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249 Cards in this Set
- Front
- Back
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What is the four-quadrant system?
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A system that divides the abdomen into four quadrants by putting a cross through the middle of the umbilicus.
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What are the five major mechanisms that produce abdominal pain?
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1. Stretching of an encapsulated organ
2. Irritation of the mucosal lining of an area/organ 3. Smooth muscle spasm 4. Peritoneal irritation 5. Direct Splanchnic nerve stimulation |
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What are the encapsulated organs?
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Liver, spleen and kidneys
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What is the mechanism of the pain caused by stretching of an encapsulated organ?
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The capsule surrounding the organ may become stretched secondary to swelling or inflammation of the organ itself. SO the organ is growing too big for its shell which causes pain.
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What is the quality and quantity of the pain caused by stretching of an encapsulated organ?
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The pain tends to be constant and dull-moderate in intensity.
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What kind of pain would be produced by liver congestion secondary to CHF?
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Right Upper Quadrant pain that is constant and dull-moderate in intensity.
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What kind of pain would be caused by splenic congestion/enlargement?
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Left Upper Quadrant pain that is constant and dull-moderate in intensity
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What kind of pain would be caused by kidney swelling and inflammation, "pyelonephritis"?
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Flank pain that is constant and moderately severe in intensity.
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What is the quality and quantity of the pain that is produced by esophagitis?
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Irritation of the mucosal lining causes a burning discomfort that can be quite severe.
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What kind of pain would be produced by gastritis or a peptic ulcer?
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A burning pain that is caused by irritation of the mucosal lining.
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What kind of pain would be caused by duodenitis or duodenal ulcer?
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Burning discomfort caused by irritation of the mucosal lining.
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What is the quality of pain that Is produced by a smooth muscle spasm in the abdomen?
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Basically the abdominal muscles are getting a cramp so the pain is crampy/colicky in nature.
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What kind of pain would be produced by viral gastroenteritis or irritable bowel syndrome?
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A crampy/colicky pain.
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What kind of pain is produced by peritoneal irritation?
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Severe abdominal discomfort that usually manifests as a sharp stabbing pain associated w/ marked tenderness on palpation.
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What kind of pain would be caused by acute appendicitis?
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A sharp stabbing pain associated w/ marked irritation on palpation caused by peritoneal irritation.
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What kind of pain would diverticulitis cause?
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Sharp stabbing pain that is tender on palpation and is associated w/ peritoneal irritation.
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What kind of pain would be produced by acute cholecystitis?
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Sharp stabbing pain that is tender on palpation and is caused by peritoneal irritation.
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What kind of pain is caused by direct splanchnic nerve stimulation?
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Poorly localized abdominal pain of moderate severity.
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What kind of pain would be caused by pancreatic cancer?
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This is a retroperitoneal process so it would cause poorly localized abdominal pain of moderate severity due to direct splanchnic nerve stimulation.
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What kind of pain would be produced by an expanding aortic aneurysm?
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Retroperitoneal process that causes poorly localized abdominal pain from direct splanchnic nerve stimulation.
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Where is the location of the pain caused by pancreatic disease?
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Mid-epigastric abdominal discomfort that radiates straight through to the back.
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Where is the pain from Gallbladder disease typically located?
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Causes RUQ or epigastric abdominal pain that radiates to the right shoulder blade along the distribution of the phrenic nerve.
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What is the pain from Gallbladder disease described as?
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Colicky in nature.
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What is the location of the pain caused by the esophagus?
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Retrosternal and may be confused w/ angina pectoris, it can also be located in the mid-epigastric region.
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How can you differentiate b/e cardiac pain and esophageal pain?
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1. Cardiac pain is typically brought on by exertion but esophageal pain is typically brought on or relieved by swallowing.
2. Maneuvers that increase intra-abdominal pressure such as bending over at the waist may cause reflux of gastric acid into the esophagus and cause esophageal pain. |
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What is the location and quality of the pain from the small intestine?
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Crampy pain that is located in the periumbilical region often caused by intestinal ischemia.
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What associated symptoms is often associated w/ appendicitis?
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Nausea
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Where is the location of the pain caused by appendicitis?
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Typically begins in the periumbilical region that peaks in 4-6 hours and then subsides only to retun later in the RLQ at McBurney's point.
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Where is McBurney's point located?
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5cm from the anterior spinous process of the ilium on a straight line drawn from the umbilicus.
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What is Rovsing's sign?
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Pain in the RLQ during left quadrant pressure that indicates appendicitis.
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Where is pain from the colon located?
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LLQ and RLQ with the pain being either constant or in spasms.
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What can be either an aggravating or relieving factor of colon disease?
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Defecation.
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Where is the location of rectal pain?
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Deep w/in the pelvis and is very poorly localized.
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What is the quality of rectal pain? what is it often associated w/?
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Pain can be intense and is often associated w/ the constant need to defecate.
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What is the location of Kidney disease?
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MOST OFTEN: Left/Right flank but may also be RUQ/LUQ or over the costovertebral angle.
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What associated symptoms often accompany pyelonephritis?
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Systemic signs of infection (fever, chills and malaise)
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Where is ureteral pain typically located?
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IN the lower quadrants and radiates to the testicles or labia.
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What is the quality of testicular pain?
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Excruciatingly severe when associated w/ passing a renal calculus (kidney stone). The pain often comes in waves until the stone is passed.
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What can you diagnose in a pt who has microscopic hematuria as well as flank pain?
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Kidney stones.
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Where is gastric pain located?
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Epigastric and may radiate to the left shoulder.
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Where is duodenal pain located?
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Epigastric in location
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How can you differentiate b/e the pain caused by gastric ulcers and duodenal ulcers?
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Gastric ulcers get worse w/ eating and improve w/ fasting. Duodenal ulcers get worse w/ fasting and improve w/ eating.
*duodenal ulcer pts typically wake up at 5AM and eat to relieve their pain. |
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Where is diaphragmatic pain referred to?
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The supraclavicular area (kehr's sign)
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Where is ureteral pain referred?
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Hypogastrium, groin and inner thigh.
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Where is cardiac pain referred to?
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Epigastrium, jaw and shoulder
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Where is appendix pain referred to?
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Periumbilical via T10
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Where is duodenal pain referred?
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Umbilical region via greater thoracic splanchnic nerve.
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Where is a hiatal hernia's pain referred?
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Epigastrium via T7 and T8
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Where is pancreas or gallbladder pain referred?
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Epigastrium.
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Where is Gallbladder and bile duct pain referred?
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Epigastrium pain that wraps around the scapula.
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What is an acute abdomen? what does it signal?
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Describes the sudden onset of severe abdominal pain and indicates an URGENT need for surgical intervention.
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What are the etiologies of an acute abdomen?
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1. Peritonitis (infection w/in peritoneal cavity)
2. Bowel infarction (dead bowel that can erode) 3. Perforation of a hollow organ (ulcers, appendix) 4. Ruptured aortic aneurysm. |
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What are the signs of an acute abdomen?
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1. Abdominal distention w/ tympany on percussion
2. Tenderness to palpation 3. Rebound tenderness 4. increased/decreased bowel sounds 5. cutaneous hypersensitivity 6. rigidity (involuntary spasm of the abdominal wall musculature) |
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What is a "board-like abdomen" HIGHLY specific for?
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An acute abdomen.
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What is nausea?
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The unpleasant sensation of impending vomiting.
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What etiologies can cause nausea?
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*sigh* sooooo many... BUT here are the common ones:
1. CNS lesions (brain tumors and increased intracranial pressure) 2. vestibular pathology (inner ear: vertigo, dizziness, disequilibrium) 3. GI pathologies 4. hormones (pregnancy) 5. medications (narcotics and really all medications) |
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What is anorexia?
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Loss of appetite
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What is vomiting?
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The forceful expulsion of gastric contents out of the mouth.
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What parts of the pt hx should you focus on for vomiting?
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Carefully establish a timeline and its relation to other symptoms (i.e. headaches may indicate a brain tumor).
ALSO the contents of the emesis. |
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What does bright red or black coffee ground material in emesis indicate?
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GI bleeding.
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What does greenish material in emesis indicate?
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bowel obstruction.
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What is early satiety?
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The inability to eat a full meal which may be due to mechanical (tumors), motility (diabetic neuropathy) or psychological (anorexia) etiologies.
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What is dysphagia?
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Difficulty swallowing.
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What should you establish when examining a pt w/ dysphagia?
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Establish whether this is w/ liquids, solids or both as well as establish a time sequence.
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What are pts at risk for w/ dysphagia?
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Aspiration of food contents into the lungs.
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What is odynophagia?
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Pain w/ swallowing
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What can cause odynophagia?
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Ulcerations of the esophagus, exposure to caustic agents and infections such as herpes simplex and candidiasis of the esophagus.
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What is Diarrhea?
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Techniqually: >200g of stool/day but REALLY it is an increase in the frequency of stools (usually >3/day) and increased liquid content of stool.
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What is acute diarrhea?
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Diarrhea lasting less than two weeks.
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What is chronic diarrhea?
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Diarrhea lasting longer than 4 weeks.
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What is constipation?
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<3 bowel movements/day along WITH hard stools.
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What is the sequence of the abdominal exam?
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It is different than the typical sequence of inspection=> palpation => percussion => auscultation it is:
Inspection => auscultation => palpation |
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Why is palpation performed after auscultation in the abdominal exam?
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b/c theoretically palpating the abdomen could change the bowel sounds.
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How is abdominal palpation performed? why?
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From the pts right side whether the examiner is right or left-handed. It is this way b/c of the way exam rooms are set up so that the pts left side is inaccessible. It also makes results more consistent from pt to pt.
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How should inspection of the abdomen be performed?
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When the pt is supine and using tangential illumination, the abdomen should be exposed from xiphoid to pubic symphysis.
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What pts present w/ a scaphoid abdomen (sucked-in abdomen)?
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Malnourished individuals
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What pts present w/ a flat abdomen?
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Most non-obese adults
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What pts have a protuberant abdomen?
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A convexity to the horizontal plane and may be an early sign of abdominal distention in many different pts.
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What are the causes of abdominal distention in order?
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*The six F's:
1. Fat 2. Fluid (ascites) 3. Flatus (air/gas) 4. Fetus (preggers) 5. Feces 6. Fatal growths (tumors) |
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Where should the umbilicus be located in adults w/ an absence of a hx of pregnancy carried to term or a hx of previous abdominal surgery?
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the umbilicus should be w/in 1 cm of the midpoint b/e symphysis pubis and xiphoid.
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What affect on the umbilicus does hepatomegaly have?
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Stretches the upper abdominal segment so that the umbilicus is displaced downward. This causes the distance b/e the xiphoid and umbilicus to be at least 2cm longer than the distance from the umbilicus to the symphysis pubis.
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What effect does pregnancy and pelvic tumors have on the umbilicus?
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Displaces the umbilicus upward so that the distance b/e the umbilicus and symphysis pubis is at least 2cm longer than the distance from the umbilicus to the xiphoid.
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What would cause discoloration that resembles a bruise on the abdomen?
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Subcutaneous blood dissecting into the abdominal wall from a retroperitoneal or intraperitoneal bleed.
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What is Grey Turner's sign?
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Ecchymosis in one or both the flanks which results from the collection of blood in the subcutaneous fascial planes.
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What would cause scars in these locations?
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blue: laparotomy
red: cholecystectomy green: appendectomy orange: Hysterectomy purple: hernia |
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What conditions cause Grey Turner's sign?
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Originally described in pancreatitis but is associated w/ a variety of conditions associated w/ retroperitoneal and intraperitoneal bleeding.
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What is Cullen's sign?
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A periumbilical ecchymosis first described in a pt w/ a ruptured ectopic pregnancy.
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What does Cullen's sign indicate?
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Retroperitoneal or intraperitoneal bleeding that causes blood to travel to the periumbilical area through the falciform ligament.
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What does the falciform ligament connect?
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Connects the retroperitoneum via the lesser omentum and transverse colon.
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What are Striae?
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"Stretch marks" that occur as a result of rupture of the elastic fibers in the reticular layer of the skin.
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What causes striae?
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Chronic stretching; often secondary to obesity, pregnancy, ascites and expanding tumors.
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How can you tell new striae from old striae?
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new striae are pink while old striae are silvery.
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What do striae that are associated w/ Cushing's syndrome have?
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A purplish hue secondary to erythrocytosis from excess adrenal androgens.
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What is the venous drainage above the umbilicus?
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Blood flow in the abdominal veins is normally upward or cephalad.
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What is the venous drainage below the umbilicus?
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Downard or caudad
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What happens to blood flow in a SVC obstruction?
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The normal direction of flow is reversed so that blood flow in the upper abdomen flows downward.
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What is the blood flow like in IVC obstruction?
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blood flow in the lower abdomen is upward w/ collaterals being especially prominent in the FLANKS.
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What disease causes caput medusae?
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Intrahepatic portal vein obstruction (cirrhosis)
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What visible Sys are present in intrahepatic portal vein obstruction or cirrhosis?
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The veins appear to radiate outward from the umbilicus in every direction.
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What is blood flow like in caput medusa?
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Flow above the umbilicus is cephalad while flow below the umbilicus is caudad.
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What causes visible peristalsis?
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Occurs when the peristaltic waves are increased in amplitude which occurs early in mechanical bowel obstruction.
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What is the normal appearance of the abdominal aorta during inspection?
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Normally there is a slight visible pulsation in the epigastrium.
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What can cause the amplitude of pulsation of the abdominal aorta to increase?
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A wide pulse pressure, tortuosity of the aorta or an AAA
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What is an umbilical hernia?
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A hernia where the navel protrudes during straining or relaxation which is common during childhood and generally resolves by ~4 years of age.
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What typically causes adult umbilical hernias?
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Ascites, pregnancy and severe emphysema.
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What does a spigelian hernia pt present with?
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A tender mass in the abdominal wall 3-5cm above the inguinal ligaments.
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What is a diastasis rectus?
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Not a true hernia but is a separation of the abdominal rectus muscles that results in a linear midline bulge w/ increased intra-abdominal pressure.
It is generally benign and rarely requires surgery. |
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What conditions cause a diastasis rectus hernia?
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pregnancy or obesity.
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How does a diastasis rectus hernia manifest itself during a physical exam?
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When a supine pt lifts his/her head off the table.
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What are bowel sounds?
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"peristaltic sounds"; represent the normal gurgling and bubbling activity heard in the abdomen as a result of air/fluid movement.
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Where are most bowel sounds generated?
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In the stomach, followed by large intestines and then small intestines.
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What are the characterstics of normal bowel sounds?
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intermittent in frequency, variable in intensity and loudest when a meal is anticipated.
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What dz has a characteristic complete absence of bowel sounds?
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"Intestinal ileus" or a decrease in bowel motility.
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What mechanisms can cause intestinal ileus?
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1. mechanical ileus
2. paralytic or adynamic ileus |
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What is mechanical ileus?
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An anatomic obstruction of the bowel lumen.
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What is the sequence of bowel sounds that occurs in mechanical ileus?
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Bowel sounds initially increase as the bowel strains to push the obstruction then as the bowel gets tired it eventually dilates, becomes congested and edematous and ceases peristaltic activity which results in a complete absence of bowel sounds.
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What dz'es can cause small bowel mechanical ileus?
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1. adhesions (scar tissue)
2. hernias 3. volvulus 4. intussusception 5. gallsone ileus |
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What is a volvulus?
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twisting of the bowel on itself, a common side-effect of situs inversus.
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What is intussusception?
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The bowel invaginating or telescoping on itself. Typically present in adults w/ tumors or kids w/ swollen lymphatics.
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What can cause large bowel mechanical ileus?
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1. tumors (much more common in large bowel)
2. volvulus (usually the sigmoid) 3. hernias 4. diverticulitis (w/ localized inflammation and matting leading to obstruction) 5. intussusception |
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How does small bowel mechanical obstruction appear on xray?
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dilated loops of bowel that are filled w/ gas proximal to the obstruction and the loops are located more or less centrally.
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How does large bowel mechanical obstruction appear on xray?
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dilated loops of bowel proximal to the obstruction that are located laterally.
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What is paralytic/adynamic ileus?
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An inhibition of normal smooth muscle contraction in the small and large bowel.
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What conditions cause adynamic/paralytic ileus?
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1. inflammation of the bowel
2. bowel ischemia 3. narcotics and other meds 4. electrolyte abnormalities 5. typically develops following bowel manipulation at the time of abdominal surgery. |
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What physical signs characterize adynamic ileus?
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abdominal distention and the absence of bowel sounds.
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How does adynamic ileus appear on xray?
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Air is seen throughout the bowel (both small and large) all the way through to the rectum.
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If a pt presents w/ acute abdominal pain and has bowel sounds can you diagnose bowel obstruction?
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No; even though the pt has abdominal pain the presence of bowel sounds argues against bowel obstruction.
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How long must an examiner auscultate the bowel?
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At least 5 minutes.
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What is simple hyperperistalsis characteristic of?
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Irritated bowel that occurs in gastroenteritis or common diarrhea, though it is also heard around mealtime.
*it is the rumbly tummy sound. |
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A pt comes into your clinic. They present w/ increased bowel sounds and describe waves of pain. What's the dx?
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Early mechanical small bowel obstruction.
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What are borborygmi?
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Increased bowel sounds that are caused by the small bowel trying to force its contents through an obstruction.
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What bowel sounds are present after borborygmi subside?
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The bowel sounds take on a quality of "high-pitched tinkles" that occur b/e long periods of silence.
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A pt presents to your clinic w/ abdominal pain. When you ascultate you hear a high-pitched tinkling sound. During the hx the pt also complains of vomiting and the abdomen is distended. what's the dx?
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Acute small bowel obstruction.
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What is the most common source of innocent abdominal bruits?
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The celial artery
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Where do epigastric systolic bruits occur?
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In the midline b/e the xiphoid and the umbilicus.
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What pts typically have innocent epigastric systolic bruits?
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Young women who are thin
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Where are renal artery bruits heard?
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In a band across the anterior abdomen two inches above the umbilicus, they often radiate to the flanks or (rarely) the costovertebral angle.
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How can you tell a systolic epigastric bruit from a renal artery bruit?
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normal systolic epigastric bruits do not radiate into the flanks.
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What can you dx from a abdominal bruit having both a systolic and a diastolic component?
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Renal artery stenosis
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Where do you hear bruits from the common iliac arteries?
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Midway b/e the umbilicus and the inguinal ligament on a line that connects the umbilicus w/ the mid inguinal ligament.
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Where are bruits due to liver tumors located?
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In the right upper quadrant, they are primarily systolic but may be continuous.
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What bruit is caused by a Hepatoma?
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A systolic bruit in the right upper quadrant.
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What bruit is caused by aortic compression due to an enlarged liver?
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A systolic bruit heard only over the left lobe of the liver that decreases with standing.
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What bruits are caused neoplasias?
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Hepatic bruits that do not change w/ position.
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What bruits are caused by vascular tumors of the liver?
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right upper quadrant bruits.
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Where do peritoneal friction rubs originate?
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Generally in the spleen or liver when their capsules rub against the peritoneum.
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What is the most common cause of a peritoneal friction rub?
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Splenic infarctions
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Where do you hear splenic infarctions? what other diseases can cause peritoneal friction rubs?
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In the LUQ; splenic abscesses and metastatic tumors
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Where are peritoneal friction rubs from the liver heard?
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RUQ
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What is the most common causes of peritoneal friction rubs in the RUQ? what other dz'es can cause this?
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Metastatic tumors of the liver are most common, but inflammatory conditions such as liver abscesses and hepatitis also cause them.
Primary liver tumors (hepatomas) can also cause them. |
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What is a RUQ rub associated w/ a systolic bruit tell you?
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It tells you it is neoplastic until proven otherwise.
*so think cancer! |
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What is a succussion splash?
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A sloshing sound heard through the stethoscope during sudden movement of the pt.
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What sound is caused by the presence of gas and fluid in a obstructed organ?
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A succussion splash.
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What does a LQU or midepigastric succussion splash that occurs 2 hours after drinking a glass of water or 5 hours after a meal caused by?
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Indicates delayed gastric emptying caused by pyloric channel ulcers or diabetes.
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Where does tympany normally occur in the abdomen?
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Over the gastric air bubble in the LUQ
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What dzes cause generalized tympany?
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mechanical and paralytic ileus and in the presence of a perforated hollow organ (intestine, stomach etc)
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Where does dullness to percussion occur in the abdomen?
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Over solid organs, fecal-filled bowel and laterally over the flanks in abdominal distention due to ascites.
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What is light palpation used for?
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To assess the abdominal wall for intramural masses, evaluate areas of tenderness before deep palpation and to detect cutaneous hypersensitivity.
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How can you use light palpation to distinguish intramural masses from intraabdominal masses?
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By having the pt raise his/her head during palpation.
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What is a palpable mass that becomes more prominent when the pt lifts their head during light palpation?
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An intramural mass
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What is a palpable mass that becomes less prominent when the pt raises their head during light palpation?
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An intra-abdominal mass
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Where does cutaneous hypersensitivity develop in the abdomen?
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On the abdominal wall overlying areas of peritoneal irritation.
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What does RLQ cutaneous hypersensitivity indicate?
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Appendicitis
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What is Boas' sign? when does it occur?
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Cutaneous hypersensitivity over the posterior right lower ribs, it occurs in some pts having inflammation of the gallbladder (acute cholecystitis)
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What is Kehr's sign? when does it occur?
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Cutaneous hypersensitivity over the left shoulder secondary to diaphragmatic irritation from splenic rupture.
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What does cutaneous hypersensitivity in a single dermatome's distribution dx?
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Early herpes zoster (shingles) prior to the onset of rash. Severe abdominal pain may also be present.
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What is the most important step of the abdominal exam?
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Deep palpation
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What is deep palpation used to evaluate?
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1. areas of pain and tenderness
2. abdominal wall muscle tone 3. position, size, shape and consistency of abdominal organs. 4. detect abnormal masses or fluid accumulations (ascites) w/in the peritoneal cavity. |
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How can you relax the patient during deep palpation?
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By having the pt flex the knees and hips and have the pt breathe slowly (not deeply) through the mouth.
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What causes reflex muscle spasm of the abdominal wall? what does spasm cause?
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Peritoneal irritation; spasm produces abdominal wall rigidity which can be classified as either voluntary or involuntary.
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What is voluntary rigidity (guarding)?
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The willful tensing of the abdominal wall musculature by the pt for whatever reason.
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How can you determine whether the pt is having voluntary rigidity?
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By applying pressure (palpating) w/ the stethoscope or by simultaneously palpating and applying pressure over the lower sternum during inspiration.
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What causes involuntary rigidity?
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peritoneal irritation.
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What is "tenderness"?
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Pain that is produced by palpation and is classified as direct, indirect and rebound.
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What causes direct tenderness?
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Localized inflammation of the abdominal wall, the peritoneum or a hollow organ.
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When does a solid organ produce direct tenderness?
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When its capsule is stretched.
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Where is the tenderness located in direct tenderness?
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On deep palpation directly underneath the examining hand.
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What is indirect tenderness?
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Develops at a location distant to the site of underlying pathology as result of peritoneal irritation.
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What is Blumberg's sign/Rebound tenderness?
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A transient, sharp, knife-like pain that results when pressure is suddenly released during deep palpation.
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What causes rebound tenderness?
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Peritoneal irritation and inflammation.
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What kind of rebound tenderness is caused by localized peritoneal inflammation?
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direct rebound tenderness
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What kind of rebound tenderness is caused by general peritoneal inflammation?
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indirect rebound tenderness
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What is the cough test?
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The more patient friendly version of the rebound tenderness test, it is used to determine peritoneal irritation.
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What can you dx w/ a positive cough test, rigidity and guarding?
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Peritonitis
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What is murphy's sign? how do you elicit it?
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A way of detected acute cholecystitis, but it is not super good.
Elicited by hooking the fingers under the right costal margin from above and asking the pt to inspire deeply. A "catch" in inspiration (b/c the pt is in pain and cannot inspire anymore) is found when there is acute cholecystitis. |
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What is Courvoisier's sign? what does it indicate?
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The presence of a palpably enlarged gallbladder in a pt w/ jaundice.
Indicates obstruction of the biliary tract w/ cancer. |
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What can you dx in a pt that presents w/ jaundice and a palpably enlarged gallbladder?
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extrahepatic obstruction
*the gallbladder/ Courvoisier's sign is how you tell whether the dz that is causing jaundice is from a common bile duct obstruction or a hepatocellular dz. |
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How do you assess whether there is costovertebral angle tenderness?
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By striking the soft tissues of the costovertebral angle on each side w/ the heel of the hand.
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What does costovertebral angle tenderness indicate?
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Inflammation of or around the kidney; "pyelonephritis".
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How do you elicit liver tenderness?
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By striking the RUQ and lower ribs w/ the heel of the hand.
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What causes tenderness in the RUQ?
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acute hepatitis or acute cholecystitis.
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What organs are palpable under normal conditions?
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Liver, lower pole of right kidney, pulsations of abdominal aorta, descending colon and sigmoid, ascending colon and cecum and the urinary bladder if it contains ~400 mLs of urine.
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What organs are not normally palpable in the abdomen?
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Gallbladder, pancreas, stomach, small bowel, transverse colon, left kidney and spleen.
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What is the goldstandard for determining liver size?
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Hepatic ultrasound
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What is the approximate liver size in a normal adult male?
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9-12cm in the mid-clavicular line. women's livers are smaller.
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Where is the upper liver border anteriorly, normally?
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At the level of the 7th or 8th rib
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What does it mean if the upper margin of hepatic dullness extends higher than the 6th rib?
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The liver is probably enlarged.
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What does it mean if the upper margin of the liver is lower than the 8th rib?
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The liver is probably being displaced downward by the lungs (emphysema).
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How do you determine the upper liver border? lower liver border?
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Upper: light percussion
Lower: percussion and palpation |
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What is the scratch test?
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Used to detect the lower liver margin (esp. when ascites or obesity is present).
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What causes hepatomegaly?
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Fatty infiltration, amyloidosis, neoplastic infiltration, acute inflammation and passive venous congestion secondary to right heart failure.
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What affect on liver size does alcoholic cirrhosis have?
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Causes a massively enlarged liver
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What affect on liver size does end-stage cirrhosis have?
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Produces a small shrunken liver measuring less than 6cm in size in the midclavicular line.
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What affect on liver size does acute massive hepatocellular necrosis have?
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Causes a reduction in liver size.
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What dz'es cause nodularity of the liver?
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Alcoholic cirrhosis and metastatic cancer.
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What dz'es does a pulsatile Liver indicate?
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Tricuspid regurgitation or constrictive pericarditis.
*a lesser extent of pulsatile liver can be detected sometimes in severe TV stenosis. |
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What is a Riedel's lobe?
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A long tail to the right lobe of the liver that is palpable a few centimeters below the right costal margin. This is a NORMAL variation that should not be confused w/ hepatomegaly.
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How should splenic palpation be performed? when is it contraindicated?
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G E N T L Y !!! generally splenic palpation is contraindicated b/c the possibility of splenic rupture in pts w/ massively enlarged spleens from infectious mononucleois
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how is splenic percussion (castell's method) carried out? what sound is elicited?
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Performed over the lower left intercostal space in the anterior axillary line and it normally produces tympany.
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What is a positive splenic percussion sign? what does it indicate?
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A change in the percussion note from tympany to dull; which indicates splenomegaly.
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What should be the initial technique performed in detecting splenomegaly? if positive? if negative?
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Percussion should be the initial technique and if its positive then ultrasound should be performed.
If negative than palpation should be performed. |
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What direction does splenic enlargement travel?
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The growing spleen moves down and toward the umbilicus.
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How should splenic palpation be performed? what does a barely palpable spleen indicate?
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W/ the pt on their right side during deep inspiration w/ support from behind. A barely palpable spleen indicates an increase in splenic size of up to 2 times normal.
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What is the most common source of confusion w/ an enlarged spleen?
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The splenic flexure of the colon filled w/ stool.
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How can you differentiate an enlarged spleen from a enlarged kidney?
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A prominent notch on the medial side of the mass is diagnostic for an enlarged spleen.
Percussion over a enlarged spleen gives a dull note, but kidneys give a tympanitic note. |
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What dz'es cause splenomegaly w/ jaundice?
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Hepatic dz w/ portal HTN.
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What dz'es cause splenomegaly and pallor?
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Leukemia and lymphoma
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What dz'es cause splenomegaly w/ lymphadenopathy?
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Lymphoma, sarcoidosis or infectious mononucleosis.
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How are the kidney's palpated?
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Using "ballottement"
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What is ballottement?
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A two-handed technique where the kidney is trapped b/e the two hands.
*this is generally attempted too low in the flanks. |
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What are the normal dimensions of the kidneys?
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11cm in length x 5 cm in width
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What do bilaterally enlarged kidneys indicate?
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Suggest the dx of polycystic kidney dz.
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What does a unilaterally enlarged kidney indicate?
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Usually due to hydronephrosis (which can also cause bilaterally enlarged kidneys if the blockage is at the urine outflow tract.)
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What does an enlarged and stony hard kidney indicate?
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The dx is most likely cancer.
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What do RLQ masses indicate?
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Feces in right colon, right colon or cecal carcinoma, ovarian cysts, appendiceal abscesses, thickened ileum of Crohn's dz and ectopic pregnancy.
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What do LLQ masses indicate?
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Feces in the left colon, colon carcinoma, diverticular abscess, ovarian cysts or ectopic pregnancies.
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What do RUQ masses indicate?
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represent hepatomegaly, an enlarged right kidney, an enlarged gallbladder, or an enlarged/inflamed pancreas.
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What do LUQ masses indicate?
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Enlarged spleen, enlarged left kidney, an inflamed/enlarged pancreas or stool in the splenic flexure.
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What do epigastric masses indicate?
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An enlarged left lobe of the liver, pancreatic enlargement, masses of the stomach and aortic aneurysms.
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What do hypogastric masses indicate?
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Increased uterine size (pregnancy, fibroids), abdominal hernias, enlarged bladder, ovarian cysts and aortic aneurysms.
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What is ascites?
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The presence of free-fluid in the abdomen.
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What is the chief complaint of most pts w/ ascites?
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Abdominal distention
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What are the two common causes of ascites?
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Cirrhosis w/ portal HTN and right-sided CHF.
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When is ascites unlikely in pts?
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When they do not have an increase in abdominal girth and when men do not have a hx of ankle edema.
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What is the most accurate non-invasive technique for detecting ascites?
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Ultrasound
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What is shifting dullness? how is it assessed?
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Assessed by percussing the abdomen from above and laterally, noting where the line of dullness to percussion occurs, the pt is then turned onto each side and the test is repeated. When the previously dull area percusses resonant, shifting dullness is present.
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How much ascites must be present in order to be detectable by shifting dullness?
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When there is less than 500 cc of free fluid in the abdomen.
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What is a fluid wave?
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A difficult technique b/c it requires three hands, but it is generated by tapping one side of the abdominal wall while palpating for the presence of a shock wave on the opposite side.
*an assistant must apply firm pressure over the anterior abdominal wall w/ the ulnar surface of the hand in a craniocaudad direction. |
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What is the most useful physical exam test for ruling in ascites?
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The presence of a fluid wave.
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What can ascites be confused w/ sometimes?
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An ovarian cyst b/c it causes a distended abdomen w/ bulging flanks and there can even be a positive fluid wave.
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How can you tell whether abdominal distention is caused by ascites or an ovarian cyst? why?
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percussion of the abdomen w/ the pt supine yields anterior dullness and lateral tympany in an ovarian cyst (ascites is opposite).
This is b/c the large ovarian cyst forces the air-filled bowel laterally toward the flanks. |
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What is the iliopsoas sign? what does it indicate?
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Elicited by having the pt extend a straight leg at the hip against resistance applied by the examiner. When the maneuver produces pelvic pain the examiner can infer the presence of retroperitoneal irritation that may be due to a ureteral calculus, retroperitoneal bleed or tuboovarian abscess.
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What is the obturator test?
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Performed by having a supine pt flex the thigh to 90 deg. while the examiner rotates the leg internally and externally at the hip by grasping the ankle and knee. The presence of pain is due to an inflamed obturator internus and indicates retroperitoneal irritation.
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What additional physical exam should be performed in every pt w/ abdominal signs or symptoms?
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A rectal exam.
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What lies anterior and superior to an examining finger in the rectum when it is pointing toward the navel?
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The rectovesical pouch
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What is the significance of the rectovesical pouch?
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In pts w/ metastatic intra-abdominal cancer, metastatic deposits occur in this area. During the exam the examiner will detect a hard shelf (blumer's shelf) on digital exam.
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What is blumer's shelf?
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A hard shelf that is detected digitally in the rectum in the rectovesical pouch. It indicates metastatic intra-abdominal cancer.
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What conditions cause positive stool guaiac testing?
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Conditions assoc. w/ passage of blood through the GI tract.
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