The Abdominal Exam Flashcards
1
Q
What are the types of abdominal pain?
A
- visceral pain
- parietal pain
- referred pain
2
Q
What causes visceral pain?
A
- visceral pain fibers
- secondary to distention, stretching or contracting hollow organs, stretching the capsule of solid organs, or organ ischemia
3
Q
Where is visceral pain usually felt?
A
- midline at the level of the structure involved
- not localized
4
Q
What type of pain is periumbilical pain with early appendicitis?
A
visceral pain
5
Q
What is parietal (somatic) pain caused by?
A
- stimulation of the somatic pain fibers
- secondary to inflammation in the parietal peritoneum
6
Q
What does parietal (somatic) pain feel like?
A
- usually constant and more severe than visceral pain
- localized
- aggravated by movement or coughing
- alleviated by remaining still
7
Q
What type of pain is RLQ parietal tenderness later finding in acute appendicitis?
A
parietal (somatic) pain
8
Q
What type of pain is LLQ parietal tenderness, later finding in acute diverticulitis?
A
parietal (somatic) pain
9
Q
What is referred pain?
A
originates within the abdomen but is felt at distant sites which are innervated at approximately the same spinal levels as the disordered structure
10
Q
What are examples of referred pain?
A
- duodenal and pancreatic pain referred to back
- biliary tree referred to right shoudler
11
Q
List what to ask for a GI focused ROS?
A
nausea vomiting diarrhea black stools blood in stool blood in vomit
12
Q
List what to ask for a GU focused ROS?
A
dysuria
polyuria
hematuria
flank or CVA pain
13
Q
List what to ask for a GYN focused ROS?
A
vaginal bleeding
vaginal discharge
LMP
possibility of pregnancy
14
Q
What is relevant PMHx in general?
A
HTN DM CAD CHF COPD
15
Q
What is relevant PMHx for an abdominal complaint?
A
Hepatitis and/or liver problems GERD/PUD GB IBD (Crohn's, UC) Cancer chronic abd pain constipation
16
Q
What are some common PSHx for the abdominal and gynocologic regions?
A
abdominal
- cholecystectomy
- appendectomy
GYN
- hysterectomy
- BTL
- C-section
- ovarian cyst
17
Q
What are medications to be aware of for GI complaints?
A
- GI prescriptions (H2 blockers, PPI, dicyclomine)
- OTC meds (tylenol, aspirin/ibuprofen, antacids, laxatives)
- herbs
- blood thinners
- NSAIDs
- Narcotics
- Steroids
18
Q
What to ask about in a social history for abdominal complaint
A
- smoking
- alcohol
- drugs
- stress
- travel
- well water
- ingestion of undercooked meat
19
Q
What is the order of a GI exam?
A
- inspect
- auscultation
- percussion
- palpation
20
Q
What are the landmarks for the abdomen?
A
- xiphoid process of sternum
- costal margins
- umbilicus
- anterior superior iliac spine
21
Q
What is in the RUQ?
A
- liver
- gallbladder
- stomach
- SB
- LB
22
Q
What is in the RLQ?
A
- appendix
- ovary
- SB
- LB
23
Q
What is in the LLQ?
A
- sigmoid colon
- ovary
- SB
- LB
24
Q
What is in the LUQ?
A
- spleen
- stomach
- SB
- LB
25
What is in the epigastric area?
- pancreas
- liver
- gallbladder
- stomach
- SB
- LB
26
What do you look for on inspection of the abdomen?
- skin color
- surgical scars
- striae
- dilated veins
- rash
- ecchymoses
- contour of abdomen: flat, round, scaphoid, bulges, obese, protuberant
27
What do you use to listen for bruits?
bell
28
What can absent bowel sounds indicate?
None for 2 minutes
- long lasting intestinal obstruction
- intestinal perforation
- mesenteric ischemia
29
What can decreased bowel sounds indicate?
None for 1 minute
- post surgical ileus
- peritonitis
30
What can increased bowel sounds indicate?
- diarrhea
| - early bowel obstruction
31
What are high pitched bowel sounds? What does this indicate?
- sounds like tinkling (raindrops on metal)
| - suggests early intestinal obstruction
32
What are bruits? What does this indicate?
- vascular sounds resembling a heart murmur over the aorta or other abdominal arteries (renal artery, iliac artery, femoral artery)
- vascular obstruction
33
What are friction rubs? What does this indicate?
- grating sounds with respiratory variation
- inflammation of the peritoneal surface of an organ
- listen over liver and spleen
34
What are venous hums? What does this indicate?
- soft humming noise
- increased collateral circulation between portal and systemic venous systems
- listen over epigastric and umbilical regions
35
What does percussion allow?
allows assessment for fluid and solid-filled masses, the amount of gas in the abdomen, and sizing of the liver and spleen
36
Where do you percuss?
all 4 quadrants
37
What is tympany during percussion?
high pitched air filled
38
What is dullness during percussion?
non-resonating solid organs or masses
39
What is resonance during percussion?
hollow abdominal organs (lungs)
40
What is hyper-resonance during percussion?
air-filled hollow organ (pneumothorax)
41
What is normal to hear during percussion of the abdomen?
- tympany
| - because of gas in the GI tract, scattered areas of dullness is normal from fluid and feces
42
What is abnormal during percussion of the abdomen?
large dull areas from a mass or enlarged organ
43
What may a protuberant abdomen tympanic throughout indicate?
intestinal obstruction
44
What is the goal of palpation of the abdomen?
to discern abdominal tenderness, resistance, superficial organs and masses
45
How do you palpate the abdomen?
- use the palmar aspect of your hand with fingers together
- gently palpate all 4 quadrants
- medium depth
- then deep depth
* *always start away from/farthest from tender area
46
Describe assessment of the liver
- mostly covered by rib cage, assessment is difficult
| - assess shape and size by percussion and palpation
47
Describe assessment of the spleen
- normally not palpable, unless enlarged
- when spleen enlarges, it expands anteriorly, downward, and medially
- percussion and palpation help assess splenomegaly
48
How do you percuss the liver?
- right MCL, start in RLQ (tympany) and percuss cephalad to an area of dullness = lower border of the liver
- right MCL, start in RUQ (lung resonance) and percuss caudad toward liver dullness = superior border of liver
49
What is the normal liver vertical span?
When is it increased?
When is it shrunken?
6-12 cm
enlarged liver = cirrhosis, lymphoma, hepatitis, right sided heart failure, amyloidosis, hemachromatosis
**falsely enlarged in right pleural effusion
shrunken liver = cirrhosis
50
How do you palpate the liver?
– Left hand behind patient supporting the right 11th and 12th ribs
– Push left hand upward, towards patient’s anterior
– Right hand on patient’s right abdomen
– Press in and cephalad gently with right hand
– Ask patient to take deep breath
– Feel the liver edge as it comes down to meet your right hand
51
What does a normal liver feel like?
slightly tender, soft, smooth surface
52
What does an irregular edge/nodules on the liver indicate?
hepatocellular carcinoma
53
What does firmness/hardness of the liver indicate?
- cirrhosis
- hemachromatosis
- amyloidosis
- lymphoma
54
How do you percuss the spleen?
– Starting from border of cardiac border of left anterior axillary line, percuss
laterally
– If tympany is prominent laterally in midaxillary line, splenomegaly not likely
– Dullness at midaxillary line= splenomegaly
55
How do you palpate the spleen?
– With left hand, reach over the patient
and grasp posterior aspect of LUQ
– With right hand below left costal margin,
press posteriorly towards spleen
– Ask patient to take deep breath in
– Try to feel edge as it comes down to meet
your left hand
56
What percent of healthy adults have a palpable spleen?
| What group of people have a palpable spleen?
5%
| -COPD - low, flat diaphragm
57
What causes splenomegaly?
- portal htn
- blood malignancies
- HIV
- splenic infarct
- mononucleosis
58
What is the shifting dullness test?
```
for ascites
• Percuss the borders of tympany and
dullness with patient supine
• Then have patient lay on side and
percuss borders again
• Normal= borders stay the same
• Ascites/ positive test= dullness
shifts to dependent side and
tympany to top side
```
59
What is the test for a fluid wave?
```
for ascites
• Ask the patient to rest his or her
hands over chest
• Have an assistant place the ulnar
aspects of hands midline, then tap
one flank sharply with finger tips
• Normal= no impulse felt on the other
flank
• Ascites/positive test= impulse
transmitted to the other flank
```
60
What is McBurney's point tenderness?
draw an imaginary line from ASIS to umbilicus and palpate 2 inches medial to ASIS on that line
+=tenderness
61
What is Rovsing's sign?
palpate deeply in LLQ
| +=pain felt in RLQ
62
What is psoas sign?
place hand above patient's right knee and ask pt to raise thigh against resistance, then turn pt onto their left side and extend right leg at the hip
+=increased abdominal pain
63
What is obturator sign?
flex pt right hip with knee bent, then internally rotate the hip
+=right hypogastric pain
64
What is Murphy's sign?
with right hand palpate deeply under the patient's right costal margin, ask the pt to take a deep breath in and palpate deeper
+=sharp increase in tenderness with stop in inspiratory effort
65
What is lloyd's sign (punch)?
pain to deep percussion in the area of CVA
+=pain in CVA with deep percussion
implies kidney pathology: pyelonephritis or ureterolithiasis
66
What is guarding?
- voluntary contraction of the abdominal wall
- when palpating the abdomen, the abdominal musculature "guards" the underlying inflamed organs from the pressure of palpation, and become tense and contracted
67
What is rigidity?
- involuntary reflex contraction of the abdominal wall
- will seen stiff, board-like muscle contraction on inspection, also may not see the abdomen move with respirations- can also be felt with palpation
68
What is rebound tenderness?
-occurs when you push down deep into the abdomen and then let go quickly
+=more tenderness when letting go than pushing in
