Quiz 2- Abdomen Flashcards
musculature of abdomen
4 layers of large flat muscle form ventral wall
can lead to low back pain when weak
helps with stabilization and movement
viscera of abdomen
SOLID ORGANS- maintain shape- liver, pancreas, spleen, adrenal, kidneys, ovaries, uterus (technically hollow but doesn’t change shape unless pregnant); some are PALPABLE
HOLLOW ORGANS- shape depends on content: stomach, gallbladder, small intestine, colon, bladder, usually NON-PALPABLE (unless colon with stool burden, distended bladder, etc.)
quadrants of abdomen
RUQ- liver, gallbladder, head of pancreas, right kidney/adrenal gland, hepatic flexure of colon, part of ascending and transverse colon
LUQ- stomach, spleen, left lobe of liver (not always), body of pancreas, left kidney/adrenal, splenic flexure of colon, part of transverse/descending colon
RLQ- cecum, appendix, right ovary/fallopian tube, right ureter, right spermatic cord
LLQ- part of descending colon, sigmoid colon, left ovary/tube/ureter/spermatic cord
MIDLINE- aorta, uterus, bladder
female abdominal pain AEIOU (not all inclusive)
appendix
ectopic pregnancy
inflammatory (PID)
ovarian-cyst/cancer
urinary
epigastric pain
MI, peptic ulcer, acute cholecystitis, perforated esophagus
RUQ pain
acute cholecystitis, duodenal ulcer, congestive hepatomegaly, hepatitis, pyelonephritis, RLL pneumonia, early appendicitis
LUQ pain
ruptured spleen, gastric ulcer, aortic aneurism, perforated colon, LLL pneumonia, pyelonephritis
RLQ pain
appendicitis, salpingitis, R ovarian abscess, ruptured ectopic, renal/uretic stone, diverticulitis, crohn’s, incarcerated hernia
LLQ pain
intestinal obstruction, pancreatitis, sigmoid diverticulitis, early appendicitis, salpingitis, L ovarian abscess, ruptured ectopic, renal/uretic stone, diverticulitis, crohn’s incarcerated hernia
examples of referred pain
cholecystitis- RUQ pain, referred straight back to below R scapula
pancreatitis- RUQ pain, referred to L shoulder/scapula area
renal colic- LUQ pain, referred to flank and mid back
surgeries and their associations
esophageal resection- associated with fat malabsorption, abnormal swallowing, obstruction
stomach resection- associated with dumping syndrome, anemia, delayed emptying, malabsorption
small bowel resection- associated with steatorrhea, fat malabsorption, anemia, short gut syndrome
cullen’s sign
intra abdominal bleed, bluish periumbilical color
infant abdomen
rounded and protuberant
blood vessels and peristalsis more visible
DIASTASIS RECTI may be noted in normal infants, but check for any herniation
ABNORMAL- exaggerated “potbelly” appearance;may indicate malabsoprtion d/t celiac, CF, constipation, or aerophagia (ingestion of air; seen in infants with difficulty feeding)
abnormal striae
prolonged stretching (pregnancy, cushing’s, obesity, ascites, tumors)
purple/dark red- cushing’s
white/red- pregnancy
shiny white-obesity
abdominal pulsations
normal=aorta pulsation, possibly peristalsis with thin pts
abnormal- marked pulsation in aortic area (AAA, HTN)
visible peristalsis+distended abdomen=obstruction
abdominal hair distribution
normal=diamond in males, triangle in females
abnormal=changes seen with endocrine disorder or hormone imbalance
sister mary joseph nodule
firm mass at umbilicus
if patients had this nodule-poor outcome from gastric CA
bowel sounds
normal= high pitched gurgling cascading sound; occurs irregularly 5-30 seconds
BORBORYGMUS- stomach growling, normal hyperactive
hyperactive bowel sounds
loud, high pitched, rushing, tinkling
indicates increased peristalsis
seen with EARLY OBSTRUCTION- hyperactivity in LUQ then absent in LLQ (below obstruction)
hypoactive bowel sounds
less frequent (longer than 30 seconds), quiet
seen after abdominal surgery, or with inflammation of peritoneum/paralytic ileus
SILENT ABDOMEN- must listen for 5 MINUTES (very uncommon)
vascular sounds in abdomen
important in patients with HTN- idenfity AAA, bruit, friction rub
NORMAL- no vascular sounds present
ABNORMAL- listen with bell or bruit: aorta, renal/iliac/femoral arteries
SYSTOLIC BRUIT- pulsating blowing sound heard with occlusion of an artery
FRICTION RUB- rare, indicates inflammation of peritoneum
liver border: scratch test
place stethoscope over liver (lower costal margin, R MCL)
start in RLQ and scratch moving up toward liver
when scratching sound in stethoscope becomes magnified you have entered onto liver border (solid transmits sounds louder)
gross assessment of size, confirm with percussion/palpation
bladder distention: scratch test
place stethoscope just above symphysis pubis, midline
scratch downward from umbilicus 1 cm, when sound intensified locates upper edge of bladder- full bladder produces sound of solid organ
purpose of abdominal percussion
assess density of abdominal contents, locate organs, look for abnormal fluid/masses
method of abdominal percussion
percuss lightly in all 4 quadrants, determine tympany vs. dullness
normal=tympany (high pitched d/t air)
abnormal= dullness over distended bladder, fat, stool, fluid or mass; hyperresonance with gaseous distention
liver span
start at MCL over lungs to percuss resonance, move down until dullness-mark this spot
start in RLQ at MCL to percuss tympany, move up until dullness- mark this spot
measure the distance- normal=6-12 cm; larger in taller perons M=5-10 cm, F=7cm
> liver span=HEPATOMEGALY
<6cm=ATROPHY
spleen
percuss posterior MAL L side
have pt take a deep breath, percuss at last IC space in L MAL- should sound resonant
normal= should NOT be able to percuss spleen
abnormal= resonance of lungs changes to dullness (splenomegaly with mono, trauma, infection; poor technique; pt just ate)
costovertebral angle tenderness
indirect first percussion causes tissues to vibrate
place hand over 12th rib at CVA, thump hand with ulnar edge of fist, assess both kidneys
normal=no pain
abnormal= pain (inflammation of kidney or paranephric area, renal stone)
fluid wave
done to assess ascites seen with CHF, portal HTN, cirrhosis, hepatitis, pancreatitis, CA
place PTS HAND ulnar edge on midline abdomen, place YOUR HAND on R flank, tap L side
ABNORMAL= blow will generate fluid wave that is felt by hand on flank
if distended from gas or fat, you will feel no change
shifting dullness
done to assess ascites, supine fluid settles by gravity into flanks
percuss top of abdomen to hear tympany (air), then percuss downside and it changes to dullness (fluid)- mark this spot
turn pt to side-percuss upper side of abdomen downwards until your hear dullness
ABNORMAL- fluid shifted with movement-ascites (spot where dullness is heard moves)
it will not detect <500 mL of fluid
purpose of abdominal palpation
judge size/location/consistency of organs; screen for abnormal masses/tenderness
have pt lay on exam table with KNEES BENT (relaxes abdomen) and hands at the side
if area of tenderness-palpate last
LIGHT palpation- depress skin 1 cm with gentle rotary motion in all 4 quadrants assessing for muscle guarding, rigidty, large masses, and tenderness
DEEP palpation- press down 5-8 cm (2-3 inches), then small circle motion
deep palpation of abdomen
move clockwise from RLQ to LLQ, imagining normal structures underneath
if pt is obese- BIMANUAL TECHNIQUE
NORMAL- xyphoid process, liver edge, muscle borders, cecum/ascending colon, sigmoid, full bladder (hollow organs will only feel if something inside- stool/urine)
ABNORMAL: tenderness occurs with local inflammation, inflammation of peritoneum/organ
palpation of liver border
RUQ place hand under back at 11-12th rib
place right hand on RUQ, push deeply down and up under costal margin
have patient take a deep breath and push down and up under rib cage
normal= feel edge of liver bump your hand, firm/smooth, often non palpable too
abnormal= hard, nodular, tender, enlarged (extending down farther into RUQ)
palpation of spleen
normally NOT PALPABLE- must be enlarged x3 to be felt
place one hand over LUQ under costal margin with fingers pointing towards L axilla, other hand underneath at 11-12th rib, turn pt slightly towards you
push down deeply while pt takes a deep breath
ABNORMAL= if enlarged, will feel firmness sliding under fingers
child/infant spleen palpation
easily palpated/movable, soft with sharp edge
projects downward like a tongue under left costal margin, 1-2 cm
SPLENOMEGALY- would feel a larger amount; d/t infection, hemolytic anemia, infiltrative disorders, portal HTN, inflammatory/autoimmune diseases
palpation of kidneys
RIGHT KIDNEY- one hand pressing upwards on right flank, other pressing deeply in RUQ, have pt take a deep breath
may feel round, smooth mass slide between fingers; may feel nothing
LEFT KIDNEY- not palpable
palpation of aorta
palpate pulsation, SHOULD BE 2.5-4CM WIDE in adult
ABNORMAL= widened with aneurysm (>4cm)
palpation of bladder
palpate a full bladder only
starting at umbilicus moving downward towards pubis
if maneuver elicits an URGE TO VOID- fundus is distended at that level
abdominal wall tenderness
pain on palpation may arise from abdominal wall, parietal peritoneum, underlying viscera
AFTER FINDING AREA OF TENDERNESS, while abdomen is relaxed, keep hand over site, have patient sit up (arms crossed over chest) and apply pressure (CARNETT’S SIGN)
if tenderness on palpation is increased by tension of abdominal muscles (upon sitting up), pain originates from the abdominal wall= +ABDOMINAL WALL TENDERNESS
+AWT usually indicates ABSENCE OF INTRAABDOMINAL PATHOLOGY (not so in children/elderly/rigidity)
+abdominal wall tenderness can be indicative of what?
muscular strain, viral myositis, fibrositis, nerve entrapment, trauma
abdominal reflex
contraction of abdominal muscles and DEVIATION OF UMBILICUS TOWARDS STIMULUS
with pen/reflex hammer/nail- start at umbilicus and lightly scratch outwards (4 directions)
can be helpful in determining SPINAL LESION (if absent); obesity may interfere with response
rebound tenderness (mcburney’s point)
pain that increases upon release of deep palpation
associated with peritoneal inflammation
apply several seconds of pressure at point (RLQ) and quickly release
PAIN= +MCBURNEY’S associated with appendicitis
rovsing’s sign
associated with peritoneal inflammation
same maneuver but apply pressure to LLQ, pain felt upon release in RLQ
PAIN IN RLQ= +ROVSINGS associated with appendicitis
murphy’s sign
seen with cholecystitis (sonographic murphy’s)
palpate during inspiration at liver margin; assess for RESPIRATORY ARREST (pt stops breathing/grasps when gallbladder presses against fingers)
PAIN WITH INSPIRATION = +MURPHY’S
iliopsoas muscle test
associated with peritoneal irriation/appendicitis
irritation of the underlying lateral iliopsoas muscles (located close to appendix)
place hand on right thigh and push down as patient raises leg- creates resistance/flexion
PAIN IN RLQ= +ILIOPSOAS associated with inflamed appendix
obturator test
associated with ruptured appendix or pelvic abscess
irritation of the obturator internus muscle (located close to appendix)
flex right leg at hip and knee, rotate leg internally and externally
PAIN IN HYPOGRASTRIC AREA (RLQ or R lower back)= + OBTURATOR SIGN
signs of peritoneal irritation
tenderness to palpation, rebound tenderness, cough tenderness, guarding, involuntary guarding, rigidity
risk factors for colorectal CA
older age, men>women, AA, jews of eastern european descendent (ashkenazi) highest risk
LIFESTYLE- obesity, inactivity, smoking, ETOH, diet high in red/processed meats, lower fiber diet, frying/grilling/cooking at high heat
PERSONAL HX- ovarian/endometrial/breast cancer, IBD (UC, crohn’s), IBS, T2DM
STRONG FAMILY HISTORY- colon CA or polyps in one first-degree relative dx at 55 or younger, or two first- degree relatives dx at any age, genetic disease (FAP, HNPCC)
colon CA
3rd leading cause of cancer related death in the US
incidence increasing but mortality decreasing
SURVIVAL RATE R/T STAGE OF DISEASE AT DIAGNOSIS- overall 5 year survival- 65%, with bowel wall only- 91% with regional involvement- 72% with metastasis- 15%
WARNING SIGNS- anemia, rectal bleeding (black/dark stools), change in bowel habits, narrowing of stools, persistent abdominal discomfort (cramping, gas, pain, bloating), unexplained weight loss, weakness/fatigue, N/V
american cancer society recommendations for colon CA
AVERAGE RISK:
screening every year from age 45-75 yo
can be STOOL-BASED TEST (cologuard) or through COLONOSCOPY
CDC recommendation for colon CA
AVERAGE RISK: screening from age 45-75 yo
TESTED EARLIER IF:
close relative has had colorectal polyps or colorectal cancer
IBD such as crohn’s disease or ulcerative colitis
genetic syndromes such as familial adenomatous polypsosis (FAP) or hereditary non-polyposis colorectal cancer (lynch synrome, HNPCC)
VAST MAJORITY OF NEW CASES OF COLORECTAL CANCER (ABOUT 90%) OCCUR IN PEOPLE WHO ARE 50 AND OLDER
positive family hx for colon cancer, screening options
CHOOSE ONE OF THE FOLLOWING:
colonoscopy every 5 years
double contrast barium enema every 3-5 years
at age 40 or 10 years before cancer was diagnosed in the youngest affects family member, whichever is earlier
familial adenomatous polyposis
flexible sigmoidoscopy or colonoscopy YEARLY
STARTING AT AGE 10-12
genetic counseling- if + consider removal of colon
lynch syndrome (3-5% of cancers)
hereditary non-polyposis colon cancer (HNPCC)
AGE 20-25 or 10 years before youngest case in family
colonoscopy every 1-2 YEARS
consider genetic counseling
IBD (ulcerative colitis and crohn’s) screening for colon cancer
colonoscopy with biopsies for dysplasia every 1-2 YEARS
7-8 YEARS after DIAGNOSIS OF PANCOLITIS
12-15 YEARS after DIAGNOSIS OF LEFT SIDED COLITIS
as you approach lou with a c/o abdominal pain, you recall that the proper order of assessing the abdomen is:
inspection, auscultation, percussion, palpation
as you are assessing the abdomen, you notice purple/blue striae. you suspect…
cushing’s
during a routine history and physical, you note thin, spoon shaped nails. you would want to order a…
CBC
indication of anemia
mary’s physical examination is unremarkable except for RUQ tenderness and positive murphy’s sign. which of the following would you most likely suspect?
cholecystitis
upon palpation of the abdomen, you elicit pain on RLQ by palpation of LLQ. this would be what?
roving’s
the american cancer society recommends a sigmoidoscopy for colon cancer screening in persons at average risk how often?
age 45 for 2 years then every 3-5 years dependent on risk
person with a +family history is not at average risk
in which patient would a slight pulsation in the epigastric area be expected?
a very thin patient
while examining the abdomen, you stroke each quadrant of the abdomen lightly with a cotton tipped swab or the end of a reflex hammer, moving outward from the umbilicus. what does this cause?
contraction of the abdominal muscles and pulling of the umbilicus toward the stroked side
reflex toward the stimulus
you note that the span of the patient’s liver is 18 cm. on palpation, the liver is enlarged, soft, and tender, suggesting…
hepatitis
you observe a proliferation of superficial veins over the abdomen and upper chest of a patient, suggesting:
portal hypertension
