Abdomen Flashcards Preview

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Flashcards in Abdomen Deck (168):
1

RUQ content

liver, gallbladder, duodenum, lower pole of right kidney, abd aorta

2

LUQ content

spleen, stomach, left kidney, pancreas, abd aorta

3

LLQ content

sig colon, transverse and desc colon, bladder, sacral promontory, utersu and ovaries

4

RLQ content

bowel loops, appendix, cecum, bladder, uterus and ovaries

5

Bladder

palpated with at least 300 cc urine. Detrusor muscle is smooth muscle that contracts.

6

Kidneys

ribs pretect upper portion. CV angle (12th rib and spine) significant for kidney tenderness.

7

Types of Abdominal pain

Visceral, Parietal, Referred

8

Visceral Pain

Hollow organs contract forcefully or are stretched- Intestines, biliary tree. Solid organs can have pain r/t stretching, swell against capsulelike liver. Difficult to localize. Usually midline at level of structure. Type: gnawing,, burning, cramping, aching. If severe can be a/w sweating, pallor, N, restlessness.

9

Parietal Pain

Inflammation of parietal peritoneum. Steady, aching, more severe than visceral pain. Is precisely located over involved structure. Worse with coughing or movement. Pts prefer to lay still. Easily localized

10

Referred Pain

Felt in distant site, innervated at approx same spinal level. Initally intense and radiates from initial site. May be felt superficially or deeply but is usually localized.

11

Visceral RUQ pain

biliary tree, or liver (distention from alcoholic hepatitis)

12

Visceral periumbilical pain

small intestines, proximal colon or early appendicitis- (later changes to parietal pain in RLQ)

13

Visceral epigastric pain

stomach, duodenum, pancreas

14

Visceral hypogastric pain

colon, bladder, uterus. Colonic pain may be more diffuse

15

Visceral suprapubic/sacral pain

rectum

16

Examples of referred pain

duodenum/pancreas- back
biliary tree- right shoulder/ right post chest
Pleurisy/AMI- epigastric

17

Renal stones

Colicky crampy pain radiating to R/L lower quad
Kidney stones could be pain from CV angle radiating to RLQ

18

knifelike epigastric

gallstone pancreatitis

19

IWMI

indigestion symptoms/ heartburn- precipitated with exertion, relieve with rest.

20

Abd pain history

timing of pain, acute/chronic, sudden gradual, when started, how long lasted, describe in own words, point to pain, severity of pain, aggravating/alleviating

21

GERD Risk factors

decr salivary flow, prolongs acid clearance by dampening action of bicarb buffer, delay gastric emptying, selected meds and hiatal hernia

22

Dyspepsia

chronic/recurrent discomfort/pain in center of upper abdomen. Bloating, N, upper abd fullness, heartburn. Patients may have functional, non ulcer dyspepsia- 3 months nonspecific upper abd discomfort or N not r/t structural abn or PUD. Sx recur and are present for more than 6 months.

23

Causes of chronic dyspepsia

delayed gastric emptying, gastritis from H pyori, PUD, psychosocial factors.

24

GERD

if pt has heartburn, acid reflux, regurgitation for more than a week assume GERD until proven otherwise. R/t mucosal damages. May have resp Sx: cough, wheeze, asp PNA, or pharyngeal: hoarseness, chronic sore throat. May have alarm symptoms: dysphasia, odyophagia (painful swallowing), recurrent V, GIB, wt loss, anemia, or RF of gastric CA.

25

GERD w/alarm Sx

Need endoscopy to look for esophagitis, peptic strictures, Barrett's esophagus( in this condition squamocolumnar junction displacedprox., replaced by intestinal metapplasia- increasing CA risk 30X). . 50% of GERD have no underlying Dz

26

Heartburn

restrosternal burning/discomfort- usually caused by food. Ex. ETOH, chocolate, citrus fruit, coffee, onions, peppermint. Could be position changes like bending over, exercising, lifting or lying down. Angina from IWMI- ma present with heartburn.

27

Appendicitis

RLQ pain, or pain that migrates from periumbilical region, a/w abd rigidity.
In women could also be PID, ruptured ovary, ectopic pregnancy
Tends to be achy

28

Diverticulitis

LLQ pain with palpable mass

29

SBO/LBO

Diffuse abd pain with no BS, firm abd, guarding, rebound on palpation
V with SBO

30

Associated symptoms

LLQ: fever, loss appetite
A, N, V

31

Colon CA

Change in bowel habits, mass lesion

32

IBS

Int pain for 12 wks of the preceding year with relief from defocation, change in freq BM, change in consistency. No structural biochemical abn.

33

Other diseases with A, N, V

DKA, adrenal insuff, hyper Ca, uremia, liver Dz, emo states, adv drug Rx, and more

34

Bulemia/ Anorexia

B-Induced vomiting w/o Nausea
A- loss/lack of appetite- may be d/t food intolerance.

35

Nausea

Retching? Regurg? Material, odor, volume, blood, clear/ mucoid, bile colors, black/brown, coffee ground. Dehydrated, electrolyte imbalance, asp?

36

Hematemesis

Varices, gastritis, PUD
Sx of blood loss: syncope, lightheaded, seen with loss of 500 ml or more

37

Fecal smelling vomit

SBO , gastrocolic fistula

38

Regurgitation

GERD, esophageal structure, esophageal CA
color, amount, blood, coffee ground

39

Burning gnawing

GERD or PUD

40

Terribly severe

Non localized peritonitis, perforation, ureteral calculi, bowel ischemia, Ao dissection

41

Increased BS

Diarrhea or early intestinal obstruction

42

Decreased BS then absent

Adynamic Ileus or peritonitis

43

High pitched tinkling BS

Intestinal fluid or air under tension in dilated bowel

44

High pitched rushing BS

Intestinal obstruction

45

Hepatic bruit

Liver CA or alcoholic hepatitis

46

Arterial bruit

Partial obstruction of Ao or renal arteries

47

HTN with bruit

Renal artery stenosis

48

Arterial insufficiency

Ao, iliacs, femerols with bruit

49

Hepatic friction rub

Intrahepatic malignancy

50

Liver percussion

MCL 6-12cm normal, longer swollen enlarged liver
MSL 4-8cm, shorter small hard cirrhotic liver

51

Friction runs

Rough grating sounds indicative of peritoneal inflammation over organs with large surface areas

52

Venous hums

Rare, periumbilical from IVC, medium pitch, continuous, may have palpable thrill. Found with portal HTN, cirrhosis

53

Percussion

Should be tympanic, air/gas filled. dullness heard over solid or enlarged organs, fluid, mass, adipose tissue

54

Aerophagia

swallowing air- may be cause of belching

55

Odyophagia

pain with swallowing.
Esophageal ulceration- ? Radiation, caustic ingestion, infections ( Candida, CMV, HSV, HIV). Can be pill induced- NSAIDS, ASA

56

Chronic lower quadrant bowel pain

ask about change in bowel habits and alternating constipation/diarrhea

57

Dehydration

prolonged vomiting can lead to dehydration and electrolyte imblance.

58

Early satiety

abd fullness after light meal, UA to eat full meal. Diabetic gastroparesis, anticholinergic meds, pastric outlet syndrome, gastric cancer, hepatitis.

59

Dysphagia

difficulty swallowing, suggests structural abn or motiltiy DO. Sensation of lump in throat or restrosternal area are not assosicated w/swallowing- not dysphagia. Ask where dysphagia occurs.

60

Oropharyngeal dysphagia

drooling, nasopharyngeal regurg, cough from asp in muscluar/neurological DO affecting motility.

61

Zenker's diverticulum

gurgling or regurg of undigested food- structural condition

62

Esophageal dysphagia

point to sternoclavicular notch

63

Dyspahgia of solid food

Structural esophageal condition: stricture, web, Schatki's ring, neoplasm.

64

Increased flatus

aerophagia, legumes, other gas producing foods. IBS, intestinal lactase deficiency

65

Diarrhea

more than 200grms/24 hrs. Duration, frequency, consistency, mucus, pus, blood, tenesmus (constant urge to defocate), pain, cramps, invol straining, nocturnal, greasy/oily, frothy, fowl, float. . Acute last 2wks/fever- cause infection. Chronic more than 4 weeks- cause nonifectious (Crohn's, UC)

66

Type diarrhea

High volume, frequent watery stools: small intestines
Small volume w/tenesmus or diarrhea w/mucus,pus, blood- rectal inflam conditions
Nocturnal diarrhea- pathological significance.

67

Steatorrhea

fatty diarrheal stools from malabsorption
celiac sprue, pancreatic insufficiency, sm bowel bacterial overgrowth.

68

Diarrhea causes

meds= PCN, macrolides, Mag based antacids, metformin, herbal/alter. medicine.
Ask about recent travel, diet patterns, baseline bowel habits, RF for immunocompromised.

69

Constipation

12 wks of past 6m. and 2 or more of: less than 3 BM/wk, 25% or more defocation- straining/sens incomplete evacuation, hard/lumpy stool, manual facilitation

70

Sigmoid colon obstruction

pencil shaped/apple core shaped hard stool

71

Causes constipation

Meds= Ca channel blockers, anticholinergic, Fe supplements, opiates. DM, hypothroid, hyperCa, MS, Parkinson, systemic sclerosis.

72

Obstipation

no gas or stool passage= obstruction

73

Melena

black tarry stool- as little as 100cc for UGIB

74

Hematochezia

red/maroon colored. 1000ml or more with LGIB

75

Hemmorrhoids

blood streak on surface of stool, not within

76

Jaundice

yellow discoloration of skin from bile pigment when Hgb broken down.

77

Normal Bilirubin

hepatocytes conjugate with unconj bilirubin, bile becomes water soluble, excreted into bile. Bile goes cystic duct- CBD-extrahepatic ducts-pancreatic ducts- duodenum at ampulla of Vater.

78

Mechanisms of jaundice

inc prod bilirubin, decr uptake bilirubin by hepatocytes, decr ability of liver to conj bilirubin, decr exc of bilirubin into bile- conj bilirubin gets reabsorbed into blood

79

Unconj bilirubn

occurs within first 3 mechanisms, hemolytic anemia inc prod and Gilbert's syndrome

80

Conj bilirubin

Viral hepatitis, cirrhosis, primary biliary cirrhosis, drug induced cholestasis- OCP, methyl testosterone, chlorpromazine

81

Intrahepatic jaundice

hepatocellular, imp exc- from damaged hepatocytes or extrahepatic ducts.

82

Extrahepatic jaundice

obs extrahepatic ducts- commonly CBD, cystic duct.

83

Jaundice r/t urine color

when conj bilirubin inc in blood, may be excreted in urine- turning urine dark amber/tea colored. Unconj bilirubin not water soluble- not excreted in urine. Dark urine - imp excr of bilirubin into GI tract.

84

Jaundice r/t stool color

when no bile is excreted into intestines, stool becomes gray/light colored.

85

Acholic stool

stool without bile- viral hepatitis, obstr jaundice.

86

Jaunidce r/t itchy skin

Cholestatic/obstr jaundice, pain may signify distended liver capsule, biliary cholic, pancreatic CA

87

RF for liver disease

Hepatitis, Alcohol hepatitis, alcoholic cirrhosis, toxic liver damage (meds, industrial solvents, env toxins), GB disease/surgery- extrabiliarty obstr., Heriditary

88

Lloyd's sign

Symptom of renal calculi. Pain in loin on deep percussion over kidneys

89

CV tenderness

Palm over CV angle, hit top of hand with ulnar side of fist. If tender: pyelonephritis, peri nephrotic abscess, kidney stones

90

Colon CA screening

Screening: 50y/o, colonoscopy q10 yrs. FOBT yearly, flex sigmoid Q 5y, barium enema Q5 y..
Screening for increased risk: single adenoma less than 1cm- 3-6 y,
Large adenoma bigger than 1cm 3y,
CRC resection: 1y after,
First degree relative younger than 60y, or 2 or more 10 years before youngest case.
H/O polyps q 3-5 yrs depending on type of polyp, usually adenomatous.
H/o Inflammatory bowel dz, first degree relative w/ polyps, CRC.
Genetic testing for inflam bowel dz.
other factors: DM, ETOH, obesity, smoking, high fat diet.
Protective factors: better diet, inc fruit/veg, high fiber, reg activity, ASA/NSAIDS.

91

Stress incontinence

Decreased intraurethral pressure

92

Involuntary/lack of awareness

Cognitive or neurosensory deficit

93

Men with partial bladder outlet obstruction

BPH, urethral structure

94

Suprapubic pain

Urinary tract, abdomen or back can be source

95

Pain of sudden overdistention of bladder

Acute urinary retention
Chronic is painless

96

Bladder Infection

Pain in Lower abdomen dull and pressure like

97

Dysuria

May feel like burning. Women- internal urethral discomfort, pressure, or ext burning across inflamed labia. Men burning proximal to glans.
Consider bladder stones, foreign body, tumor, acute prostatitis. Women- urethritis, ext burning- vulvovaginitis.

98

Prostatic pain

Perineum occasionally rectum

99

Urgency

May lead to urge incontinence.
Suggests bladder infection or irritation.

100

Urethritis

In men may have pain with voiding wo frequency or urgency.

101

Urinary tract symptoms

Urgency, frequency, hesitancy in starting, strain, reduced caliber and force of stream, dribbling
Frequency wo polyuria during day/ night suggests impairment to flow at or below bladder neck

102

Polyuria

Exceeding 3L in 24hrs. Abnormally high renal production.

103

Nocturia

Frequency at night. More than once. Volume varies. Clarify intake during day.

104

Urinary incontinence

Loss with increased abdominal pain or when urge to void. Stress inc- inc abd pressure- dec contractilty of urethral sphincter or poor support of bladder neck. Urge inc- unable to hold urine, detrussor over activity. Overflow inc bladder doesn't empty fully- anatomical obs by prostatic hypertrophy, strictures or neuro abn. Functional inc- imp cognition, MS

105

Hematuria

Frank or microscopic. May be pink or brown tinged. Ask about beets, meds, menses

106

Flank pain

At or below posterior margin near CV angle. May radiate anterior lay toward umbilicus. Visceral pain, dull, achy, steady.

107

Ureteral colic

Sudden obstruction of ureter. Severe and colicky, at CV angle radiating around trunk into lower quad, upper thigh, testicles, labium. Ask about fever, chills, hematuria. Urinary stones or clots

108

ETOH

H/o pancreatitis, family Hx, DUI.
Exam: hepatoaplenomagaly, ascites, spider angioma, palmar erythema, peripheral edema, caput medusa ( collateral pathways of recanalized umbilical veins, radiating up abdomen, decompressing portal HTN).
Sequelae: fatal car accidents, suicide, mental health disorders, family disruption, violence, HTN, cirrhosis, malignancies upper Gi and liver.

109

Substance abuse

Rearranges brain neurotransmitters:
Tolerance, physical dependency, sensitization, craving, relapse.

110

Alcohol screening

Women: >= 3/occasion, >=7/ week
Men >= 4 /occasion, >=14/week

111

Hepatitis A RF

Fecal oral. Contaminated food or water, infected households. Hep A vaccine. Treat with immune serum globulin. Good hand washing

112

Hepatitis B RF

Sexual contact, people w/exposure to percutaneous blood, travelers. Hep B vaccine.

113

Hepatitis C RF

Blood exposure. High risk IVDA, Transfusion with clotting factors- before 1987. Other RF: HD, partners IVDA, blood Tx/ organ transplant before 1992, unDx liver dz, infants of +mothers, occupational exposure, mult sex partners, infected sex partner. Sexual transmission rare. Avoid tattoos.

114

Tips for Abd exam

Empty bladder, supine, pillow, arms at sides or folded a Ross chest. Point to pain before palpation, warm hands and stethoscope, avoid long fingernails, war h pt face for pain, if scared or ticklish palpate with patients hand first then use own.
Order inspect, auscultation, percussion, paplaption

115

Tips for Abd exam

Empty bladder, supine, pillow, arms at sides or folded a Ross chest. Point to pain before palpation, warm hands and stethoscope, avoid long fingernails, war h pt face for pain, if scared or ticklish palpate with patients hand first then use own.
Order inspect, auscultation, percussion, paplaption

116

Inspection of abdominal skin

scars, straie(pink purple straie with Cushing's syndrome), dilated veins(hepatic cirrhosis or IVC obstr., rash/lesions

117

Inspection of umbilicus

contour, location, inflammation, bulges, hernias

118

Contours of the abdomen

flat, rounded, protuberant or scaphoid(concave/hollow)
Flanks bulge(ascites), local bulges. Suprapubic bulge- distended bladder or pregnant uterus
Check inguina/femerol areas.
Symmetrical- may be assymmetrical- enlarged organ or mass

119

Peristalsis

May be visible in very thin people. Increase waves- intestinal obstruction

120

Pulsations

Normal Ao pulsation visible in epigastrum. Increased pulsation- Ao aneurysm or inc pulse pressure

121

Ausculation

Bowel sounds reflect motility. 5-35X/min= normal.

122

Borborygmi

prolonged gurgles of hyperparistalsis

123

Bruit

may suggest vascular occlusive disease.
Listen over epigastrum(systole), and each upper quadrant. when pt sits, listen in CV angles.
Bruit at Renal, Iliac or Femerol arteries suggest S/D components- renal artery stenosis- d/t HTN.
If bruit only systolic- usually not occlusive
If S/D- turbulent flow- part. art. occlussion or arterial insufficiency

124

Friction Rub

Listen over liver and spleen.
Liver- tumor, gonococcal infection around liver, splenic infarction.

125

Percussion

Assess amount and distribution of gas in abd, identify possible masses that are solid/fluid- filled. Estimate liver/spleen size.
Percuss in all 4 quads, tympany(gas)/dullness(fluid/feces).

126

Protuberant abd tympanic throughout

Intestinal obstruction

127

Large dull areas of percussion

underlying ass, enlarged organ, pregnant uterus, ovarian tumor, large liver/spleen

128

Protuberant abd, dull sides

Note where dullness starts, may suggest ascites

129

lower ant chest percussion

right dull d/t liver. left tympanic d/t gastric air bubbles, splenic flexure of colon.
Situs Inversus rare- organs reversed.

130

Palpation

ID tenderness, muscular resistance, superficial organs, masses. Palpate with light gentle dipping motion.

131

Restistance on palpation

voluntary gaurding vs involuntary muscular spasm. Relax methods, feel relaxation of abd muscles that normally accompany exhalation, mouth breathe with jaw dropped open: Voluntary guarding decreases with these manuevers

132

Deep Palpation

To delineate abd masses: location, size, shape, consistency, tenderness, pulsations, mobility with respirations- correlate findings with percussion.

133

Abd masses

physiologic(pregnant uterus)
Inflammatory(diverticulitis)
vascular(AAA)
neoplastic(CA colon)
obstructiove(distended bladder or loop of bowel)

134

Peritoneal Inflammation

Abd pain/tenderness- esp a/w muscular spasm- suggest inflam of parietal peritoneum. Ask pt to cough- ?induce pain? Palpate to map tender area.

135

Rebound tenderness

Press fingers down with other handfirmly- withdraw quickly. Worse with pressure or when let go? point to exact pain. Rebound tenderness- peritoneal inflam.

136

Liver percussion

measure vertical span of dullness in R MCL. Start in area of typany(below umbilicus) and percuss upwards. ID lozer boarder of dullness in MCL.
Upper boarder of liver dullness in MCL: nipple line, lightly percuss from lung resonance down to liver dullness, move breasts aside.
Measure in cm distance between points.
6-12 cm R MCL or 4-8cm in MSL
Span of dullness increased when liver enlarged.

137

Liver dullness span decreased

decreased when liver small or free air present below diaphragm(perf. hollow viscus). Decreasing span- resolving hepatitis, CHF, progression of fulminant hepatitis.

138

Liver dullness displaced downward

COPD, span normal

139

Alter results of percussion

dullness of pleural effusion/lung consolidation may falsely increase estimated liver size. Gas in colon may produce tympany- falsey obscure liver dullness- decreasing liver size.

140

Palpabe Liver right costal margin

only half palpable- but if palpable, liklihood og hepatomegaly doubles.

141

Liver palpation

supine, left hand behind 11/12 rib posteriorly and forward- liver up. Right hand right abd, fingertips below lower border of liver dullness. Deep breathfeel liver meet fingers, slip fingers under- normal is soft, sharp, regular with smooth surface. May be tender- normal. Firm/hard, blunt/rounding, irregularity- abn liver.
Inspiration- liver palpable 3 cm below right costal margin in MCL.
If hard to find- move hands closer to coatal margin and repear. Maybe started too high in abd, start lower.

142

Gallbladder obstruction

oval mass below edge of liver- two are merges, dull- percussion

143

Hooking technique

use for obese pt., stand at right side facing feet. Use both hands, breath deep, bend fingers around lower edge of liver

144

Percussion tenderness of liver

left hand flat on lower rib cage, hit with ulnar side of fist of right hand- tenderness may be inflammation(hepatitis) or congestion(HF)

145

Spleen percussion

If enlarged, expands ant, down, medially-typany replaced with dullness. Becomes palpable at costal margin. Suggests splenic enlargement. 2 techniques:
1. Left lower anterior chest wall- resonance above costal margin (Trabue's soace), percuss towards back. Normally spleen posterior to midaxillary line. If dullness present- splenomegaly 80% chance. If tympany +, esp laterally- unlikely splenomegaly.
2. Splenic percussion sign- percuss lowest interspace in left axillary line(tympanic), deep breath, percuss again. If spllen normal, stays tympanic. If dullness, + splenic percussion sign. Could be + with normal spleen.

146

Spleen palpation

left hand reach over to press back up, right hand press in at costal margin, deep breath and feel tip. 5% normal people have palpable tip. Causes: low, flat diaphragm(COPD) and deep inspiratroy descent. May miss spleen if start too high. Splenomegaly 8X more likely if spleen palpable. Causes: portal HTN, hematologic malignancies, HIV, splenic infarct/hematome.
Repeat in side lying position: left hand on back, right hand pushing in (2cm below left costal margin on deep insp).

147

Kidney palpation

not usually palpable. left side, right hand behind pt below/parallel to 12th rib, fingertips at CV angle. Left hand in LUQ, deep breath, press left hand in below costal margin to capture kidney between hands. If kidney palpable, note size, contour and tenderness.Repeat on eft side.

148

Left flank mass

may be splenomegaly or enlarged left kidney. Splenomegaly if notch is plapated on medial border, edge beyond midline, percuss dull, can probe deep to medial/lateral borders but not between mass and costal margin.
Enlarged kidney: normal tympany in LUQ, can probe with fingers between mass and costal margins, not deep to medial/lower borders.

149

Palpation right kidney

may be palpable, can feel supine, left hand under pushing up.May/may not be tender. May be located more anteriorly- confused with liver. Liver edge sharp/medial/lateral. lower pole kidney rounded.

150

Kidney enlargement

hydronephrosis, cysts, tumors. Bilateral enlargement- polycystic kidney disease

151

Percussion tenderness kidneys/CV

palm on back at CV angle, hit with ulnar surface opposite fist. Tenderness- pyelonephritis, may also be musculoskeletal

152

Bladder palpation

not usually palpable unless distended past symphysis pubis Dome feels smooth, rounded. ? Tenderness.
Bladder distention- outlet obstruction (urethral strictures, prostatic hyperplasia), medications and neurologic(CVA, MS). Suprabic tenderness- bladder infection.

153

Aorta palpation

deep, firm, slightly to left of midline. Not more than 3cm. RF for AAA: 65 y/o, Hx smoking, male, 1st degree relative with Hx of AAA repair.

154

Periumblical/upper abdominal mass

with expansive pulsations- more than 3 cm- suggests AAA. Do US after palpation. Pain=sign of rupture. AAA greater than 4cm, 15X more likely to rupture than smaller aneurysms

155

Ascites

fluid generally is dependant, gas floats. Percuss outward, should have tympany and dullness in circular pattern from rib to rib.

156

Ascites causes

Increase hydrostatic pressure: cirrhosis, CHF, constr. pericarditis, IVC or hepatic obstr.
Osmotic pressure: nephrotic syndrome, malnutrition, ovarian cancer.

157

Ascites shifting dullness

turn pt on one side and map tympany/dullness. In pt wo ascites, borders stay same. In ascites, dull is dependant, tympany on top.

158

Ascites fluid wave

Another person hands on both sides abd and pressin. You tap on one side and see if it you feel it on other side. Often negative with ascites.

159

Abd mass

Ballotte the organ or mass, with flat hands use ulnar side of palms and jab toward structure.

160

ppendicitis

Point to pain- usually umbilicus, then shift to RLQ, coughing increases it. Localized tenderness RLQ/flank. Early voluntary guarding may be replaced by invol rigidity. Rebound tenderness- peritoneal inflam
Rectal exam in men, vag exam in women- could be from inflammed seminal vesicle or adnexa

161

Rovsing's sign

press deep into LLQ, resulting with pain in RLQ- + finding. Also with rebound tenderness- referred.

162

Psoas sign

hand above knee, pt raise thigh against hand. then left side- extend right leg, flex left hip. Flexion of leg at hp- muscle contracts extension stretches. Inc abd pain- + psoas muscle- irritation- inflammed appendix.

163

Obturator sign

flex right thigh at hip, knee bent, rotate leg internally at hip. Stretchs internal obturator muscle. Right hypogastric pain- + obturator sign, can be from irritation of inflamed appendix.

164

Cutaneous hyperesthesia

Pick a fold of skin without pinching. Localized pain with RLQ pain- appendicitis

165

Acute Cholecystitis

RUQ pain/tenderness. Murphy's sign- hook fingers of right hand under costal margin. If liver enlarged- hook fingers and thumb under liver edge- deep breath- note degree of tenderness. + sign is sharp increased tenderness with sudden stop in insp effort. Means cholecystitis. Hepatic tenderness- increase with this manuever but ususally less well localized.

166

Ventral Hernia

Raise head and shoulders off table- bulge of ventral hernia will appear. Intestinal obstr or peritonitis may be missed by overlooking strangulated hernia.

167

Abd wall mass

raise head and shoulders. Mass in abd wall remains palpable, intra abd mass is obsured by musclular contractions

168

Tips for Abd exam

Empty bladder, supine, pillow, arms at sides or folded a Ross chest. Point to pain before palpation, warm hands and stethoscope, avoid long fingernails, war h pt face for pain, if scared or ticklish palpate with patients hand first then use own.
Order inspect, auscultation, percussion, paplaption