The Abdomen Flashcards
EVALUATION OF CHOLECYSTITIS
Assessing possible acute cholecystitis
**When assessment suggests acute cholecystitis (RUQ pain and tenderness), assess Murphy’s sign**
- A marked, sharp tenderness reported on inspiration indicates a positive Murphy sign–an abnormal exam finding which triples the likelihood of acute cholecystitis
TYPES OF
URINARY INCONTINENCE
Stress incontinence: increased abdominal pressure causes the bladder pressure to exceed urethral resistance
- there is poor urethral sphincter tone or poor support of the bladder neck
Urge incontinence: urgency is followed by involuntary leakage due to uncontrolled detrusor contractions that overcome urethral resistance
Overflow incontinence: neurologic disorders or anatomic obstruction from pelvic organs or the prostate limit bladder emptying until the bladder becomes overdistended
**If the patient reports incontinence, explore how and its related factors: is there a leakage of a small amount of urine during coughing, sneezing, laughing, or lifting? This may be associated with the increased intra-abdominal pressure seen in stress incontinence. Is there an involuntary and large amount of urine lost after a sudden urge associated with urge incontinence? Or is there a constant feeling of bladder fullness and intermittent leakage of small amounts of urine that is associated with an inability to empty the bladder all the way as seen in overflow incontinence?
ASSESSMENT OF
DYSURIA
Dysuria refers to pain on urination, or difficulty voiding, often caused by infection or irritation of the bladder or urethra. Women may describe an internal urethral discomfort commonly described as pressure, or an external burning caused by the flow of urine. Men often report a burning sensation proximal to the glans penis. Urgency is a commonly associated urinary symptom that is characterized by an immediate and intense need to void, and can lead to involunary voiding seen in urge incontinence, and frequency.
- When assessing dysuria, ask about any related fever or chills, blood in the urine, or pain in the abdomen, flank, or back. Men with partial obstruction to urinary outflow often report hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urinary stream, or dribbling as voiding is completed.*
- Painful urination is associated with cystitis (bladder infection), urethritis, and urinary tract infections, bladder stones, tumors, and in men, acute prostatitis. Women report internal burning in urethritis and external burning in vulvovaginitis.*
- Urgency suggests urinary tract infection or irritation from possible urinary calculi. Frequency is common in urinary tract infection and bladder neck obstruction. In men, painful urination without frequency or urgency suggests urethritis. Associated flank or back pain suggests pyelonephritis.*
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ask about any related fever or chills
*
ASSESSMENT OF
ASCITES
Ascites is the most common complication of cirrhosis (reflecting the increased hydrostatic pressure) and is characterized by a protuberant abdomen with bulging flanks. Ascites is also seen in heart failure, constrictive pericarditis, or inferior vena cava or hepatic vein obstruction. It my also signal decreased osmotic pressure seen in nephrotic syndrome, malnutrition, or ovarian cancer
Ascitic fluid sinks with gravity, whereas gas-filled loops of bowel rise–thus dullness appears in the dependent areas of the abdomen
- Percuss for dullness outward in several directions from the central area of tympany to map the border of ascites (dullness shifts to the more dependent side, whereas tympany shifts to the top)
Test for shifting dullness: percuss the border of tympany and dulnnes with the patient supine, and then ask the patient to roll onto one side. In a normal person, areas of tympany and dullness will remain relatively the same while areas of shifting dullness will help to confirm the presence of ascites on physical exam.
Test for a fluid wave: have the patient place the edges of both hands firmly down the midline of the abdomen while using one hand to tap one flank sharply while feeling on the opposite flank with the other hand for an impulse transmitted through fluid. An easily palpable impulse suggests ascites and is a positive fluid wave.
A positive fluid wave, shifting dullness, and peripheral edema makes the presence of ascites three to six times more likely.
EXAMINATION OF THE
ABDOMEN
IAPP
(INSPECTION, AUSCULTATION, PERCUSSION, PALPATION)
- Make the patient comfortable in a supine position with a pillow under the head and under the knees, if needed.
- Ask that the patient keep their arms at their sides or folded across their chest. Arms above the head will stretch and tighten the abdominal wall, hindering palpation. Arching the back pushes the abdomen forward and tightens the abdoinal muscles.
- DRAPE YOUR PATIENT. To expose the abdomen, place the drape at the level of the symphysis pubis, then raise the gown to below the nipple line just above the xiphoid process. The groin should be visible but the genitalia should remain covered. The abdominal muscles should be relaxed to enhance all aspects of the examination, especially palpation.
- BEFORE YOU BEGIN, ASK THE PATIENT TO POINT TO ANY AREAS OF PAIN SO THAT YOU CAN EXAMINE THESE AREAS LAST.
- Warm your hands and stethoscope by rubbing them together or running under warm water.
- Approach your patient calmly and avoid quick, unexpected movements. Avoid having long fingernails which can scratch or scrape the patient’s skin.
- STAND AT THE PATIENT’S RIGHT SIDE AND PROCEED IN A SYSTEMATIC FASHION WITH INSPECTION, AUSCULTATION, PERCUSSION, AND PALPATION. VISUALIZE EACH ORGAN IN THE REGION YOU ARE EXAMINING. WATCH THE PATIENT’S FACE FOR ANY SIGNS OF PAIN OR DISCOMFORT.
- If needed, distract your patient with conversation or questions. If the patient is frightened or ticklish, start palpation with the patient’s hand under yours and then gradually slip your hand underneath to palpate directly.
OBTURATOR SIGN
Assess the obturator sign by flexing the patient’s right thigh at the hip, with the knee bent, and rotate the leg internally at the hip.
This maneuver stretches the internal obturator muscle, which–if irritated by an inflamed appendix–may elicit right hypogastric pain in a positive obturator sign.
This sign has very low sensitivity.
FRICTION RUBS
Friction rubs are rare grating sounds with respiratory variation. They indicate inflammation of the peritoneal surface of an organ, as in liver cancer, chlamydial or gonococcal perihepatitis, recent liver biopsy, or splenic infarct.
When a systolic bruit accompanies a hepatic fruction rub, suspect carcinmona of the liver.
