abdominal exam

Question 1

ladder pattern+visible peristaltic waves+hyperactive bowel sounds

Answer 1

intestinal obstruction!

Question 2

cupid’s bow

Answer 2

acute pancreatitis

central dimple at umbilicus

Question 3

auenbrugger’s sign

Answer 3

large pericardial effusion

-localized bulge in epigastric area

Question 4

sister mary joseph’s nodule

Answer 4

palpable lymph node

intrabdominal metastasis

Question 5

cullen’s sign and grey turners sign

Answer 5

periumbilical ecchymosis/bilateral discoloration assoc. w/ acute hemorrhagic pancreatitis

Question 6

venous pattern: obstructed SVC

Answer 6

vv are engorged on upper abdominal wall and when you milk them you get downward flow

Question 7

venous pattern: obstructed IVC

Answer 7

vv are engorged in lateral abdominal wall and when you milk them you get upward flow

Question 8

caput medusae

Answer 8

cirrhotics and portal HTN (umbilical v reopened)

Question 9

venous pattern obstructed portal system

Answer 9

periumbilical v: rostral drain up (to internal mammary) and lower drain down (inferior mammary)

Question 10

percussion: central dullness + lateral resonance

Answer 10

pregnancy

Question 11

central tympany/resonance and lateral dullness

Answer 11

ascites/fluid

Question 12

murmurs/bruits in epigastrum

Answer 12

pregnancy, normal thin women, d/t celiac tripod

Question 13

murmurs/bruits in RUQ

Answer 13

hepatoma, cirrhosis, metastatic liver disease, AV malformation, tricuspid regurg

Question 14

murmurs/bruits in LUQ

Answer 14

pancreatic ca or vascular anomaly of spleen

Question 15

murmurs/bruits in both upper quadrants +/- epigastrium

Answer 15

renovascular disease

Question 16

cruveilhier-baumgarten murmur/sign

Answer 16

• continuous venous hum/murmur

- due to reopening of umbilical v d/t portal HTN

Question 17

hepatic friction rub

Answer 17

hepatoma

Question 18

hepatic bruits

Answer 18

arterial (in systole), if assoc/ w/ a rub=neoplasia

Question 19

hepatic venous hums

Answer 19

systolic and diastolic

indicate portal venous hypertension

Question 20

percussion of spleen

Answer 20

• nixon’s technique: percuss whole spleen with patient in R lateral decubitus (best specificity)–dullness>8cm=bad
• catell’s technique: percuss lowest left ICS while patient breathes in and out (best sensitivity)–dullness in 8th ICS=bad
• percussion of traube’s semilunar space: dullness can indicate splenomegaly

Question 21

splenic rubs

Answer 21

splenic infarct

Question 22

splenic murmur

Answer 22

massive splenomegaly or pancreatic carcinoma

Question 23

costophrenic tenderness

Answer 23

pyelonephritis or renal infarct

Question 24

tender flank and costovertebral region

Answer 24

renal colic

Question 25

renovascular disease

Answer 25

can have anterior systolic murmur, posterior systolic murmur, anterior continuous bruit

Question 26

right supraclavicular node

Answer 26

drains R lung, R breast, and contralateral *Left lung base!

Question 27

left supraclavicular node

Answer 27

drains L lung, L breast Trossier: L node (stomach, intestine, liver, kidney, pancreas, testicles, endometrium) Virchow: L node draining stomach (gastric carcinoma)

Question 28

gallbladder disease 4 Fs

Answer 28

fat, fertile, female, forty

Question 29

murphy's sign

Answer 29

-painful reflex arrest in inspiration, triggered by palpation of edge of inflamed gallbladder

Question 30

Courvoisier's law

Answer 30

painless jaundice + enlarged, palpable, non-tender gallbladder -cancer of biliary tract or pancreatic head

Question 31

Boa's sign

Answer 31

area of hypersensitivity over R. costophrenic angle (and R. shoulder)

Question 32

big clues to ascites

Answer 32

recent wt gain or hx of liver disease

Question 33

PE tests for ascites

Answer 33

1. bulging lfanks 2. flank dullness 3. shifting dullness 4. fluid wave (only specific test) 5. ballottement sign * *only good if 500-1000cc of fluid (if less than US is gold standard, can detect 100cc fluid)

Question 34

tests to rule-in ascites

Answer 34

fluid wave and hx of ankle edema

Question 35

tests to r/o ascites

Answer 35

absence of shifting dullness, esp in abscence of ankle edema/abd girth

Question 36

transudate ascitic fluid

Answer 36

cirrhosis, CHF, nephritic syndrome

Question 37

exudative ascitic fluid

Answer 37

ruptured viscus with peritonitis, tumors

Question 38

causes of distension w/o ascites

Answer 38

aerophagia, malabsorption, chronic pancreatic insufficiency, bowel obstruction

Question 39

induced guarding/carnett's sign

Answer 39

``` touch chin to chest (activate abdominal mm) if tender (+ sign), lesion in abdominal wall if not tender (-sign), lesion is intra-abdominal ```

Question 40

modified induced guarding/abdominal wall tenderness

Answer 40

differentiate abdominal wall mischief from intra-abdominal | -don't do in kids or elderly, pts with diffuse abdominal pain and rigidity, patients with intra-abdominal abscess

Question 41

rebound tenderness (blumberg sign)

Answer 41

don't need to do if already have guarding/rigidity | -indicates localized peritonitis

Question 42

referred rebound tenderness

Answer 42

palpable quadrant contralateral to patient's pain + if it elicits pain in original site variants: cough test, jar test, valsalva

Question 43

closed eye sign

Answer 43

if have true intraabdominal pathology, will keep eyes open and monitor exam

Question 44

PE signs of liver disease

Answer 44

1. spider teleangiectasias (nevi): abnormally inc. ratio estradiol:testosterone, pregancy, malnutrition 2. palmar erythema (hepatic inability to inactivate vasodilators) 3. asterixis (hepatic encephelopathy) 4. palpable spleen (portal HTN) 5. fetor hepaticus (severe parenchymal disease) 6. dilated abdominal vv 7. clubbing 8. . orthodeoxia/platypnea b/c created shunts

Question 45

tests for appendicitis

Answer 45

none are sensitive 1. MucBurney's (focal tenderness/rigidity 2 inch medial of R ASIS) 2. Rovsings (pain in R. iliac fossa d/t pressure over LLQ) 3. Obturator: pain if flex and rotate hip 4. reverse psoas: retrocecal processes 5. rectal tenderness: perforation

Question 46

PE findings: absent bowel sounds and tympany

Answer 46

late stage of bowel obstruction (paralytic ileus)

Question 47

PE findings: hyperactive high pitched bowel sounds and tympany and visible hyperperistalsis

Answer 47

early stage obstruction

Question 48

PE findings: vascular bruit

Answer 48

dissecting arterial aneurysm

Question 49

PE findings: distension, absent sounds, absent liver dullness

Answer 49

free intraperitoneal air due to perforated viscus