PD Abdomen Flashcards Preview

Physical Diagnosis > PD Abdomen > Flashcards

Flashcards in PD Abdomen Deck (154):
1

Preparations for abdominal exam

Privacy, proper draping
Expsoure of abdomen from xiphoid to symphysis pubis
Empty bladder before exam
Warm hands
Gentile touch, patience

2

Patient positioning for abdominal exam

Supine, relaxed
Arms at sides
Legs slightly flexed, keeping soles on table
Approach from patient's right side

3

When are painful areas percussed and palpated?

Last on the exam!

4

Always think of what ... underlie the area being examined?

Organs

5

Solid viscera

Liver
Spleen
Kidneys
Adrenals
Ovaries
Uterus

6

Hollow viscera

Stomach
Small bowel
Colon
Gallbladder
Bladder

7

Watch patient's facial ... throughout the exam

Expressions

8

Order of abdominal exam

Inspection
Auscultation
Percussion
Palpation and special maneuvers
DRE

9

Where does the kidney lie in relation to the ribs

Protected by 11th and 12 th ribs, and pokes out right underneath

10

RUQ

Liver
Gallbladder
Duodenum
Head of pancreas
Right adrenal gland
Portion of right kidney
Hepatic flexure
Portions of ascending and transverse colon

11

RLQ

Lower portion of right kidney
Cecum and appendix
Portion of ascending colon
Bladder
Right ureter
Ovary/uterus
Spermatic cord

12

LUQ

Stomach
Spleen
Body and tail of pancreas
Left adrenal gland
Splenic flexure
Portions of transverse and descending colon

13

LLQ

Lower portion of left kidney
Portion of descending colon
Sigmoid colon
Left ureter
Ovary/uterus/salpinx
Spermatic cord

14

Inspection

Shape/contour
Scars
Striae
Vascular patterns
Masses, hernias
Ecchymoses
Pulsations
Peristaltic waves

15

Shape and contour of abdomen

Obese
Protuberant
Distended
Flat
Scaphoid

16

Striae on abdomen
Causes

"Stretch marks"
Pregnancy
Obesity
Cushing's

17

What color are striae in Cushing's syndrome?

Purple from hypercortisolism

18

Ecchymoses

Cullen sign
Grey Turner sign

19

Cullen sign

Bluish discoloration/bruising around the umbilicus due to intraperitoneal bleeding

20

Causes of Cullen sign

Hemorrhagic pancreatitis
Ruptured ectopic pregnancy

21

Grey Turner sign

Ecchymoses of flanks causes by retroperitoneal bleeding

22

Causes of Grey Turner sign

Coagulopathies
Acute hemorrhagic pancreatitis
Ruptured AAA
Trauma

23

Hernia

Protrusion or projection of an organ (or part) through the wall of the cavity that normally contains it

24

Reducible hernia

Contents of the hernia sac are easily replaced

25

Types of hernia

Congenital
Umbilical
Direct/indirect inguinal
Incisional
Ventral
Sliding
Incarcerated
Strangulated

26

Incarcerated hernia

Hernia sac contents can't be reduced

27

Strangulated

Blood supply to an incarcerated hernia is compromised, contents may become gangrenous

28

Special maneuvers

Deep breath
Head lift

29

Deep breath special maneuver

Displaces abdominal contents downward and may reveal previously unseen hernias or masses

30

Head lift special maneuver

Increases intra-abdominal pressure which may also protrude hernias and /or separate the recti muscles

31

Diastasis recti
Causes

Right and left rectus muscles have separated
Often due to obesity or pregnancy

32

Is a diastasis recti a true abdominal hernia?

No, no fascial defect
No risk for incarceration or strangulation

33

Caput medusa
Causes

Dilated cutaneous veins around the umbilicus
Newborns, portal HTN, cirrhosis

34

Diaphragm or bell?

Diaphragm

35

What abdominal sounds are normal?

Clicks and gurgles

36

How many bowel sounds are normal?

3-30 per minute, irregularly spaced is normal

37

Borborygmi
Causes

Loud, prolonged gurgles associated with hyper peristalsis
Diarrhea
Hunger
Early obstruction

38

High pitched, tinkling BS indicates...

Fluid or air under pressure and often indicative of small bowel intestinal obstruction

39

Causes of decreased bowel sounds

Adynamic ileus
Obstruction
Peritonitis
Common post surgically

40

When can we determine that there are truly no bowel sounds?

Established only after full 5 minutes of continuous listening
Auscultate all 4 quadrants to not miss any localized bowel sounds

41

Where do we listen for bruits?

Aorta (above umbilicus)
Renal arteries (2) (sides of aorta)
Iliac arteries (2) (sides of umbilicus)
Femoral arteries (2) (sides of groin)

42

Bell or diaphragm for bruits

Bell

43

Venous hum

Soft, low systolic diastolic hum over liver, umbilical area
Indicative of increased collateral circulation between portal and systemic venous systems

44

Causes of venous hum

Cirrhosis
Portal HTN

45

Friction rub

Rare to hear in abdomen
High (possibly low) pitched grating sound
Vary with inspiration, may be referred from pleurae

46

Causes of friction rubs

Peritoneal irritation
Peritonitis
Enlarged liver
Splenic infarct

47

Where do we percuss?

All four quadrants
Liver
Spleen
Bladder

48

What is the normal percussion sound? What is it due to?

Tympany
Due to gas in GI tract

49

Dullness on percussion

Solid organ
Mass/tumor
Fecal matter
Fluid accumulation

50

How do we determine the size of the liver?

Determine the upper and lower margins of the liver by percussion

51

How do we perform percussion for liver span?

Percussing inferiorly from lungs (resonant) and superiorly from lower abdomen (tympanic)

52

What does percussion over the liver sound like?

Dull

53

Normal liver span

6-12 cm at right mCL
4-8 cm at midsternal line

54

What individuals have normally larger livers?

Men, taller individuals

55

Increased liver span

Cirrhosis
Hepatomegaly
Hepatitis
Liver carcinoma
CHF

56

Causes of falsely enlarged liver

Obesity
Ascites
Pleural effusion
Lung consolidation
Stool filled colon
Mass

57

Where is the spleen percussed?

Posterior to left midaxillary line, percussed in several directions noting dullness
6-10th ribs

58

Most normal spleens do not traverse the...

Left anterior axillary line

59

What is heard on percussion of the spleen?

Dullness

60

What does a large area of dullness suggest?

Splenomegaly

61

What conditions can mimic splenomegaly?

Full stomach or stool filled colon

62

Where do we start palpation?

Start opposite of area of complaint
Systematic approach, all four quadrants

63

What structures do we palpate?

Liver edge
Spleen
Kidneys
Bladder
Masses
Aorta
CVA (costovertebral angle)

Light palpation
Deep palpation

64

Light palpation

Soft, using right hand only
Pressing down about 1 cm

65

What do we identify with light palpation

Guarding
Areas of tenderness
Superficial masses

66

Guarding

Involuntary muscle resistance, may be due to peritoneal irritation/inflammation

67

What do we identify with deep palpation?

Delineate organ size
Masses
Aorta
Areas of tenderness

68

Deep palpation

May use 1 or 2 hands
Press down 4-5 cm or more

69

Examples of abdominal masses

Tumors
Hernias
Aneurysms
Pregnant uterus
Stool
Abdominal muscles
Enlarged organ

70

Description of masses

Location
Size
Shape
Consistency
Tenderness
Mobility
Pulsatility

71

Consistency of masses

Hard or soft, smooth or nodular

72

Palpating liver edge

Approach from inferior aspect
Left hand under patient at 11-12th ribs lifting up
Right hand just below costal margin pointing toward head
May also stand facing patients feet and hook fingers under costal margin

73

In a normal healthy patient, the liver should not be felt below..

The costal margin

74

If liver is felt below costal margin, how should it feel

Firm
Smooth
Non tender

75

Asses liver for...

Size
Surface texture - smooth versus irregular / nodular
Tenderness

76

Causes of hepatomegaly

Hepatitis
Cirrhosis
Liver ca, mets
CLL
Lymphoma
Fatty infiltration of liver
Portal venous HTN
Hepatic vein thrombosis
Passive congestion from CHF
Amyloidosis
Mononucleosis
Hepatic abscess

77

Palpating the spleen

Bimanual palapation
Right hand pushing into abdomen in LUQ
Left hand lifting from the back

78

Position of patient for palpation of spleen

Patient supine and also right lateral decubitus

79

What should the patient do to increase the chance of palpating the spleen?

Inspiration

80

Can we feel the spleen in most patients?

Tip of spleen is barely palpable in small percentage of adults normally
If you can feel it, it's enlarged

81

Causes of splenomegaly

Lymphoma
CML, CLL
Polycythemia vera
Mono, viruses
Hepatitis
TB
Cirrhosis
Splenic abscess
SLE
Hemolytic anemia
Sarcoidosis
Sicle cell anemia
Portal HTN
Liver/abdominal malignancy
Long standing CHF
Amyloidosis

82

Are the kidneys palpable? Which kidney is more palpable?

May be barely palpable in thin individuals
Right kidney more palpable than left

83

Cause of enlarged kidneys

Hydronephrosis
Polycystic kidney disease
Tumor (renal cell carcinoma most common)
Wilm's tumor

84

Where should we assess for renal tenderness?

CVA tenderness

85

What does CVA tenderness indicate?

Kidney infection - pyelonephritis
Musculoskeletal

86

What is the diameter of the descending aorta in most healthy individuals?

2-3 cm

87

How is the aorta assessed?

Deep palpation just left of midline in the upper abdomen
Should be non tender
Looking for pulsatile mass

88

What does enlargement of the aorta suggest?

Abdominal aortic aneurysm

89

What individuals are more likely to have an AAA?

Men older than 50
Hx of atherosclerosis

90

When is the bladder palpable?

Not usually palpable unless distended with urine

91

Where are masses present with the bladder is distended?

Rounded/tense/smooth mass is palpable midline above the pubis symphysis

92

What is heard on percussion over a mass in the bladder?

Dull

93

What condition might mimic a mass in the bladder?

Ovarian cysts

94

Special maneuvers

Assessing for peritoneal signs - rebound tenderness, guarding
Iliopsoas test
Obturator test
McNurney's sign
Rovsing's sign
Murphy's sign
Assessing for ascites - fluid wave/shifting dullness

95

What is rebound tenderness used to detect?

Peritoneal irritation

96

Rebound tenderness

Press gently and deeply into area remote from area of patient's discomfort
Rapidly withdraw hand and fingers

97

What is another name for positive rebound tenderness

Positive Blumberg sign

98

Why is there pain in rebound tenderness?

The return to position of structures that were compressed by your fingers causes a shape pain at the site of peritoneal inflammation

99

Iliopsoas test

Place hand over lower thigh and have patient raise leg while you push downward
Will cause pain if iliopsoas is irritated

100

What is the iliopsoas used to detect?

Appendicitis
Iliopsoas abscess

101

Obturator test

Have patient flew leg at the hip and knee to 90 degrees
Hold leg just above knee, grasp ankle
Rotate leg laterally and medially
Inflammation of obturator will cause pain

102

What is the obturator test used to detect?

Ruptured appendix
Pelvic abscess

103

McBurney's point

Halfway between umbilicus and anterior superior iliac spine

104

Cause of McBurney's point tenderness

Acute appendicitis

105

Rovsing's sign

Palpate patient's LLQ
If this causes pain in the RLQ

106

What is the Rovsing's sign used to detect?

Appendicitis

107

Murphy's sign

Ask patient to inspire while your fingers are held under the liver border where the gallbladder may be depressed into them
Inspiration will abruptly stop when inflamed gallbladder comes into contact with fingers

108

What is Murphy's sign used to detect?

Cholecystitis

109

What kind of patients should we suspect ascites?

Protuberant abdomens or flanks that bulge in supine position

110

Conditions that produce ascites

Cirrhosis
Alcoholic hepatitis
CHF
Hypoalbuminemia (nephrotic syndrome, malnutrition)
Malignancy
Renal failure

111

What are we percussing for when assessing ascites?

Areas of dullness and tympany

112

Shifting dullness

Helps to determine presence of fluid
Have patient lie on one side and again percuss for tympany and dullness and mark borders
Fluid will settle in dependent position

113

Fluid wave

Requires two people
Have patient or other examiner place edge of hand and forearm along vertical midline of abdomen
Place hands on each side of abdomen and strike one side sharply with fingertips
Feel implies of a fluid wave with fingertips of the other hand
Easily detected wave suggests ascites

114

What do we confirm a fluid wave with?

Ultrasound

115

DRE structures

Anal mucosa
External sphincter
Internal sphincter
Rectal mucosa
Transverse folds

116

What is another name for transverse folds?

Houston valves

117

Which transverse fold can be palpated?

Inferior fold

118

Where is the prostate gland in relation to the bladder?

Base of the urinary bladder

119

Which surface of the prostate is accessible?

Posterior surface is accessible on DRE

120

Parts of the prostate

Median sulcus
Right and left lobes

121

.... rectal wall lies adjacent to ... aspect of vagina

Anterior rectal wall lies adjacent to posterior aspect of vagina

122

How are female structures assessed?

Two fingers, but commonly performed without pelvic exam

123

Patient preparation for rectal exam

Uncomfortable/embarassing - be sensitive
Explain procedure clearly and purpose
Respect patient's wishes if refuses, but document
Calm, slow, gentle manner leads to patient cooperation, trust, and understanding

124

Positioning for rectal exam

Supine, knees flexed
Left or right lateral with knees flexed
Standing, hips flexed, torso supported

125

Inspection areas rectal exam

Perianal area
Anus

126

Palpation areas rectal exam

Perianal area
Sphincter/anal ring
Rectal walls
Prostate gland

127

Inspection perianal area

Smooth skin contours
Lumps, growths
Rashes
Inflammation
Excoriations

128

Inspection anus

Gently spread buttocks apart

Skin pigmentation
Lesions
Hemorrhoids
Fissures
Fistulas

129

What maneuver will make abnormalities of the anus more apparent?

Asking patient to bear down

130

Hemorrhoids

Veins around anus or lower rectum are swollen and inflamed

131

Risk factors for hemorrhoids

Constipation
Pregnancy
Aging
Overweight/sedentary
Anal intercourse

132

External hemorrhoids cause

Caused by increase pressure within the external hemorrhoidal veins

133

Where do external hemorrhoidal veins arise?

Arise at lower end of the anal canal near the anus, below the dentate line

134

Where do internal hemorrhoids arise?

Develop above the dentate line

135

When might an internal hemorrhoid be visible?

Not visible unless prolapsed

136

What patients usually suffer from rectal prolapse?

Mainly in elderly
Children under 6

137

Anal fissure
Symptoms

Tear in the skin of the anal canal
Usually cause pain and rectal bleeding

138

Tx anal fissure

Over 90% heal without surgery
Topical creams
Suppositories

139

Pilonidal cyst
Symptoms

Cyst develops along the tailbone near cleft of buttocks
May cause pain and inflammation as often become secondarily infected

140

How old are patients who get pilonidal cysts?

15-24

141

Tx for pilonidal cyst

Often need surgical resection

142

Palpation perianal area

Masses
Tenderness

143

Palpation sphincter/anal ring

Lubricate index finger
Rest pad of finger against anal opening
Ask patient to bear down - relaxes external anal sphincter

Sphincter tone
Smoothness of anal ring
Tenderness
Consistency of stool in vault

144

What do we need to be aware of about the patient with a DRE?

Be aware of patient's urge to defecate

145

Tenderness of anal ring causes

Fissure
Fistula
Abscess

146

Palpation of rectal walls

Rotate examining finger both directions to thoroughly evaluate entire anal wall

Masses
Polyps
Tenderness
Nodules
Irregularities

147

Rectal wall male

Prostate

148

Rectal wall female

Uterus
Cervix
Septum

149

Size of prostate

Size of walnut

150

Contour of prostate

Symmetric with median sulcus

151

Consistency of prostate

Firm and smooth, similar to the tip of nose
Assess for tenderness

152

Stool

Color
Consistency
Presence of pus or blood
Test for occult blood

153

What substance do we use to test for occult blood?

Guiac testing

154

What color does a positive stool test turn?

Blue