Physical exam- rectum and abdomen

Question 1

Types of Abdominal Pain

Answer 1

Visceral Pain (colic pain): source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. Not well localized-why?.
Parietal Pain: Caused by inflammation of the peritoneum. Steady aching pain that is usually well localized.
Referred Pain: From a distant sight. Right shoulder – gallbladder, left shoulder – spleen, back – pancreas or aorta.

Question 2

Some Referral Patterns:

Answer 2

Gallbladder /liver – right shoulder
Spleen – left shoulder (Kehr’s sign)
Pancreas / Aorta – back
Renal System Pain – refers to the flank and groin. A.K.A.- “Renal Colic”

Question 3

adequate exposure of the abdomen

Answer 3

xiphoid to pubis

Question 4

inspection of the abdomen

Answer 4

Skin - scars, striae, superficial veins
Umbilicus – hernia, “Caput medusa”
Contour – flat, scaphoid, protuberant
Pulsations or peristalsis

Question 5

auscultation of abdomen

Answer 5

Listen for bowel sounds before palpation and percussion.
All 4 quadrants
RLQ – best place to listen d/t cecum
Normal bowel sounds – high pitched “tinkle” about every 3-5 seconds.
No bowel sounds after 2 minutes – report as “absent”.

Question 6

Borborygmi

Answer 6

(bor-bo-rig-me)
Increased, hyperactive bowel sounds,
Low pitched rumbling
Hyperperistalsis

Question 7

Abdominal bruits

Answer 7

A soft sound made by disrupted arterial flow through a narrowed artery.
Aortic – between the umbilicus and xiphoid
Renal artery – just lateral to the aorta
Femoral artery – along the inguinal ligament

Question 8

Percussion of abdomen

Answer 8

helps evaluate the presence of:
Gaseous distention
Fluid
Solid masses
Size and location of the liver and spleen
Percuss all 4 quadrants
Best done with the patient in the supine position

Question 9

Tympany

Answer 9

Most common percussion note.

Presence of gas in the stomach and small bowel.

Question 10

Percussion of the liver

Answer 10

Percuss along the right mid-clavicular line from top to bottom.
Resonant (lungs) to dull (liver) to tympanic (intestine)

Question 11

Fluid wave

Answer 11

Place patient’s or
assistant’s hand in midline.  Tap on
one flank and palpate with the other
hand.  An easily palpable impulse 
suggests ascites.

Question 12

Shifting dullness

Answer 12

percuss the patient on their
back and then their side. Note where the sound
changes from tympany to dull and the shift of the
sound when the patient is turned to the side.

Question 13

Technique for light palpation

Answer 13

Detect tenderness and areas of muscular spasm or rigidity.

Palpate all 4 quadrants.

Use finger tips with a gentle motion.

Question 14

technique for deep palpation

Answer 14

Used to evaluate organ size, abnormal masses, aorta, deep pain etc.

One hand placed on top of the other.

Question 15

rebound tenderness

Answer 15

Evaluate for peritoneal tenderness and inflammation.
Technique
In the suspected area of the abdomen, slowly, gently and deeply palpate.
Then, quickly remove the palpating hand.
If the patient experiences pain = “+ rebound tenderness”.
Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.

Question 16

palpation of the liver

Answer 16

Place left hand under the right 11th and 12th rib.

Right hand in the RUQ

Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.

Can repeat the maneuver.

Question 17

Hooking technique (liver)

Answer 17

Stand near the patient’s head .

With both hands “hook” your fingers around the lower right costal margin.

Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver.

Question 18

palpation of the spleen

Answer 18

Place left hand under the 11th and 12th ribs.

Place right hand in the LUQ under the costal margin.

Instruct the patient to breath deeply as the examiner gently presses inward and upward.

Repeat the maneuver for deeper palpation.

The spleen is normally not palpated in normal conditions.

Question 19

palpation of the aorta

Answer 19

Press firmly and deep in the upper abdomen with two hands.
Normal aorta is 2.5 to 3.0 cm wide.
Aortic aneurysm – pathologic dilatation of the aorta. Can be associated with a bruit.
Assessed with an ultra sound or CT scan.

Question 20

palpation of the kidneys

Answer 20

“Sandwich method”

Place a hand above and below the costal margins just lateral to the midline.

Deep and gentle palpation attempt to palpate the lower pole of each kidney.

The kidneys are normally not palpated under normal conditions.

Question 21

percussion of the kidneys

Answer 21

a.k.a. CVA tenderness

With a fist, gently hit the area over the costovertebral angle on each side of the spine.

Pain over a kidney may indicate an inflammatory or infectious process of the kidney.

The examiner may also place a flat hand over the CVA and strike the hand.

Question 22

the rectal examination: inspection

Answer 22

Spread the buttocks
Sacrococcygeal and perianal areas
Anus and rectum
Note: Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors

Question 23

the rectal exam: palpation

Answer 23

Palpation or Digital Rectal Examination (DRE)
Inform the patient of what is going to happen.
Lubricate your gloved index finger.
Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.
Slowly insert the finger as the sphincter relaxes as far as possible.

Rotate your hand to palpate as much of the
rectal surface as possible.
Gently withdraw the glove and note the color
of the fecal material and test for occult blood.
Note: nodules, irregularities, masses, tenderness,
induration.

Question 24

fecal occult blood testing- what to do when positive

Answer 24

Patients with a positive FOBT require
a through evaluation for CRC.
Colonoscopy is the study of choice.
Sigmoidoscopy and air contrast barium
enema are acceptable alternatives.

Question 25

appendicitis: etiology and history

Answer 25

Etiology
Obstruction of the appendicular lumen. Fecal or foreign matter, tumors or lymphomas.
History
Pain starts peri-umbilical then shifts to the right lower quadrant.
Nausea and vomiting
Anorexia
Fever

Question 26

appendicitis: physical exam

Answer 26

RLQ pain and RLQ rebound tenderness
Decreased or absent bowel sounds
Rovsing’s sign – referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.
Psoas sign – turn patient on left side and extend the right leg to check for psoas muscle inflammation.
Obturator sign – place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.
Always do a rectal examination and a pelvic exam on a female

Question 27

appendicitis: diagnostic workup

Answer 27

CBC – moderate leukocytosis with left shift.
Urine – may contain a few WBC or RBC. Helps R/O any GU condition.
Plain x-ray – rarely helpful.
Ultrasound – enlarged and thick walled appendix.
CT scan – most sensitive. 90 – 98% sensitive.
Female patient – Must do a pregnancy test to R/O ectopic pregnancy.
BMP – evaluate electrolytes and renal functions, especially if patient has been vomiting.

Question 28

acute cholecystitis: etiology and history

Answer 28

Etiology
Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.
History
RUQ postprandial pain. Biliary colic pain.
Pain radiating to the right shoulder.
Nausea and vomiting.
Anexoria
Obesity
Fever
The 5 “f’s” – female, fat, fertile, fair, flatulent.

Question 29

acute cholecystitis: physical exam

Answer 29

Physical Examination
RUQ pain and RUQ rebound tenderness.
Decreased or absent bowel sounds.
Abdominal distention.
Murphy’s sign – RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
Diagnostic Triad – RUQ pain, fever and leukocytosis.

Question 30

acute cholecystitis: diagnostic workup

Answer 30

CBC – leukocytosis with left shift
Serum bilirubin – can be mildly elevated.
AST/ALT – can be elevated.
Ultrasound – will detect stones, thicken GB wall, dilated bile duct and fluid.
HIDA scan – radionuclide biliary scan.
CT scan