Flashcards in PD Abdomen Deck (154):
Preparations for abdominal exam
Privacy, proper draping
Expsoure of abdomen from xiphoid to symphysis pubis
Empty bladder before exam
Gentile touch, patience
Patient positioning for abdominal exam
Arms at sides
Legs slightly flexed, keeping soles on table
Approach from patient's right side
When are painful areas percussed and palpated?
Last on the exam!
Always think of what ... underlie the area being examined?
Watch patient's facial ... throughout the exam
Order of abdominal exam
Palpation and special maneuvers
Where does the kidney lie in relation to the ribs
Protected by 11th and 12 th ribs, and pokes out right underneath
Head of pancreas
Right adrenal gland
Portion of right kidney
Portions of ascending and transverse colon
Lower portion of right kidney
Cecum and appendix
Portion of ascending colon
Body and tail of pancreas
Left adrenal gland
Portions of transverse and descending colon
Lower portion of left kidney
Portion of descending colon
Shape and contour of abdomen
Striae on abdomen
What color are striae in Cushing's syndrome?
Purple from hypercortisolism
Grey Turner sign
Bluish discoloration/bruising around the umbilicus due to intraperitoneal bleeding
Causes of Cullen sign
Ruptured ectopic pregnancy
Grey Turner sign
Ecchymoses of flanks causes by retroperitoneal bleeding
Causes of Grey Turner sign
Acute hemorrhagic pancreatitis
Protrusion or projection of an organ (or part) through the wall of the cavity that normally contains it
Contents of the hernia sac are easily replaced
Types of hernia
Hernia sac contents can't be reduced
Blood supply to an incarcerated hernia is compromised, contents may become gangrenous
Deep breath special maneuver
Displaces abdominal contents downward and may reveal previously unseen hernias or masses
Head lift special maneuver
Increases intra-abdominal pressure which may also protrude hernias and /or separate the recti muscles
Right and left rectus muscles have separated
Often due to obesity or pregnancy
Is a diastasis recti a true abdominal hernia?
No, no fascial defect
No risk for incarceration or strangulation
Dilated cutaneous veins around the umbilicus
Newborns, portal HTN, cirrhosis
Diaphragm or bell?
What abdominal sounds are normal?
Clicks and gurgles
How many bowel sounds are normal?
3-30 per minute, irregularly spaced is normal
Loud, prolonged gurgles associated with hyper peristalsis
High pitched, tinkling BS indicates...
Fluid or air under pressure and often indicative of small bowel intestinal obstruction
Causes of decreased bowel sounds
Common post surgically
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
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)
Bell or diaphragm for bruits
Soft, low systolic diastolic hum over liver, umbilical area
Indicative of increased collateral circulation between portal and systemic venous systems
Causes of venous hum
Rare to hear in abdomen
High (possibly low) pitched grating sound
Vary with inspiration, may be referred from pleurae
Causes of friction rubs
Where do we percuss?
All four quadrants
What is the normal percussion sound? What is it due to?
Due to gas in GI tract
Dullness on percussion
How do we determine the size of the liver?
Determine the upper and lower margins of the liver by percussion
How do we perform percussion for liver span?
Percussing inferiorly from lungs (resonant) and superiorly from lower abdomen (tympanic)
What does percussion over the liver sound like?
Normal liver span
6-12 cm at right mCL
4-8 cm at midsternal line
What individuals have normally larger livers?
Men, taller individuals
Increased liver span
Causes of falsely enlarged liver
Stool filled colon
Where is the spleen percussed?
Posterior to left midaxillary line, percussed in several directions noting dullness
Most normal spleens do not traverse the...
Left anterior axillary line
What is heard on percussion of the spleen?
What does a large area of dullness suggest?
What conditions can mimic splenomegaly?
Full stomach or stool filled colon
Where do we start palpation?
Start opposite of area of complaint
Systematic approach, all four quadrants
What structures do we palpate?
CVA (costovertebral angle)
Soft, using right hand only
Pressing down about 1 cm
What do we identify with light palpation
Areas of tenderness
Involuntary muscle resistance, may be due to peritoneal irritation/inflammation
What do we identify with deep palpation?
Delineate organ size
Areas of tenderness
May use 1 or 2 hands
Press down 4-5 cm or more
Examples of abdominal masses
Description of masses
Consistency of masses
Hard or soft, smooth or nodular
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
In a normal healthy patient, the liver should not be felt below..
The costal margin
If liver is felt below costal margin, how should it feel
Asses liver for...
Surface texture - smooth versus irregular / nodular
Causes of hepatomegaly
Liver ca, mets
Fatty infiltration of liver
Portal venous HTN
Hepatic vein thrombosis
Passive congestion from CHF
Palpating the spleen
Right hand pushing into abdomen in LUQ
Left hand lifting from the back
Position of patient for palpation of spleen
Patient supine and also right lateral decubitus
What should the patient do to increase the chance of palpating the spleen?
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
Causes of splenomegaly
Sicle cell anemia
Long standing CHF
Are the kidneys palpable? Which kidney is more palpable?
May be barely palpable in thin individuals
Right kidney more palpable than left
Cause of enlarged kidneys
Polycystic kidney disease
Tumor (renal cell carcinoma most common)
Where should we assess for renal tenderness?
What does CVA tenderness indicate?
Kidney infection - pyelonephritis
What is the diameter of the descending aorta in most healthy individuals?
How is the aorta assessed?
Deep palpation just left of midline in the upper abdomen
Should be non tender
Looking for pulsatile mass
What does enlargement of the aorta suggest?
Abdominal aortic aneurysm
What individuals are more likely to have an AAA?
Men older than 50
Hx of atherosclerosis
When is the bladder palpable?
Not usually palpable unless distended with urine
Where are masses present with the bladder is distended?
Rounded/tense/smooth mass is palpable midline above the pubis symphysis
What is heard on percussion over a mass in the bladder?
What condition might mimic a mass in the bladder?
Assessing for peritoneal signs - rebound tenderness, guarding
Assessing for ascites - fluid wave/shifting dullness
What is rebound tenderness used to detect?
Press gently and deeply into area remote from area of patient's discomfort
Rapidly withdraw hand and fingers
What is another name for positive rebound tenderness
Positive Blumberg sign
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
Place hand over lower thigh and have patient raise leg while you push downward
Will cause pain if iliopsoas is irritated
What is the iliopsoas used to detect?
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
What is the obturator test used to detect?
Halfway between umbilicus and anterior superior iliac spine
Cause of McBurney's point tenderness
Palpate patient's LLQ
If this causes pain in the RLQ
What is the Rovsing's sign used to detect?
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
What is Murphy's sign used to detect?
What kind of patients should we suspect ascites?
Protuberant abdomens or flanks that bulge in supine position
Conditions that produce ascites
Hypoalbuminemia (nephrotic syndrome, malnutrition)
What are we percussing for when assessing ascites?
Areas of dullness and tympany
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
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
What do we confirm a fluid wave with?
What is another name for transverse folds?
Which transverse fold can be palpated?
Where is the prostate gland in relation to the bladder?
Base of the urinary bladder
Which surface of the prostate is accessible?
Posterior surface is accessible on DRE
Parts of the prostate
Right and left lobes
.... rectal wall lies adjacent to ... aspect of vagina
Anterior rectal wall lies adjacent to posterior aspect of vagina
How are female structures assessed?
Two fingers, but commonly performed without pelvic exam
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
Positioning for rectal exam
Supine, knees flexed
Left or right lateral with knees flexed
Standing, hips flexed, torso supported
Inspection areas rectal exam
Palpation areas rectal exam
Inspection perianal area
Smooth skin contours
Gently spread buttocks apart
What maneuver will make abnormalities of the anus more apparent?
Asking patient to bear down
Veins around anus or lower rectum are swollen and inflamed
Risk factors for hemorrhoids
External hemorrhoids cause
Caused by increase pressure within the external hemorrhoidal veins
Where do external hemorrhoidal veins arise?
Arise at lower end of the anal canal near the anus, below the dentate line
Where do internal hemorrhoids arise?
Develop above the dentate line
When might an internal hemorrhoid be visible?
Not visible unless prolapsed
What patients usually suffer from rectal prolapse?
Mainly in elderly
Children under 6
Tear in the skin of the anal canal
Usually cause pain and rectal bleeding
Tx anal fissure
Over 90% heal without surgery
Cyst develops along the tailbone near cleft of buttocks
May cause pain and inflammation as often become secondarily infected
How old are patients who get pilonidal cysts?
Tx for pilonidal cyst
Often need surgical resection
Palpation perianal area
Palpation sphincter/anal ring
Lubricate index finger
Rest pad of finger against anal opening
Ask patient to bear down - relaxes external anal sphincter
Smoothness of anal ring
Consistency of stool in vault
What do we need to be aware of about the patient with a DRE?
Be aware of patient's urge to defecate
Tenderness of anal ring causes
Palpation of rectal walls
Rotate examining finger both directions to thoroughly evaluate entire anal wall
Rectal wall male
Rectal wall female
Size of prostate
Size of walnut
Contour of prostate
Symmetric with median sulcus
Consistency of prostate
Firm and smooth, similar to the tip of nose
Assess for tenderness
Presence of pus or blood
Test for occult blood
What substance do we use to test for occult blood?