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91 Cards in this Set
- Front
- Back
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Abdominal wall landmarks
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Midclavicular line
Umbilicus Iliac crest Pubic symphysis |
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Female abdominal and pelvic anatomy
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See image
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Male abdominal and pelvic anatomy
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See image
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Abdominal Quadrants
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Right Upper Quadrant (RUQ)
Right Lower Quadrant (RLQ) Left Upper Quadrant (LUQ) Left Lower Quadrant (LLQ) |
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What organs are located in the RUQ?
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Small bowel
Liver Gallbladder Pylorus Duodenum Head of pancreas Hepatic flexure of colon Portions of ascending and transverse colon Right adrenal gland Portion of right kidney |
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What organs are located in the RLQ?
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Small bowel
Cecum Appendix Portion of ascending colon Lower pole of right kidney Right ureter |
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What organs are located in the LUQ?
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Small bowel
Left lobe of liver Spleen Stomach Body of pancreas Splenic flexure of colon Portions of transverse and descending colon Left adrenal gland Portion of left kidney |
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What organs are located in the LLQ?
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Small bowel
Sigmoid colon Portion of descending colon Lower pole of left kidney Left ureter |
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Abdominal Regions
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Right hypochondriac
Epigastric Left hypochondriac Right lumbar Umbilical Left lumbar Right iliac Hypogastric Left iliac |
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Common GI Complaints/Symptoms
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Heartburn
Gas/bloating/distension Nausea/Vomiting Early satiety Pain Bleeding Hematemesis (vomiting blood) Dysphagia (difficulty swallowing) Odynophagia (pain when swallowing) Jaundice Masses Hernia Bowel changes (caliber, bleeding, amount, color) |
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Urinary and Renal Complaints/Symptoms
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Suprapubic pain
Kidney, flank or groin pain Dysuria, urgency or frequency Hesitancy, decreased stream Polyuria, nocturia, oliguria |
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What is visceral pain?
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Internal organs activate specific receptors (nociceptors) for stretch, inflammation, and oxygen starvation (ischemia).
Frequently produces referred pain to the back. Visceral pain may become parietal pain as in appendicitis. |
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Characteristics of visceral abdominal pain
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Often poorly localized
Gnawing Burning Vague deep ache Cramping or colicky in nature Typically palpable near midline at levels that vary with structure involved. |
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What is parietal pain?
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Parietal peritoneum activate somatic innervation receptors in the spinal nerves, caused by inflammation.
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Characteristics of parietal pain
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Precisely localized
Steady aching pain Sharp Aggravated by movement, couching Patients typically prefer to lie still |
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Referred abdominal pain
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Is felt in more distant sites, which are innervated at approximately the same spinal levels as the disordered structure.
Ex: 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. |
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What attributes of abdominal pain/discomfort should you ask patients about?
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Describe the pain in their own words
Ask patients to point to the area of pain Severity of pain (scale of 1 to 10) What brings on the pain (timing) How often they have the pain (frequency) How long the pain lasts (duration) If the pain goes anywhere else (radiation) Anything aggravates the pain or relieves the pain Symptoms associated with the pain |
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What changes in upper GI should you ask patients about?
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Nausea, vomiting, indigestion, and regurgitation
Emesis (color, blood, coffee ground, hematemesis) Diet, anorexia, early satiety, and appetite Swallowing, dysphagia, or odynophagia Which type of foods provoke symptoms: solids and/or liquids? Jaundice |
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Possible causes of dysphagia
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Difficulty swallowing solids
- Probably structural, such as stricture, web or shatzki’s ring. Difficulty swallowing liquids - Probably motility disorder |
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What changes in bowel habits should you ask patients about?
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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. |
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Melena
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Black, tarry stool
Benign causes include Pepto Bismol, iron supplements, Oreos and licorice. |
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Hematochezia
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Bright, red blood in stool, usually caused by a small tear in the rectum.
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History related to abdominal conditions/symptoms
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Prior medical problems related to the abdomen
- Ex: hepatitis, cirrhosis, gallbladder problems, or pancreatitis Prior surgeries of the abdomen Foreign travel and occupational hazards Tobacco, alcohol, illegal drugs, medication history Hereditary disorders affecting the abdomen in the history of the patient’s family. |
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History related to urinary tract conditions/symptoms
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Frequency (how often one urinates) and urgency (feeling like one needs to urinate but very little urine is passed).
Pain with urination (burning at the urethra or aching in the suprapubic area of the bladder). Color and smell of the urine - red urine usually means hematuria (blood in the urine). Difficulty starting to urinate (especially in men) or the leakage of urine (incontinence, especially in women). Back pain at the costovertebral angle (kidney) and in the lower back in men (referred pain from the prostate). Men-ask about symptoms in penis and scrotum. |
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What abdominal health screenings should be encouraged?
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Alcohol screening
Hepatitis risk factors/screening Colorectal cancer screening |
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What alcohol screenings should be completed?
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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 |
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How does an abdominal exam differ than other exams?
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Other exams:
Inspections, palpation, percussion, auscultation Abdominal exam: Inspection, auscultation, percussion, palpation You must auscultate the abdomen first because palpation and percussion may move air in abdomen and change bowel sounds. |
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Components of abdominal inspection
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Skin
- scars, striae (stretch marks), vein pattern (caput medusae), hair distribution, rashes, or lesions Umbilicus - observe contour/location - 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) - pulsations (within blood vessels such as the aorta) |
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Caput medusae
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Vein distension, usually due to cirrhosis or inferior vena cava obstruction.
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What could increased palpable pulsations in the abdomen indicate?
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Abdominal aorta aneurysm
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What could increased peristalsis indicate?
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Abdominal obstruction
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Ascites
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Excessive fluid accumulation in the peritoneal cavity.
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Components of abdominal ascultation
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Bowel sounds in four abdominal quadrants
Bruits Friction rub |
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How should you auscultate the four quadrants?
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Place the diaphragm over the abdomen to hear bowel sounds.
Occasionally you may hear borborygmi (long gurgles of hyperperistalsis), as with “stomach growling”. Normal frequency of bowel sounds - 5-34 sounds per minute. Decreased - hypoactive Increased - hyperactive |
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How should you auscultate for bruits?
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A murmur like sound of vascular rather than cardiac origin.
- Aortic artery - Renal arteries - Femoral arteries |
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How should you auscultate for friction rub?
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Grating, scrapping, or rubbing sound produced be visceral pleura rubbing against parietal pleural.
- Spleen (listen over spleen) - Liver (listen over liver) Friction rubs can indicate a tumor, gonococcal infection around the liver or splenic infarct. |
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CAGE screening
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Cut down, Annoyed, Guilty, Eye opener (CAGE)
Ask the patient: Have you ever felt you should cut down (C) on your drinking? Have people annoyed (A) you by criticizing your drinking? Have you ever felt bad or guilty (G) about your drinking? Have you ever had a drink first thing in the morning, an eye-opener, to steady your nerves or to get rid of a hangover (E)? Two more "yes" answers indicates a positive CAGE. |
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AUDIT screening
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Alcohol Use Disorders Identification Test (AUDIT)
10-question screening evaluating alcoholism. A score of 8 or greater could indicate harmful alcohol use. |
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Components of abdominal percussion
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Percuss all 4 quadrants to assess the distribution of tympany and dullness:
- Gastric bubble - Liver - Spleen Note any large areas of dullness. - Could indicate a mass, enlarged organ, stool, or fluid. |
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Components of abdominal palpation
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Light Palpation
Start palpating the abdomen using gentle probing with the hands; this reassures and relaxes the patient. Deep Palpation Used to delineate abdominal masses and organs. |
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What should you look for when lightly palpating the abdomen?
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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 patient breath out may help relax muscles - Involuntary guarding indicates peritoneal inflammation |
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What should you look for when deeply palpating the abdomen?
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Delineate abdominal masses and organs
Mass types: Physiologic - pregnant uterus Inflammatory - diverticulitis of the colon Vascular - abdominal aortic aneurysm Neoplastic - carcinoma of the colon Obstructive - distended bladder or dilated loop of bowel |
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Signs of peritoneal inflammation
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Abdominal pain and tenderness, especially when associated with muscular spasm (guarding), suggests inflammation of the parietal peritoneum.
- Cough worsens pain (Dunphy’s Sign) - Light palpation percussion to localize the pain worsens it - Rebound tenderness Positive peritoneal signs signify an acute abdomen. |
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What is rebound tenderness?
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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. |
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What is a Dunphy's sign?
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Pain that worsens with coughing.
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Percussion of the liver
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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 (4-8 cm) |
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Palpation of the liver
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Left hand supporting 11th and 12th ribs
Deep palpation with right hand, press gently and up (deep inspiration may aid palpation) Normal liver should be: - Soft - Sharp (distinct) edge - Smooth surface “Hooking” technique may be helpful to palpate liver in obese patients. |
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Components of a spleen exam
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Normally not palpable
Expands anteriorly, caudally, and medially Tympany of gastric bubble may be displaced or absent. Percuss using Taube’s space or “percussion sign.” |
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Traube's space
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Crescent-shaped space overlying the stomach.
Surface markings - left sixth rib, - left mid-axillary line - left costal margin Percussion should be carried out at one or more levels of Traube’s space from medial to lateral. Anatomical boundaries: Right - inferior margin of the left lobe of liver Left - anterior border of the spleen Superior - lower edge of left lung (Resonance of lung) Inferior - costal margin If dull with percussion, palpation correctly detects presence or absence of splenomegaly more than 80% of the time. |
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Splenic percussion sign
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Percuss lowest interspace in left anterior axillary line
- should be tympanic Ask patient to take a deep breath in and re-percuss - normally remains tympanic Positive sign is tympany to dullness on inspiration. |
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Palpation of the spleen
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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. |
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Palpation of the left kidney
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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 muscle, during inspiration (which displaces the kidney inferiorly). Have patient exhale and hold their breath briefly. Slowly release the Left hand pressure, feeling for the kidney to slide back into its expiratory position. If “captured” describe the size, contour, and tenderness of the kidney. |
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Palpation of the right kidney
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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. |
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What are some possible causes of kidney enlargement?
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Hydronephrosis
Cysts Tumors - bilateral enlargement suggests polycystic kidney disease |
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How to test for costovertebral angle (CVA) tenderness
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Have patient sit upright facing away from you.
Place palm of left hand over CVA. Strike back of left hand with ulnar surface of right fist. CVA tenderness may indicate renal disease particularly pyelonephritis. |
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Examination of the bladder
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Normally cannot be examined unless it is distended above the symphysis pubis.
Dome of distended bladder feels smooth & round. Use percussion to check for dullness and to determine how high bladder rises above syphysis. Dullness may indicate an outlet obstruction. |
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What are some possible causes of a bladder outlet obstruction?
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Urethral stricture
Prostate enlargement Neurologic disorders (stroke and MS) Medications Neoplasms Suprapubic tenderness with cystitis |
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Examination of the abdominal aorta
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Identify aortic pulsation with firm deep palpation.
Use in patients >50 years to assess width of aorta. - Normal Aorta < 3.0 cm Periumbilical or upper abdominal mass with expansile pulsations that are >3 cm suggests abdominal aortic aneurysm (AAA). Pain may signify rupture - rupture is 15x more likely in AAA’s >4 cm |
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Risk factors for an abdominal aortic aneurysm
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Age >65
History of tobacco use Male First degree relative with a history of AAA or repair Screening with palpation followed by ultrasound decreases mortality especially in male smoker 65 years old or older. |
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What are some possible causes of ascites?
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Increased hydrostatic pressure in cirrhosis, CHF, constrictive pericarditis
Hepatic or inferior vena cava obstruction Decreased osmotic pressure in nephrotic syndrome and malnutrition Inflammatory from infection or masses Transudative ascites – cirrhosis, CHF, hepatic or IVC occlusion, nephrotic syndrome, malnutrition Exudative ascites – cancer, infection, pancreatitis, TB |
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S/S of ascites
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Abdominal distension
Bulging flanks Shortness of breath (SOB) Leg swelling Bruising Hematemesis Encephalopathy Shifting dullness Fluid wave Dullness in dependent areas (due to gravity) |
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Diagnosis of ascites
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Serum ascites-albumin gradient (SAAG)
Used to determine the cause of ascites High gradient (>1.1 g/dL) - indicates portal hypertension, usually due to cirrhosis, CHF Low gradient (<1.1 g/dL) - indicates not due to portal hypertension as in nephrotic syndrome, TB, cancers |
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Shifting dullness
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Percussion of fluid – dullness
Percussion of air filled bowel – tympany Patient in the supine position: Percuss from midline moving out towards perimeter Mark position where sound changes from tympany to dullness Patient in the lateral decubitus position: Repeat percussion Gravity dependent fluid will have shifted in a patient with ascites. |
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Abdominal ascites fluid wave
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Patient lying supine
Have patient occlude midline of abdomen with the edge of his/her hand Tap one flank Feel for transmission of the sensation on the opposite flank Positive fluid wave, shifting dullness and peripheral edema make the diagnosis of ascites highly likely - LR 3.0-6.0 |
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What is appendicitis?
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Inflammation of the appendix
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S/S of appendicitis
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“Classic” presentation:
Initial periumbilical pain then localizes to RLQ, followed by nausea/vomiting, then lastly fever Diarrhea very unlikely Peritoneal inflammation |
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What is an Alvarado score?
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A 10-point scale to assess the likelihood that a patient has appendicitis or not.
< 5 appendicitis unlikely 5-6 – order CT or US to r/o or confirm appendicitis > 7 appendicitis very likely |
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What exams should be performed to evaluate for appendicitis?
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Perform a rectal examination in both sexes and a pelvic examination in women may help identify or suggest other causes of abdominal pain.
Rovsing's sign Psoas sign Obturator sign Dunphy's sign McBurney's point Jar test |
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Rovsing's sign
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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 |
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Psoas sign
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Ask patient to raise 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 |
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Obturator sign
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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 |
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McBurney's point
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Midpoint between anterior superior iliac spine (ASIS) and umbilicus.
Deep palpation at McBurney’s point reproducing pain = positive McBurney’s sign - suggests appendicitis |
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Jar test
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Tap heel of patient while supine
Increased pain = positive - suggest appendicitis |
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S/S of cholecystitis
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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 – indicates complications Abscess formation, ascending cholangitis, fistula |
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Murphy's sign
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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 - suggests cholecystitis |
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Cholecystitis
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Inflammation of the gallbladder, usually caused by cholelithiasis, a stone blocking the cystic duct.
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Pancreatitis
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Inflammation of the pancreas
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Causes of pancreatitis
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Alcohol abuse is most common
Gall stones Medication Hypertriglyceridemia Autoimmune, infection, neoplasm, obstruction GETSMASHED - often used to remember 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 associated include azathioprine, valproic acid |
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Grey Turner sign
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Bruising/echymosis of the flanks suggestive of retroperitoneal hemorrhage in severe pancreatitis with necrosis.
Takes 24-48 hours to appear. |
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Cullen sign
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Echymosis/bruising of the periumbilical area suggestive of pancreatitis with necrosis.
Takes 24-48 hours to appear. |
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Abdominal hernia
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Protrusion of any organ, structure, or portion thereof through its normal anatomical confines.
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Types of abdominal hernia
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1. Ventral Hernia
2. Umbilical 3. Incisional 4. Epigastric 5. Diastasis recti |
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Complications of abdominal hernia
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Always look for signs of:
Incarceration - herniated tissue becomes trapped in hernia sack Strangulation - when blood supply is cut off (strangled) in an incarcerated hernia |
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Umbilical hernia
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Most common type of hernia
Incomplete umbilical closure allows protrusion of omentum or bowel. |
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Omphalocele
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Incomplete closure of umbilicus, abdominal contents herniate into the base of the umbilical cord including organs.
Perinatal emergency! |
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Gastrochisi
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No cover of herniated abdominal contents
Perinatal emergency! |
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Incisional hernia
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Protrusion of abdominal contents through a prior fascial incision.
CT may be needed for diagnosis C/O – bulge, pain, discomfort at site, bowel obstruction |
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Causes of an incisional hernia
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Deep wound infection (most common)
Obesity Steroid dependence Multiple prior operations |
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Diastasis recti
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Fascial weakness, not a true defect, rectus muscle separate in the upper midline.
Treatment: - Reassurance - Weight loss - Abdominal muscle strengthening |
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Epigastric hernia
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Congenital or acquired herniation through the linea alba, superior to the umbilicus.
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Special considerations for females with abdominal pain
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Ask about:
- pregnancy - last menstrual period (LMP) - “protection” Get pregnancy test despite above answers. Consider pelvic exam - PID, ectopic, ovarian cysts, other causes |
