Phys Di - Abdominal Exam Flashcards
(109 cards)
1
Q
What to keep in mind when females c/o abdominal pain
A
- can arise from gynecological problem
- PID
- ectopic pregnancy
- torsion of ovary
- ovarian cyst
- so always consider pelvic exam
2
Q
wavelike/”colicky” pain
A
- pain that comes on in a wave, hits a hard peak, then goes down
- typically a sign of the body trying to push something out
- i.e: constipation, ureteral calculi, obstruction of bowel, gallstone
3
Q
what to consider with continuous or constant abdominal pain
A
- infection
- abcess
- cyst
- diverticulitits
- IBD
- mesenteric adenitits
4
Q
What to consider w/ stabbing, searing, boring abdominal pain
A
- pancreatitis
- PUD
- cholangitis
5
Q
ripping pain is characteristic of?
A
-rupturing AAA
6
Q
out of proportion pain to physical findings is characteristic of what?
A
- mesenteric ischemia
- IBS
7
Q
HPI for for abdominal exam
A
big 8 always works
8
Q
additional things to consider in GI HPI
A
- relation to menstrual cycle
- relation to BM
- stool characteristic details
- ALWAYS find out about blood
- remember blood can be black
- constipation is VERY subjective
- pts often won’t offer info on fetal incontinence so ask
9
Q
melena
A
black, tarry stool; indicates GI bleed is NOT from colon depending on transit time
10
Q
hematochezia
A
bloody stool, passing of blood from rectum w/ or w/o stool
11
Q
steatorrhea
A
oily, greasy stool, sign of malabsorption
12
Q
suprapubic
A
area of abdomen just above pubis
13
Q
hematuria
A
bloody urine
14
Q
tenesmus
A
rectal “dry heave”
15
Q
proctalgia fugax
A
rectal spasm
16
Q
oliguria
A
small amout of urine
17
Q
chyluria
A
milky urine
18
Q
urolithiasis
A
stones in urinary tract
19
Q
borborygmi
A
audible rumbling sound of digestion
20
Q
post-prandial
A
after meals
21
Q
BRBPR
A
bright red blood per rectum
22
Q
NABS
A
normal active bowel sounds
23
Q
PUD
A
peptic ulcer dz
24
Q
family hx for GI
A
- **colon CA
- any abdominal CA
- IBD
- IBS
- GERD, gastric ulcer
- celiac dz
25
social hx for GI
- smoking
- ETOH
- eating habits
- stress level
- caffeine
- fiber
- sexual contact
26
GI ROS
- abdominal pain
- n/v/d
- hematemesis
- indigestion
- belching/flatulence
- appetite change
- food intolerance
- jaundice
- hx of hepatitis
- constipation
- BM change or frequency
- steatorrhea
- melena
- hematochezia
- hemorrhoids
- hx of laxative use
- hx of colon polys/colonoscopy
27
what is something you ALWAYS ask about in GI work up?
colon CA
28
when should one start getting colonoscopys?
50 unless fam hx then 40
29
what is the order of PE for GI?
- inspection
- auscultation
- percussion
- palpation
- special tests
30
general summary of what to look at during inspection
- contour (round, flat, protuberant)
- symmetry
- masses
- surface features (striae, lesions, masses, visable pulsations/peristalsis)
31
general summary of what to look at during auscultation
- verify bowel sounds in 4 quadrants
- describe bowel sounds as normoactive, high-pitched, tinkling, rumbling, hyper or hypo active or absent
- listen for bruits
32
what do you focus on during percussion of the abdomen?
difference in sounds
33
general summary of what to look at during palpation
- light: feel for any superficial masses, if soft, rigid, guarding and aortic pulsation
- deep: feel for stool, deep tenderness, organs, masses, McBurney's, Rovsings, rebound last
34
locations of the abdomen (other than the normal RUQ, LUQ etc)
- costal margins
- suprapubic
- inguinal
- ASIS
- peri-umbilical
- flank
- epigastric
- generalized
35
skin/eye inspection during GI PE
- jaundice
- scleral icterus
- pallor
- skin turgor
- nail clubbing
- spider nevi
36
abdomen inspection
- contour, distention
- symmetry
- masses
- scars
- have patient lift head, crunch
- purple striae (Cushing's)
- dilated vein
37
Why do you have the patient lift head/"crunch" during the abdomen inspection?
to assess if the pain is deep or within the muscular abdominal wall
38
skin turgor
- "pinch test"
| - check it if evaluating a pt who is severely dehydrated (n/v/d)
39
striae
- purple colored stretch marks
- sign of Cushing's if >1cm
- caused by high cortisol levels
40
gray turner sign
- retroperitoneal hemorrhage
- can be sign of acute pancreatitis
- on side**
41
cullen sign
- sign of retroperitoneal hemorrhage
- blood diffuses from retroperitoeum to the subQ tissue of abdomen
- around umbilicus**
42
diastiasis recti
- "reverse 6-pack"
- men may say they have hernia
- common in younger women after pregnancy
43
auscultation of all 4 quadrants
-auscultate for bowel sounds using diaphragm
44
borborygmi
normal sounds of peristalsis / "stomach growling"
45
absence of bowel sounds on ausultation
- intra-abdominal catastrophe, ileus, complete obstruction
| - cannot determine they are actually absent unless you listen for full 5 min
46
high pitched tinkling sounds on auscultation
partial bowel obstruction or stricture of bowel
47
liver scratch test
- use bell
- pretty worthless in clinical setting
- used to determine liver size by auscultation of scratching sound over abdomen
48
what is the technique of the liver scratch test
- place bell just below xyphoid
- scratch up from RLQ at mid-clavicular line
- sudden increase of sound is where inf. liver edge begins
- document if inf liver edge is below costal margin (enlarged)
- an enlarged liver will extend beyond the right costal margin
- in nl test: sound changes AT right costal margin
49
what do you percuss for in the RUQ?
- liver size
- dullness heard when percussing over solid organ
- really only able to percuss if liver is enlarged, palpating is better
50
What do you percuss in the LUQ aka Traube space
- the gastric bubble
- if NOT tympanic, possible enlarged spleen or mass?
- should NOT be dull
51
What do you percuss for in the suprapubic area?
- enlarged or distended bladder
| - would be dull
52
what is a normal finding on percussion of abdomen?
nl to have different areas of flat tones and tympanic throughout
53
palpation on PE of abdomen
- for tenderness
- for masses
- for organomegaly
- light vs deep
- for rebound tenderness (LAST)
- keep fingernails trimmed
- bimanual technique
54
what to do if pt is extremely ticklish
put their hand on yours
55
what is the normal finding on palpation?
-soft to touch, non-tender (meaning no pain elicited w/ palpation)
56
how would you document nl findings upon palpation?
"abdomen is soft and non tender to palpation w/ no guarding, rebounding, masses or organomegaly noted"
57
If tenderness is present upon palpation of the abdomen, what do you need to pay attention to?
- where? which quadrant? localized or diffuse?
| - how bad? mild, moderate, severe?
58
abnl findings on palpation of abdomen
- guarding
- rebounding/rebound tenderness
- rigidity
59
guarding
involuntary contraction of anterior abdominal muscles, usually a sign of peritoneal irritation or inflammation
60
rebounding/rebounding tenderness
also a sign of peritoneal irritation or inflammation
61
rigidity
sign of severe issue, involuntary muscle contraction
62
what could be a cause of suprapubic tenderness?
- cystitis
| - also, pelvic structures could normally be tender on palpation of RLQ and LLQ
63
how should you accurately assess for hernias?
-examine w/ pt standing +/- valsalva
64
what to document if abdominal wall hernia is found
- size
- if it easily reduced
- overlying skin changes (indication of strangulation or incarceration )
65
When do you palpate/percuss the kidneys?
after auscultating the posterior chest and before laying the pt down
66
what could tenderness to first percussion of the CVA suggest?
- renal inflammation
- pyelonephritis
- stones
- so be gentle, kidney inflammation causes bad pain
67
technique for palpation of masses
- use 2 hands
- have pt lift head
- if floating, use ballottement technique
68
when palpating for masses, what all do you need to determine?
- size
- shape
- tenderness
- location
- consistency
- mobility
- is it midline and pulsatile?
69
what could be confused for a mass in the LLQ?
poop
70
murphy's sign
- deeply palpate RUQ
- ask pt to take deep breath
- if breath is abruptly stopped d/t pain, consider GB dz (positive murphy's)
71
liver edge
- where measured
- how to describe
- measured in right mid-clavicular line
- described by # of finger breadths it extends below costal margin
- nl finding could be: liver edge not palpable or no hepatomegaly
72
what is the preferred method of examination of the liver?
liver hooking technique
73
what to palpate at LUQ?
spleen
74
when is it possible to palpate the spleen?
never, unless there is a pathologic enlargement
75
how to palpate for spleen
- deeply palpate at LUQ at costal margin
- have pt take deep breath (enlarged spleen may come forward)
- can also apply posterior pressure to flank
- nl: no spleen palpated
76
how do document nl spleen palpation
- no splenomegaly present
| - no splenomegaly noted on palpation of the LUQ
77
structures at RLQ
- appendix
- ileocecal valve
- distal ileum
78
tenderness at McBurney's point indicates what?
appendicitis
79
in what other conditions might the RLQ be tender?
- IBD
| - IBS
80
where is McBurney's point?
1/3 of the way between the ASIS and umbilicus
81
what often causes LLQ tenderness?
- diverticulitis
| - colitis
82
Rovsing's sign
if deep palpation of LLQ produces referred pain in RLQ
83
what is rovsing's sign a sign of?
acute appendicitis
84
what are the special tests for appendicitis?
- psoas sign: flex hip against resistance and look for pain in RLQ
- obturator sign: internally rotate right rip
- heel jar test: "jar" heel w/ hand
85
what are the special tests for ascites?
- shifting dullness: fluid moves as you move the patient to side
- fluid wave
86
What would a note look for for PE of abdomen
The abdomen is soft and non-distended with normal contour, withtout visible scars, masses,, acites, or striae present. Normoactive bowel sounds in all 4 quadrants w/ no bruits (aortic, renal iliac, femoral) noted. The abdomen is non tender to palpation w/ no guarding, rebounding, masses, hepatosplenomegaly or CVA tenderness noted. The aortic pulse has normal width. No pelvic or suprapubic tenderness present
87
what to consider with rectal exam
- protect pts privacy, use drape
- chaparone
- lay pt on side
- use lube
- have guiac or hemoccult card ready before you begin
88
how to position patient for rectal exam
left lateral decubitis
89
what to inspect for during rectal exam
- skin abnormalities (perianal candidiasis, condyloma)
- external hemorrhoids, thrombosed?
- fissure
- prolapse
- neoplastic lesions
- polyps
- fistula (Crohn's)
- abscess
90
What to palpate for in rectal exam
- masses/polyps
- prostate if applicable
- collect stool if hemoccult is needed
- internal hemorrhoids
- sphincter tone
91
technique of rectal exam
- use lube
- apply gentle pressure w/ pad of finger onto anal opening
- insert finger to examine entire canal
- should be painless if pt is relaxed
- ask pt to bare down or squeeze if need to check sphincter tone
92
what causes visceral abdominal pain
- noxious stimuli to visceral organs
| - ischemia, stretch, distention, inflammtion
93
how is visceral abdominal paint described?
- many words used
- belly ache, stomach ache, cramping, gnawing, burning, etc.
- does NOT get worse by moving around
- brain has difficult localizing the pain
- happens early in dz (appendicitis)
94
what is the cause of parietal (somatic) pain
-carried by somatic nerves and enters the spinal cord unilaterally
afferent receptors on the parietal surface
95
description of parietal/somatic pain
- sharply localized
- peritoneal pain/peritonitis
- easier to localize b/c it is unilaterally innervated
96
What is the differential if pain is in the RUQ
- biliary dz
- hepatitis
- renal colic
- diverticulitis
97
Differential if pain is in the epigastric region
- MI
- PUD
- panreatitis
- biliary dz
98
differential if pain is in LUQ
- splenic injury
- renal colic
- diverticulitis
99
differential if pain is in RLQ
- appendicitis
- ovarian dz
- PID
- ruptured ectopic preg
100
differential if pain is in the LLQ
- ovarian dz
- PID
- ruptured ectopic preg
101
differential if pain is in the umbilicus
- IBD
- bowel obstruction/ischemia
- appendicitis
- AAA
- IBS
- DKA
- gastroenteritis
102
review charts
- slide 70: localization of pain
- 71: notable causes
- 72: "NOT" clues
- 73: pain referral patterns
103
duodenal ulcer pain
- poorly localized to midline early b/c visceral
- commonly awakens pt at night
- made better by eating** and worse by fasting
- "burning or gnawing"
- worsed by ETOH and ASA
- rarely refers to back
104
acute cholecystitis
- RUQ
- almost always post-prandial**
- often refers to scapula or right shoulder (phrenic)
105
acute pancreatitis
- poorly localized, usually above umbilicus/epigastrium
- made worse by eating
- commonly radiates straight through to mid back
- associated w/ ETOH and n/v
106
acute pancreatitis can be cause by gallstones obstructing what duct?
common bile duct
107
acute appendicitis
- can be in epigastrum or centrally if early
- localized to RLQ (unless retrocecal)
- ck for peritoneal signs like rebound tenderness
- younger pts
- ck for fever
- rectal exam reveals tenderness to peritoneal pouches
108
diverticulitis
usually felt as diffuse (visceral) lower abd pain
- if perforation, pain becomes acutely severe w/ N/V
- more localized pain if inflammation is transcolonic
- MC in LLQ but possible in RLQ
- can feel some relieve after defecation
- stool changes: narrow, mucoid, small vol.
109
renal colic
- often begins in CVA
- ipsilateral and SEVERE
- commonly associated w/ stone
- wavelike pain = colic
- commonly radiates to testicle/vaginal area as stone moves
- transureteral inflammation can feel like need to have BM
- not effected by meals, vomiting common
- pts are agitated, pacing or rocking
