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PCM II > Physical Examination of theAbdomen & Rectum - Schaffner > Flashcards

Physical Examination of theAbdomen & Rectum - Schaffner Flashcards

1
Q

Describe visceral pain

source, duration, character, localization

A

–source is usually hollow organ caused by distension or stretching. Comes and goes, crescendo/decrescendo pattern. Not well localized.

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2
Q

________________ : Caused by inflammation of the peritoneum. Steady aching pain that is usually well localized.

A

Parietal pain

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3
Q

___________________: From a distant sight. Right shoulder – gallbladder, left shoulder – spleen, back – pancreas or aorta.

A

–Referred Pain

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4
Q

What are the six components of the examination of the abdomen?

(pretty general here)

A
  2. –Inspection
  3. –Auscultation
  4. –Percussion
  5. –Palpation
  6. –Rectal examination
  7. –Special techniques
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5
Q

What are the 4 quadrants?

A

Right upper, right lower

left upper, left lower

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6
Q

What are the nine regions of the abdomen?

A

Right hypochondrium, epigastric, left hypochondrium

right lumbar, umbilical, left lumbar

right inguinal, suprapubic, left inguinal

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7
Q

Adequate exposure of the abdomen is essential, from where to where should we expose?

A

Xiphoid to the pubis

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8
Q

What is caput medusa?

What is it caused by?

A

vericose veins around umbilicus.

caused by portal HTN

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9
Q

On inspection, what should we be looking for (4)? What are some things to be on the lookout for in each?

A
  • Skin - scars, striae, superficial veins
  • Umbilicus – hernia, “Caput medusa”
  • Contour – flat, scaphoid, protuberant
  • Pulsations or peristalsis
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10
Q

When should you listen for bowel sounds?

Where should you listen?

A

Before palpation and percussion

All 4 quadrants

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11
Q

Why is the RLQ the best place to listen?

A

due to cecum

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12
Q

Describe normal bowel sounds

A

–high pitched “tinkle” about every 3-5 seconds.

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13
Q

No bowel sounds for 2 min = ?

A

Absent

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14
Q

____________:

–Increased, hyperactive bowel sounds,
–Low pitched rumbling
–Hyperperistalsis

A

•Borborygmi – (bor-bo-rig-me)

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15
Q

______________:

–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

A

•Abdominal bruits

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16
Q

Where should we listen for bruits?

A

Listen for bruits in the

midline between the

xiphoid and umbilicus.

Femoral arteries B/L.

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17
Q

Where are the common locations of abdominal bruits?

A
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18
Q

What does percussion help evaluate the presence of?

A

–Gaseous distention
–Fluid
–Solid masses
–Size and location of the liver and spleen

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19
Q

In what position is percussion best performed?

A

•Best done with the patient in the supine position

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20
Q

______________:

–Most common percussion note.
–Presence of gas in the stomach and small bowel.

A

Tympany

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21
Q

Where do you percuss the liver? How should it sound?

A

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

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22
Q

What is the normal liver size?

A

less than 10 cm

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23
Q

How do you detect a fluid wave?

A

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.

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24
Q

______________________:

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.

A

Shifting dullness

25
Q

In what segments in the palpatory exam divided into?

(6)

A

–Light palpation
–Deep palpation
–Liver palpation
–Spleen palpation
–Kidney palpation
–Rebound palpation

26
Q

Describe the technique for light palpation

A

Detect tenderness and areas of muscular spasm or rigidity.

Palpate all 4 quadrants.

Use finger tips with a gentle motion.

27
Q

What is deep palpation used for? How should it be performed?

A

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

One hand placed on top of the other.

28
Q

What does rebound tenderness test for?

A

–Evaluate for peritoneal tenderness and inflammation.

29
Q

How do you test for rebound tenderness?

A
  • In the suspected area of the abdomen, slowly, gently and deeply palpate.
  • Then, quickly remove the palpating hand.
30
Q

What is rovsing’s sign?

A

–– referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.

31
Q

What are the steps in palpation of the liver?

A
  1. Place left hand under the right 11th and 12th rib.
  2. Right hand in the RUQ
  3. Instruct the patient to breath deeply as the examiner gently presses inward and upward with the right hand.
  4. Can repeat the maneuver.
32
Q

What is the other technique for palpating the liver? How is it performed?

A

The hooking technique

  1. Stand near the patient’s head .
  2. With both hands “hook” your fingers around the lower right costal margin.
  3. Instruct the patient to breath deeply while gently pulling inward and upward with both hands to palpate the liver
33
Q

How do we palpate the spleen? What should we feel in normal conditions?

A
  1. Place left hand under the 11th and 12th ribs.
  2. Place right hand in the LUQ under the costal margin.
  3. Instruct the patient to breath deeply as the examiner gently presses inward and upward.
  4. Repeat the maneuver for deeper palpation.

The spleen is normally not palpated in normal conditions.

34
Q

How do we palpate the aorta? What is nl?

A

Press firmly and deep in the upper abdomen with two hands.

Normal aorta is 2.5 to 3.0 cm wide.

35
Q

What is an aortic aneurysm? How is it detected? Assessed?

A

pathologic dilatation of the aorta. Can be associated with a bruit.

Assessed with an ultra sound or CT scan.

36
Q

How should we palpate the kidney? What should we feel underl NL conditions?

A

“Sandwich method”

  1. Place a hand above and below the costal margins just lateral to the midline.
  2. Deep and gentle palpation attempt to palpate the lower pole of each kidney.

The kidneys are normally not palpated under normal conditions.

37
Q

How do we percuss the kidney?

A

a.k.a. CVA tenderness

  1. With a fist, gently hit the area over the costovertebral angle on each side of the spine.
  2. Pain over a kidney may indicate an inflammatory or infectious process of the kidney.
  3. The examiner may also place a flat hand over the CVA and strike the hand.
38
Q

What is CVA (costovertebral angle) Tenderness also known as?

A

Lloyd’s sign

39
Q

What should all abdominal exams conclude with?

A

Every abdominal examination should conclude with a DRE (digital rectal examination).

40
Q

What are the three positions we perform the rectal exam in?

A

Patient on their back – Modified Lithotomy

Lying on left side – a.k.a. – Sims’ Position

Standing, bent over the exam table

41
Q

What should we look for in rectal exam?

A

Inflammation, excoriations, ulcers, rashes, fissures, fistulas, nodules, hemorrhoids, warts, skin tags, tumors

42
Q

How does one perform the DRE?

A
  1. Inform the patient of what is going to happen.
  2. Lubricate your gloved index finger.
  3. Place your finger on the external sphincter and ask the patient to relax the sphincter muscles.
  4. Slowly insert the finger as the sphincter relaxes as far as possible.
  5. 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.

43
Q

What should we look for in a male’s anterior rectal wall?

A

The prostate

44
Q

Patients with a positive FOBT require a throrough evaluation for CRC (colorectal cancer). In what ways should this be done?

A

Colonoscopy is the study of choice.

Sigmoidoscopy and air contrast barium

enema are acceptable alternatives.

45
Q

What is going on here?

A

Prolapsed internal hemorrhoid

46
Q

What is this? What conditions cause this?

A

Anal warts

Condyloma acuminata - HPV

Condylomata lata – syphilis

47
Q

What is this?

A

CRC

48
Q

What is etiology of appendicitis?

A

–Obstruction of the appendicular lumen. Fecal or foreign matter, tumors or lymphomas.

49
Q

What are components of the history that are clues for appendicitis?

A

–Pain starts peri-umbilical then shifts to the right lower quadrant.
–Nausea and vomiting
–Anorexia
–Fever

50
Q

What is Rovsing’s sign?

A

–referred rebound tenderness. Press on the LLQ and release, positive if pain in the RLQ.

51
Q

What is the psoas sign?

A

– turn patient on left side and extend the right leg to check for psoas muscle inflammation.

52
Q

Obturator sign –

A

place the right leg in a “figure 4”. Press on the right knee while holding down the left iliac crest.

53
Q

What are the diagnostic workups for appendicitis? What do they detect?

A

–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.

54
Q

What is the etiology of acute cholecystitis?

A

–Obstruction of the cystic duct usually by a gallstone, sometimes a neoplasm.

55
Q

What are the historical elements that clue us into acute cholecystitis?

A

–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.

56
Q

What are elements of phys. exam that point to acute cholecystitis?

A

–RUQ pain and RUQ rebound tenderness.
–Decreased or absent bowel sounds.
–Abdominal distention.
- murphy’s sign

  • diagnostic triad
57
Q

Describe Murphy’s sign and the diagnostic triad.

A

–Murphy’s sign – RUQ pain and sudden arrest of inspiration during palpation of the liver and gallbladder.
–Diagnostic Triad – RUQ pain, fever and leukocytosis.

58
Q

What are the diagnostic workups for acute cholecystitis? What do they reveal?

A

–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

PCM II (6 decks)

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