Flashcards in Abdominal Physical Exam Deck (45):
Order of the 4 major components of the physical exam
-do auscultation first b/c mechanical stress to the intestines may disturb activity/bowel sounds
Draping of the abdominal exam
-expose only the area right below the breast to the pelvic brim
=> cover breast and everything below pelvic brim to retain modesty
Where should arms/legs be during abdominal exam?
-arms/hands down by side
-if abdomen is tensed, have pt bend their knees to relax their stomach
General: What to look for upon inspection of the abdomen
-flat vs. distended (distention possibly due to air, fat, or fluid)
-any skin abnormalities
-ventral hernias: distinguishable b/c become more pronounced via Valsalva maneuver
-pt's movement: staying still (ex: periotnitis) vs. writhing (ex: kidney stones)
Describe a pt's movement- distinguish staying very still vs. writhing
Pt w/ peritonitis (inflammation of the serosa = lining of the abdominal organs) often stays very still b/c any movement may irritate peritoneal
-ex: appendicitis, cholecystitis
Writhing/squirming- can't find a comfortable position, may be indicative of kidney stones
Typical writeup of inspection on abdominal exam
Flat/distended abdomen, no scars
-can give pertinent negatives of liver failure if clinical picture warrants such as no striae, dilated veins, spider angiomata, caput medusa
Describe the technique of abdominal auscultation
-listen in each of the 4 quadrants for about 10-15 seconds
-not rlly pathognomonic for anything, just to see if they are present and describe quantity/quality
Some causes of absent or hypoactive bowel sounds
-several days after surgery it is common for bowel sounds not to be present => landmark of recovery is the reappearance of bowel sounds
-late stage of an obstruction when nothing can move past the obstruction
-peritonitis (inflammation of the serosa) can result in a quiet abdomen
Describe the progression of bowel sounds in a early to late bowel obstruction
-starts w/ rushes of content rushing past a slightly stenosed opening
-twinkling when just fluid can get past the obstruction
-finally when nothing can get thru the obstruction => silence = absence of bowel sounds
rushes --> twinkles --> silence
-know treatment of obstruction has been successful when you hear reappearance of bowel sounds
Some causes of hyperactive bowel sounds
-inflammation of intestinal mucosa such as seen in IBD or diarrhea
Where and how do you listen for renal artery bruits?
Listen a few cm above the umbilicus on the lateral edges of the rectus muscle on both sides
Listen w/ the diaphragm, press firmly and deeply since the renal arteries are retroperitoneal structures
What are renal artery bruits indicative of?
Indicative of renal artery stenosis- b/c bruit sound is created by the turbulent flow of blood thru a stenosed renal artery
General: what to listen for upon auscultation of the bowel
-listen for quantity and quality of bowel sounds
-listen for renal artery bruits laterally a bit above the umbilicus
Example of abdominal auscultation write up
ex: Bowel sounds normal, no renal bruits noted
ex: Hyperactive bowel sounds noted in LLQ
General: what you're percussion for on the abdominal exam
-liver edge to look for enlarged liver
-air-fluid level to test for ascites (if warranted)
-all 4 quadrants to note tympanitic vs. dull sounds (if warranted)
-from RLQ diagonally up towards left rib edge if suspecting enlarged spleen
Describe how to percuss the liver
For top border: Start midclavicularly right below the right breast and percuss downwards until you hear tympanic (over lungs) to dull (over liver)
For the inferior margin of the liver: keep percussing until it goes from dull (liver) to tympanic (bowel)
Technically does percussing over the lungs or intestines make a more tympanitic sound?
Both are air-filled => gives 'drum-like' tympanitic sound
-sound over the lungs are dampened by the pectoralis muscle and ribs => less tympanitic over the lungs than over the intestines
How may COPD cause an abnormality on percussion of the abdominal exam?
COPD- may have hyperinflation of the lungs depending on the degree of air trapping in the lungs
hyperinflation of the lungs push down the liver => low inferior margin of the liver but not due to hepatomegaly
Describe how to assess for ascites via
Assessing for ascites via
(a) percussion by testing for shifting dullness- see if the air-fluid level rises when the pt lies on his/her side
(b) palpation by assessing for fluid wave- have pt put hand at umbilicus, tap on one side and feel for wave on the opposite side
Describe how to assess air-fluid level
Start percussion at the umbilicus and move laterally, should be equidistant on each side
-air is less dense than water
=> fluid-air level will rise when the pt moves on his/her side
-have the pt lie on their side then re-percuss and see if the air-fluid level rises
If negative shifting dullness => abdominal distention not due to fluid (may be fat or gas)
General: what are you palpating for on the abdominal exam
Palpating light then deeper
-assessing for pain, tenderness, rebound, guarding
-palpating for solid structures: liver and spleen
-measuring width (or just feeling for) abdominal aorta
-check CVAT if any indication of kidney inflammation (fever, urinary tract symptoms, back pain)
-look for any masses
Where do you start palpation of the abdominal exam?
RUQ or in the quadrant farthest away from the pain.
RUQ --> LUQ --> LLQ --> RLQ
What are you palpating for in each quadrant of the abdomen?
All: palpating for any pain, tenderness, rebound, or guarding
-palpating for liver edge: try hook or inhale technique
-palpating for enlarged spleen (start at the umbilicus and palpate upwards towards the left rib angle)
-stool-filled sigmoid colon
-bladder or pregnant uterus may be palpable
Maneuver to make it easier to feel the liver edge
Have the pt take and hold a big inhale b/c the downward mov't of the diaphragm will push down the liver
What is a way on abdominal exam to test for renal inflammation?
CVAT = costavertebral angle tenderness
-pound gently w/ bottom fo fist on the CVA => this will cause pain if the kidney is inflamed
-CVA = where the last ribs articulate w/ the vertebral column
How to measure the width of the abdominal aorta?
First feel for the abdominal aorta pulse by pushing down deeply w/ entire hand over the umbilicus. If you can feel pulsation, estimate size by using both thumbs pointing up towards the pts head on either edge of the pulsating structure
Example of abdominal palpation write up
ex: soft, non-tender abdomen; no guarding or rebound; liver palpable 2 cm below the right costal margin, spleen not palpable, no masses
ex: tender abdomen, positive Murphy's sign,
How to examine a pt for abdominal pain on palpation
Watch their face while examining the suspected tender area
Clinical signs of hyperbilirubinemia
Liver cannot conjugate or secrete bilirubin => high bilirubin in serum
-icterus = yellowing of sclera (eyes)
-jaundice = yellowing of skin
-bilirubinemia = yellow/browning of urine
How can cirrhosis cause ascites?
-Portal HTN => fluid backs up into interstitial space due to increase in abdominal capillary hydrostatic pressure
Clinical signs of increased systemic estrogen levels
Seen in cirrhosis when liver cannot breakdown estrogen precursors
-gynecomastia (breast development)
-spider angiomata: estrogen causes dilation of arterioles
Where are spider angiomatas most visible?
Skin of the upper chest
How can cirrhosis cause lower extremity edema?
Liver loses its synthetic ability to produce albumin => hypoalbuminemia => low oncotic pressure in dependent capillaries
Describe two clinically relevant manifestations of varices (and how they present)
Varices = when portal HTN causes blood to use collateral circulation to bypass the liver to get back to the heart from the portal vein
(i) most common = esophageal varices
-may present w/ emesis (vomiting up blood) if they rupture => blood in the esophagus
(ii) less common = caput medusa (looks like snakes) when the umbilical vein is recanalized and the blood pushes thru the superficial veins of the abdominal wall which dilate and become visible
Which is more common- esophageal or umbilical varices?
Esophageal varices are more common (or more likely to come before) caput medusa
-pain is worse upon lifting up hands after applying pressure
-indicative of peritoneal pain
-press away from the tenderness (press on the LLQ) and the pt feels pain in the affected area (RLQ) when you lift your hand
= gentler way of assessing rebound tenderness
-have pt press their entire hand against your hand's resistance => pain
-indicative of appendix inflammation
-pain upon passive flexion and rotation of the patient's hip (which causes stretching of the obturator muscle)
-indicative of appendix inflammation
Which maneuvers can be helpful to assess for appendicitis?
-rebound tenderness in RLQ (at McBurney's point)
-psoas and obturator sign
Which clinical findings are rare but indicative of acute pancreatitis?
Grey-Turner's and Cullen's sign- both indicative of pancreatic necrosis w/ retroperitoneal or intraabdominal bleeding => indiactive of acute pancreatitis
Which maneuvers can be helpful to assess for cholecystitis?
pushing towards the liver at the right costal margin causes pain and inspiratory pause/gasp
-indicative of cholecystitis (inflammation of the gall bladder)
-bruised lateral flanks (flanks are the space btwn the last rib and the top of the hip bone)
-uncommon sign of acute pancreatitis