured ectopic preg
differential if pain is in the umbilicus
- IBD
- bowel obstruction/ischemia
- appendicitis
- AAA
- IBS
- DKA
- gastroenteritis
review charts
- slide 70: localization of pain
- 71: notable causes
- 72: “NOT” clues
- 73: pain referral patterns
duodenal ulcer pain
- poorly localized to midline early b/c visceral
- commonly awakens pt at night
- made better by eating** and worse by fasting
- “burning or gnawing”
- worsed by ETOH and ASA
- rarely refers to back
acute cholecystitis
- RUQ
- almost always post-prandial**
- often refers to scapula or right shoulder (phrenic)
acute pancreatitis
- poorly localized, usually above umbilicus/epigastrium
- made worse by eating
- commonly radiates straight through to mid back
- associated w/ ETOH and n/v
acute pancreatitis can be cause by gallstones obstructing what duct?
common bile duct
acute appendicitis
- can be in epigastrum or centrally if early
- localized to RLQ (unless retrocecal)
- ck for peritoneal signs like rebound tenderness
- younger pts
- ck for fever
- rectal exam reveals tenderness to peritoneal pouches
diverticulitis
usually felt as diffuse (visceral) lower abd pain
- if perforation, pain becomes acutely severe w/ N/V
- more localized pain if inflammation is transcolonic
- MC in LLQ but possible in RLQ
- can feel some relieve after defecation
- stool changes: narrow, mucoid, small vol.
renal colic
- often begins in CVA
- ipsilateral and SEVERE
- commonly associated w/ stone
- wavelike pain = colic
- commonly radiates to testicle/vaginal area as stone moves
- transureteral inflammation can feel like need to have BM
- not effected by meals, vomiting common
- pts are agitated, pacing or rocking
