Reading...
Play button
Play button
Use LEFT and RIGHT arrow keys to navigate between flashcards;
Use UP and DOWN arrow keys to flip the card;
H to show hint;
A reads text to speech;
65 Cards in this Set
- Front
- Back
|
Landmarks of abdominal wall
|
Midclavicular, umbilical, illiac crest, pubic symphysis, xyphoid process, etc.
|
|
|
Location/Description
|
1. Quadrants - RUQ, LUQ, RLQ, LLQ
2. Regions - R hypochondriac, gastric, umbilical, R lumbar and L lumbar, R & L iliac, hypogastric/pubic. |
|
|
Common complaints or symptoms: GI disorders
|
Heartburn, gas, bloating, N/V/D, abdominal distention, early satiety, abdominal pain, bleeding, hematemesis, dysphagia/odynophagia, changes in bowel habits (caliber of stool, bleeding, amount per day, color), jaundice, masses, hernia
|
|
|
Common complaints or symptoms: Urinary and renal disorders
|
Suprapubic pain, kidney, flank, or groin pain, dysuria, urgency, or frequency, hesitancy, decreased stream, polyuria, nocturne, oliguria, urinary incontinence, hematuria.
|
|
|
Visceral abdominal pain
|
Source - internal organs
Receptors activated - specific receptors (nociceptors) for stretch, inflammation, and oxygen starvation (ischemia). -Characteristics – Often poorly localized, Gnawing, Burning, Vague deep ache, Cramping or colicky in nature, Typically palpable near midline at levels that vary with structure involved -Frequently produces referred pain to the back |
|
|
Parietal abdominal pain
|
-Source – parietal peritoneum
-Receptors activated - Somatic innervation (spinal nerves). -Caused by inflammation -Characteristics - precisely localized, steady aching pain, sharp, aggravated by movement, couching -Patients typically prefer to lie still -Visceral pain may become parietal pain as in appendicitis |
|
|
Referred pain
|
Is felt in more distant sites, which are innervated at approximately the same spinal levels as the disordered structure.
-ie: pain form a duodenal or pancreatic origin may be referred to the back. -Pain from the biliary tree to the right shoulder or right posterior chest -Pleuritic pain or MI pain referred to the epigastric |
|
|
Attributes of a pain/discomfort
|
Ask patients to describe the pain in their own words
Ask patients to point with one finger to the area of pain Ask about the severity of pain (scale of 1 to 10) Ask what brings on the pain (timing) Ask patients how often they have the pain (frequency) Ask patients how long the pain lasts (duration) Ask if the pain goes anywhere else (radiation) Ask if anything aggravates the pain or relieves the pain Ask about any symptoms associated with the pain |
|
|
Changes in upper GI
|
Ask about nausea, vomiting, indigestion, and regurgitation
Ask about emesis (color, blood, coffee ground, or hematemesis) Ask about diet, anorexia, early satiety, and appetite Ask about swallowing, dysphagia, or odynophagia ( which type of foods provoke symptoms: solids, or solid and liquids) Ask about jaundice (what causes?) |
|
|
Change in bowel habits
|
Frequency of the bowel movements
Consistency of the bowel movements (diarrhea vs. constipation) Any pain or pain relief with bowel movements Any blood (hematochezia) or black, tarry stool (melena) with the bowel movement Ask about the color of the stools (white or gray stools can indicate liver or gallbladder disease) Look for any associated signs such as jaundice or icteric sclera |
|
|
Historical information
|
Ask about prior medical problems related to the abdomen
Hepatitis, cirrhosis, gallbladder problems, or pancreatitis, for example Ask about prior surgeries of the abdomen Ask about any foreign travel and occupational hazards Ask about use of tobacco, alcohol, illegal drugs, as well as medication history Ask about hereditary disorders affecting the abdomen in the history of the patient’s family |
|
|
Urinary tract
|
Ask about frequency (how often one urinates) and urgency (feeling like one needs to urinate but very little urine is passed)
Ask about any pain with urination (burning at the urethra or aching in the suprapubic area of the bladder) Ask about the color and smell of the urine; red urine usually means hematuria (blood in the urine) Ask about difficulty starting to urinate (especially in men) or the leakage of urine (incontinence, especially in women) Ask about back pain at the costovertebral angle (kidney) and in the lower back in men (referred pain from the prostate) In men, ask about symptoms in the penis and scrotum |
|
|
Alcohol screening
|
CAGE, AUDIT, Heavy drinking days screening (women 4 or more, men 5 or more) (pg 144 ch 5, ch 3 pg 84)
Cutoffs for risky or hazardous drinking are: Women >= 3 per occasion and >=7/week Men >= 4 per occasion and >= 14/week |
|
|
Hepatitis risk factors
|
IV drug use, risky sexual behavior, blood transfusions before a certain date
|
|
|
Colorectal cancer screening
|
Family history, melana, blood in stool.
|
|
|
Abdominal examination
|
1. Inspection
2. Auscultation 3. Percussion 4. Palpation Why do we do the exam in this order?? Palpation and percussion may change bowel sounds by manipulating the abdomen |
|
|
Inspect the abdomen
|
Skin: scars, striae (stretch marks), vein pattern (caput medusae), hair distribution, rashes, or lesions
Umbilicus: observe contour and location and any signs of an umbilical hernia Contour of the abdomen: flat, rounded, protuberant, or scaphoid Is the abdomen symmetric? Evidence of peristalsis (rhythmic movement of the intestine that can be seen in thin people) and pulsations (within blood vessels such as the aorta) |
|
|
Caput medusa
|
Vein distention of cirrhosis or inferior vena cava obstruction
|
|
|
Auscultation: 1. All four quadrants
|
Place the diaphragm over the abdomen to hear bowel sounds. Occasionally you may hear borborygmi which are long gurgles of hyperperistalsis as with “stomach growling”.
The normal frequency of bowel sound is 5-34 sounds per minute. Decreased is hypoactive. Increased is hyperactive |
|
|
Auscultation: 2. Bruits
|
A murmur like sound of vascular rather than cardiac origin
Aortic artery Renal arteries Femoral arteries |
|
|
Auscultation: 3. Friction Rub
|
Grating, scrapping, or rubbing sound produced be visceral pleura rubbing against parietal pleural
Spleen (listen over spleen) Liver (listen over liver) Friction rubs in liver tumor, gonococcal infection around the liver, splenic infarct |
|
|
Percussion
|
All 4 quadrants to assess the distribution of tympany and dullness
Gastric bubble Liver Spleen Note any large areas of dullness Mass, enlarged organ, stool, or fluid |
|
|
Palpation: 1. Light palpation
|
Start palpating the abdomen using gentle probing with the hands; this reassures and relaxes the patient
Identify any superficial organs, masses, areas of tenderness, or increased resistance to your hand If Resistance/Guarding is present: Distinguish voluntary guarding from involuntary muscular spasm (involuntary guarding) (having pt breath out may help relax muscle) Involuntary guarding indicates peritoneal inflammation |
|
|
Palpation: 2. Deep palpation
|
Used to delineate abdominal masses and organs
Masses types: 1. Physiologic- pregnant uterus 2. Inflammatory- diverticulitis of the colon 3. Vascular- abdominal aortic aneurysm 4. Neoplastic- carcinoma of the colon 5. Obstructive- a distended bladder or dilated loop of bowel |
|
|
Peritoneal inflammation/signs
|
Abdominal pain and tenderness, especially when associated with muscular spasm (Guarding), suggests inflammation of the parietal peritoneum.
1. Does cough worsen pain (Dunphy’s Sign) 2. Does light palpate or lightly percuss to localize the pain or worsen 3. Rebound tenderness- press down with your fingers firmly and slowly, then withdraw them quickly. “Which hurts more, when I press or let go?”. Pain induced or increased by quick withdraw constitutes rebound tenderness caused by rapid movement of an inflamed peritoneum Positive peritoneal signs signify an Acute Abdomen |
|
|
Liver exam: Percussion
|
Measure the vertical span of the liver in the right midclavicular line
Define the upper and lower border Percussion will change from tympany to dullness Normal range Midclavicluar line – 6-12 cm Midline – 4-8cm |
|
|
Liver exam: Palpation
|
Left hand supporting 11th and 12th ribs
Deep palpation with right hand, press gently and up (deep inspiration may aid palpation) Normal liver : Soft Sharp (distinct) edge Smooth surface “Hooking” technique Helpful in obese pts |
|
|
Spleen exam
|
Normally not palpable
Expands anteriorly, superiorly, and medially Tympany of gastric bubble may be displaced or absent 1. Percussion - Taube’s space - “percussion sign” |
|
|
Traube's space
|
It's a crescent-shaped space overlying the stomach. The surface markings for Traube’s space the left sixth rib, the left mid-axillary line and the left costal margin.
|
|
|
Percussion of Traube's space
|
Percussion should be carried out at one or more levels of Traube’s space from medial to lateral. Anatomical boundaries are: 1. Right : the inferior margin of the left lobe of liver. 2. Left : the anterior border of the Spleen. 3. Superior : lower edge of the left lung (Resonance of lung). 4. Inferior : Costal margin. If dull with percussion palpation correctly detects presence or absence of splenomegaly more than 80% of the time
|
|
|
Splenic percussion sign
|
Percuss the lowest interspace in the left anterior axillary line. (should be tympanic)
Ask the patient to take a deep breath in and re-percuss. (normally remains tympanic) Positive sign is tympany to dullness on inspiration |
|
|
Spleen palpation
|
Stand on the right side
With your left hand push up on the lower left posterior rib cage. With your right hand below the left costal margin, press in and up towards the spleen The spleen is not normally palpable ( about 5% of normal adults the tip of the spleen is palpable) Inspiration by the patient may facilitate palpation Feel for tenderness, assess the splenic contour, measure the lowest point below the costal margin Repeat the maneuver with the patient laying on his/her right side. |
|
|
Left Kidney palpation
|
From the patient’s left, lift the posterior rib cage with you right hand. Try to displace the kidney anteriorly
Push in with the fingertips of your left hand laterally to the rectus abdominus mm, during inspiration (which displaces the kidney inferiorly) Have the patient exhale and then hold their breath briefly Slowly release the Left hand pressure, feeling for the kidney to slide back into its expiratory position |
|
|
Right kidney palpation
|
More anterior than left
May be palpable in thin relaxed patients Differentiate from liver Liver cannot be captured Liver edge is sharp and extends medially and laterally |
|
|
If "captured"...
|
describe the size, contour, and tenderness of the kidney
Enlargement causes: Hydronephrosis Cysts Tumors (bilateral enlargement suggests Polycystic kidney disease) Others |
|
|
Kidney: Costovertebral angle tenderness
|
Indicative of renal disease particularly pyelonephritis
|
|
|
Bladder exam
|
Normally cannot be examined unless it is distended above the symphysis pubis
The dome of the distended bladder feels smooth and round Use percussion to check for dullness and to determine how high the bladder rises above the syphysis Causes: outlet obstruction -Urethral stricture -Prostate enlargement -Neurologic disorders (stroke and MS) -Medications -Neoplasms Suprapubic tenderness with cystitis |
|
|
Aorta exam
|
Identify the aortic pulsation with firm deep palpation
Use in patients older than 50 to assess width of the aorta Normal Aorta < 3.0 cm Abdominal Aortic Aneurysm (AAA) Risk factors: Age >65 History of tobacco use Male First degree relative with a history of AAA or repair Periumbilical or upper abdominal mass with expansile pulsations that are >3 cm suggests AAA Screening with palpation followed by ultrasound decreases mortality especially in male smoker 65 yo or older Pain may signify rupture Rupture is 15times more likely in AAA’s >4 cm than smaller |
|
|
Ascites
|
Fluid in the peritoneal cavity”
Causes 1. Increased hydrostatic pressure in cirrhosis, CHF, constrictive pericarditis 2. Hepatic or inferior vena cava obstruction 3. Decreased osmotic pressure in nephrotic syndrome and malnutrition 4. Inflammatory from infection or masses Types: Transudative – cirrhosis, CHF, hepatic or IVC occlusion, nephrotic syndrome, malnutrition Exudative – cancer, infection, pancreatitis, Tb |
|
|
Ascites exam: S+S
|
Abdominal distension, bulging flanks, SOB, leg swelling, bruising, hematemesis, encephalopathy
Shifting dullness, fluid wave, dullness in dependent areas (due to gravity) |
|
|
Ascites exam: Serum ascites-albumin gradient (SAAG)
|
Used to determine the cause of ascites
High gradient (>1.1 g/dL) indicates portal hypertension, usually related to cirrhosis, CHF Low gradient (<1.1 g/dL) indicates not due to portal hypertension as in nephrotic synd., Tb, cancers |
|
|
Shifting dullness
|
Shifting Dullness
Percussion of fluid – dullness Percussion of air filled bowel – tympany 1. In the supine position: Percuss from midline moving out towards the perimeter. Mark position where sound changes from tympany to dullness 2. Pt in the lateral decubitus position: Repeat percussion Gravity dependent fluid will have shifted in a pt with ascites |
|
|
Fluid wave
|
1. Patient Supine
2. Have patient occlude midline of abdomen with the edge of his/her hand 3. Tap one flank 4. Feel for transmission of the sensation on the opposite flank Positive fluid wave, shifting dullness and peripheral edema make the diagnosis of acites highly likely (LR 3.0-6.0) |
|
|
Appendicitis exam
|
Inflammation of the appendix
S+S “Classic” presentation: Initial periumbilical pain then localizes to RLQ, followed by, N/V, lastly fever Diarrhea very unlikely Peritoneal inflammation Perform a rectal examination in both sexes and a pelvic examination in women may help identify or suggest other causes of abdominal pain |
|
|
Alvarado score for appendicitis
|
Migratory R iliac fossa pain, anorexia, rebound tenderness, left shift, fever >37 C, N/V: all worth 1 pt
R iliac fossa tenderness, leukocytosis >10K: worth 2 pts <5 appendicitis unlikely 5-6 do a CT of US >7 appendicitis very likely |
|
|
Appendicitis: Rovsing's sign
|
Deep palpation in LLQ, then withdraw quickly.
Pain in the RLQ during LLQ pressure = positive. RLQ pain with withdrawal = referred rebound tenderness. Both suggest appendicitis |
|
|
Appendicitis: Psoas sign
|
Ask the patient to raise the right leg with resistance applied above right knee (or on L side extend R hip).
Increased pain with either = positive psoas sign (suggests irritation of the psoas muscle by an inflamed appendix) |
|
|
Appendicitis: Obturator sign
|
Flex the patient's right thigh at the hip with the knee bent, and rotate the leg internally at the hip. This stretches the internal obturator muscle.
Positive = right hypogatric pain (suggests irritation of obturator muscle by inflamed appendix) |
|
|
Appendicitis: Dunphy's sign
|
Abdominal pain worsened with cough. (may be a sign of appendix irritation)
|
|
|
Appendicitis: McBurnery's point
|
Deep palpation at McBurney’s point reproducing pain = positive McBurney’s sign (suggests appendicitis)
|
|
|
Appendicitis: Jar test
|
Tap heel while supine
Increased pain = positive |
|
|
Cholecystitis exam
|
“Inflammation of the Gallbladder”
Usually caused by Cholelithiasis – stone blocking the cystic duct S+S RUQ pain – constant, severe, referred to groin or scapula, exacerbated by fatty/greasy foods Low grade fever, N/V/D, granulocytosis High grade fever, shock, jaundice – indicate complications Abscess formation, ascending cholangitis, fistula Do Murphy's sign test |
|
|
Cholecystitis: Murphy's exam
|
Hook the fingers under right costal margin at the lateral border of the rectus muscle intersects with the costal margin. Ask the patient to take deep breath.
Sharp increase in pain with a sudden stop of inspiratory effort = positive Murphy’s |
|
|
Pancreatitis
|
Inflammation of the pancreas
Causes: Alcohol = most common Gall stones Medication Hypertriglyceridemia Autoimmune, infection, neoplasm/obstruction, other Pneumonic: GETSMASHED is often used to remember the common causes of Pancreatitis: G - Gall stones E - Ethanol T - Trauma S - Steroids M - Mumps A - Autoimmune Pancreatitis S - Scorpion sting H - Hyperlipidemia, Hypothermia, Hyperparathyroidism E - Endoscopic retrograde cholangiopancreatography D - Drugs commonly azathioprine, valproic acid |
|
|
Pancreatitis: Grey Turner sign
|
Bruising/echymosis of the flanks suggestive of retroperitoneal hemorrhage in severe pancreatitis with necrosis
(Take 24-48 hrs to appear) |
|
|
Pancreatitis: Cullen sign
|
Echymosis/bruising of the periumbilical area suggestive of pancreatitis with necrosis
(take 24-48 hours to appear) |
|
|
Hernias of the abdominal wall
|
Hernia – protrusion of any organ, structure, or portion thereof through its normal anatomical confines
Look for signs of: Incarceration- herniated tissue becomes trapped in the hernia sack Strangulation- when blood supply is cut off (strangled) in an incarcerated hernia |
|
|
Types of hernias
|
1. Ventral Hernia
2. Umbilical 3. Incisional 4. Epigastric 5. Diastasis recti |
|
|
Umbilical hernia
|
Most common type of hernia
Incomplete umbilical closure allows protrusion of omentum or bowel. |
|
|
Omphalocele
|
incomplete closure of umbilicus, abdominal contents herniate into the base of the umbilical cord (including organs)
Perinatal emergency |
|
|
Gastrochisis
|
No cover of herniated abdominal contents
Perinatal emergency |
|
|
Incisional hernia
|
Protrusion of abdominal contents through a prior fascial incision
Causes Most common deep wound infection Obesity Steroid dependence Multiple prior operations CT may be needed for diagnosis C/O – bulge, pain, discomfort at site, bowel obstruction |
|
|
Diastasis recti
|
Fascial weakness, not a true defect
Rectus muscle separate in the upper midline Treatment: Reassurance Weight loss Abdominal mm strengthening |
|
|
Epigastric hernia
|
Congenital or acquired
Herniation through the linea alba, superior to the umbilicus |
|
|
Females with abdominal pain
|
Ask about pregnancy, LMP, “protection”
Get pregnancy test (consider despite above answers) Consider pelvic exam (PID, ectopic, ovarian cysts, other) |
