Week 5: Abdominal Exam Flashcards
Visceral vs. Parietal
Visceral is agains the organ vs parietal, internal lining of the skin
GI/Abdomen Symptoms/Questions
Appetite? Heartburn? Reflux? Dysphagia? Food Intolerance? - lactose intolerance? N/V? How much? Describe Blood/Coffee Ground? Frequency? BM Pattern? Change? Diarrhea/Melena/Constipation, Weight loss/gain? liquid stool? does it break apart in the water? PAIN: OLDCART Acute or Chronic? Aggravating/Alleviating factors Travel History? Occupational Hazards? Dietary Habits (24 hr diet recall) Suspicious Foods or new foods? Ill Contacts? Drinking water? Adventurous food? Meds? PMH? FH? Social Hx: ETOH, Tobacco
Urinary Symptoms?
Suprapubic pain Dysuria: painful urination Urgency Frequency Hesitancy: difficulty to start or stop Incomplete emptying: unable to empty urination Nocturia: get up to pee at night Hematuria: blood in pee Polyuria: pee a lot Urinary incontinence Stress vs. urge Do you pee when you cough, sneeze or laugh Flank pain: is it traveling down? Ureteral colic: pain that comes and goes in the area of your uterers
Alarm Symptoms (red flag)
Dysphagia (difficulty swallowing/choking) Odynophagia (pain with swallowing) Recurrent vomiting Severe abdominal pain GI Bleeding Unintentional Wt Loss Unexplained anemia: source for loss of blood Risk Factors for GI CA Palpable Mass Jaundice
RUQ pain
Gallstones/cholecystitis, liver inflammation, gas, kidney stone, duodenum
Epigastric pain
:Reflux, gastritis, gallstones, indigestion/dyspepsia
LUQ:
Spleen, indigestion, pancreatitis, constipation
LLQ
: colitis, diverticulitis, constipation, left ovarian pain, renal stones
Suprapubic
: Bladder infection, pelvic pain/fibroids, STI etc
RLQ
: Appendicitis, Right ovarian pain, diverticulitis, gas, renal stones
Visceral Pain:
when hollow organs (stomach, colon) forcefully contract or become distended. Solid organs (liver, spleen) can also generate this type of pain when they swell against their capsules. Visceral pain is usually gnawing, cramping, or aching and is often difficult to localize (hepatitis)
Parietal Pain:
when there is inflammation from the hollow or solid organs that affect the parietal peritoneum. Parietal pain is more severe and is usually easily localized (appendicitis)
Referred Pain:
originates at different sites but shares innervation from the same spinal level (gallbladder pain in the shoulder)
SEQUENCE OF EXAM: for abdomen
Inspect, Auscultate, Percuss, Palpate
Inspection for abdomen
\: Shape/Contour Symmetry Umbilicus Skin/Scars Pulsations, movement Hair Pattern
Abnormal Conditions: Diastasis Recti
Splitting of abdominal muscle wall
Mid line bulge- most obvious when doing a “sit up”
Caused by abdominal obesity or pregnancy, more common with rapid weight gain
Abdominal Exam: Auscultation
Always auscultate before palpating or percussing the abdomen: otherwise induces hyperactive bowel sounds
Place the diaphragm of the stethoscope over the abdomen
Listen to bowel sounds in All 4 Quadrants: start with RLQ
Normal, hypoactive or Hyperactive? (normal 5-30/minute) Hypo: less than 5/min
Absent, count for a full minute or two
Gurgling, high pitched, clicking
Place diaphragm over the aorta: where is it located?
Bruit?
Peristalsis: the movement of smooth muscle tissue in GI tract which propels food and fluid along the tract. This is what causes bowel sounds, may feel it.
Normal, hyperactive vs hypoactive? Bowel sounds
hypoactive:Less than 5 per min in a quad
6 or more a min in a quad
Hyperactive: 30 or more a min in a quad
5 min a quadrant to diagnosis absence
Percussion
Assists to assess the amt and distribution of gas, fluid, presence of masses, and size of the liver and spleen
Percuss over all four quadrants
Percuss over the liver in both the midclavicular line
and at the midsternal line
Midclavicular percussion should demonstrate a vertical span of 6–12 cm; longer indicates an enlarged liver
Midsternal line percussion should be 4–8 cm; shorter than this can indicate a small, hard cirrhotic liver
Liver: right upper, dont percuss - dull sound (otherwise not organ sounds flat)
3 cm or more percussed below the margin
Spleen:
Epigastric
Umbilicus
Superpuic area
Abdominal Exam: Palpation
Start with NONTENDER area, work your way to tender area
Slide your hands to each area, don’t pick them up (you will miss something)
Dominant hand first, most sensitive, use that hand
Light Palpation: 1-2 cm
Light palpation in 4 quadrants
Be deliberate; identify any superficial organs or masses
Assess for voluntary guarding vs. involuntary guarding
Use relaxation techniques to assess voluntary guarding (distraction)
Watch the patient’s face for grimacing
Deep Palpation: 5-8cm
Delineate abdominal masses and organ size, may use bimanual technique
Hollow visceral: more tympanic
Liver or organ: more dull
Hyperresonance = more gas
Palpation: Light vs. Deep
Palpation: Liver
Using the left hand to support the back at the level of the 11th and 12th rib, the right hand presses on the abdomen inferior to the border of the liver and continues to palpate superiorly until the liver border is palpated
Ask the patient to take a deep breath
This can illicit pain in liver or gallbladder disease and also makes it easier to find the inferior border of the liver
Hooking Technique
Useful with obese patients
Costovertebral Angle Tenderness: Indirect Percussion
Fist Percussion
+ in Pyelonephritis
Documented as : No CVAT or +CVAT
Costovertebral angle - kidney infection and stone
A little below the rib and trap. Below the back and abdomen and percuss
If you are right handed be on right side of patient, if you are left handed be on left side of patient
Palpation of the Spleen
Left upper quadrant, just below midaxellary line, push in and up, palpate the edge
Should not feel spleen unless you are a child
Turn on their right side to get to their left upper quadrant easier
Palpation of the Bladder
Palpate over suprapubic area for tenderness
The Bladder is normally not palpable unless distended
Inspect & Palpate Aortic Pulsation
Normal Aortic Width:
2.5-3 cm; >3cm (pulsatile) = AAA
Peritonitis
Inflammation of the parietal peritoneum = Acute Abdomen
Guarding – voluntary contraction of the abd wall, often accompanied by grimacing, may be distractible
Rebound tenderness: pain increases when the examiner quickly withdrawals his/her hand from the abdomen
Ask pt if it hurts to go over speed bumps or step down stairs, hop on one foot
Heel drop test: drop heel on table- causes jarring of inflamed peritoneum or Heel Strike test: strike the bottom of the foot (while pt lying on the table)
Hurt in abdomen
Emphasis of strike the heel, jars their peritoneum
Guarding –
voluntary contraction of the abd wall, often accompanied by grimacing, may be distractible
Rebound tenderness:
pain increases when the examiner quickly withdrawals his/her hand from the abdomen
Ask pt if it hurts to go over speed bumps or step down stairs, hop on one foot
Heel drop test:
drop heel on table- causes jarring of inflamed peritoneum or Heel Strike test: strike the bottom of the foot (while pt lying on the table)
Hurt in abdomen
Emphasis of strike the heel, jars their peritoneum
Appendicitis
Inflammation of appendix of ascending colon
Check for involuntary guarding and rebound tenderness in the right lower quadrant
Palpate for McBurney’s point tenderness
Psoas & Obturator sign
McBurney’s point
1/3 distance from hip bone (anterior superior iliac spine) and 2/3 way from linea alba (umbilicus)
Tenderness over McBurney’s Point +Appendicitis
Obturator Sign
Flex right leg, rotate hip internally
+Pain= appendicitis
Psoas Sign
Extend the right leg back +pain= appendicitis
Lying back and Bend knee against resistance with provider
Rovsing’s Sign:
Push on left side, causes pain on right side
Test for appendicitis
Acute Cholecystitis
Inflammation of the gallbladder: caused by stones blocking flow of bile
Liver inflammation
Murphy’s Sign
Deep Palpation of the RUQ along costal margin
Ask pt to take a deep breath
Positive if sharp increase in pain with inspiratory arrest
Quick inspiratory = positive
Hernias of the abdominal wall
Defect or hole in the abdominal wall
Umbilical
Incisional
Painful: worse with activity, prolonged standing/walking, worse with sit-up or engaging abd muscles
Reducable?
Warm, red
Concerning signs: fever, body aches, chills, diarrhea, n/v, worsening pain - - - incarcerated
Ascites
Protuberant abdomen with bulging flanks
Fluid is dull on percussion
Dullness will shift to the dependent side and tympany to the top
Check for fluid shift
Fluid movement when pressing one side of abd ?
Causes?
Fluid build-up from CHF, cirrhosis, Kidney dz, CA
Diverticulitis
Infection of Diverticula (may have colonoscopy w/ diverticulosis seen)
Adults mid-40s or older
Mild to Severe pain
May have n/v
Possible diarrhea during attack
Decreased appetite
Fever/no fever
Typically progressively worsens over time
Any part of colon- usually descending (LLQ), but ascending RLQ
Crohns
\: any part of GI tract from mouth to anus Harvey Bradshaw Index Cramping abdominal pain Severe diarrhea w/blood, pus & mucus Fever, weight loss, fatigue, malaise ↓ hgb/hct, ↑ ESR during exacerbations Colo: cobblestoning
Ulcerative Colitis: colon
Abd pain in LLQ Diarrhea w/blood and pus Rectal pain w/bleeding Weight loss Fever, tachy, anemia, elevated ESR Stool cultures have WBCs Colo: ulcerations of mucosal lining
Irritable Bowel syndrome:
abdominal pain associated w/bowel pattern changes
Very common
Lifestyle related, but can be related to other conditions
ROME IV criteria
Diarrhea or Constipation Predominant or Mixed
Abdominal pain 1 day/week > 3mos w/altered bowel pattern- usually relieved w/defacation
Diarrhea, constipation or both
Gas, bloating, periods of exacerbation and remission
Exacerbated by stress, and/or eating
Dyspepsia:
upper abdominal discomfort
Usually brought on by eating
Abdominal discomfort, sensation of bloating
Can be periods of intense pain “gnawing” “twisting” “stabbing”
May radiate to back or up into chest
May be relieved by antacids, pepto, alkaline foods such as yogurt, milk
Exacerbated by known triggers suc
Gastroesophageal Reflux Disease “Heartburn”
Pain in chest or epigastric area
Burning, gnawing or pressure sensation
Difficulty swallowing or globus sensation
Worse after meals or w/certain foods (citrus, alcohol, spicy, fatty/fried foods, large meals)
Relieved w/antacids or other alkaline foods
Cough, hoarseness- even may mimic bronchitis
Regurgitation
Worse at night w/lying flat
Pediatric Exam
Exam Techniques Protuberent belly until 4-5 years old Spleen easily palpable 1-2cm below costal margin Soft with sharp edge
Clinical Considerations for abdominal
Celiac disease: Antibody tests, endoscopy of shortened or flattened intestinal villi (gold standard)
Inflammatory bowel disease: CBC with differential that has a high WBC count, endoscopy with biopsy that shows crypt abscesses (gold standard)
Hepatitis: Acute viral hepatitis panel, comprehensive metabolic panel
Pancreatitis: High amylase and lipase levels
Cholecystitis: Ultrasonography, hepatobiliary scan
Gastroesophageal reflux disease (GERD): Upper endoscopy and biopsy, esophageal pH monitoring
Appendicitis: Graded compression ultrasound
Hepatomegaly and splenomegaly: Ultrasound, CT, and MRI
