Week 9 - Chapter 22

Question 1

What are the Surface landmarks of the abdomen ?

Answer 1

The abdomen is a large oval cavity extending from the diagphragm down to the top of the pelvis

It is bordered in the back by a vertebrael column and paravertebrael muscle

Bordered at the sides and front by the lower rib cage and abdominal muscles

There are four layers of large, flat muscles from the ventral abdominal wall that are joined at the midline by a tendinous seam called the Linea Alba

The Rectus Abdominis forms a strip extending the length of the midline and its edge is often palpable

The muscles protect and hold the organs in place and flex the vertebrael column

Question 2

What is the Viscera ?

Answer 2

All the internal organs are called the Viscera

Question 3

What is the Solid Viscera ? What does it contain ?

Answer 3

Solid Viscera are those that maintain a characteristic shape (liver, pancrease, spleen adrenal glands, kidneys, ovaries, uterus)

Liver fills most of the Right Upper Quadrant (RUQ) and extends over the midclavicular line - the lower edge of the liver and the right kidney may normally be palpable

Ovaries are normally palpable only on bimanul assesment during pelvic examination

Question 4

What is the hollow viscera ? What does it contain ?

Answer 4

The Hollow Viscera shape is dependent on its contents (stomach, gallbladder, small intestine, colon, bladder)

They are not usually palpable - stomach is just below the diagohragm between the liver and spleen

Gallbladder rests under the posterior surface of the liver just lateral to the right midclavicular line

The small intestine is located in all four quadrants extending from the right stomachs pyloric valve to the ileocecal valve in the Right Left Quadrant (RLQ) where it joins the colon

Question 5

What is the spleen ?

Answer 5

The spleen is a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity, immediately under the diaphragm

It lies obliquely with its long axis behind and parallel to the tenth rib, lateral to the midaxilaary line

Width extends approximately 7cm from the 9th to the 11th rib - normally not palpable

** if it becomes enlarged, its lower edge moves downward and toward the midline**

Question 6

What is the Aorta ?

Answer 6

The aorta is just left of midline in the upper part of the abdomen

It descends behind the peritoneum and bifurcates 2 cm below the umbilicus into the right and left common iliac arteries opposite the fourth lumbar vertebra

Aortic pulsations can be palpated easily in the upper anteriorabdominal wall

The right and left iliac arteries become the femoral arteries in the groin area.

Their pulsations are also easily palpated, at a point halfway between the anterior
superior iliac spine and the symphysis pubis

Question 7

What is the Pancreas ?

Answer 7

The pancreas is a soft, lobulated gland located behind the stomach

It stretches obliquely across the posterior abdominal wall to the left upper quadrant (LUQ)

Question 8

What are the Kidneys ?

Answer 8

The bean-shaped kidneys are retroperitoneal, or posterior to the abdominal contents

They are well protected by the posterior ribs and musculature

The twelfth rib forms an angle, the costovertebral angle, with the vertebral column

The left kidney lies at that point, at the eleventh and twelfth ribs

Because of the placement of the liver, the right kidney rests 1 to 2 cm lower than the left kidney and is sometimes palpable

Question 9

How many Quadrants in teh abdomin divided into ?

Answer 9

Four Quadrants - by a horizontal and vertical line bisecting the umbilicus

Epigastric is the area between the costal margins

Umbilical is for the area around the umbilicus

Hypogastric or Suprapubic for the area above the pubic bone

Question 10

What does each of the four quadrants posses ?

Answer 10

Right Upper Quadrant (RUQ): Liver, Gallbladder , Duodenum, Head of pancreas , Right kidney and adrenal gland, Hepatic flexure of colon, Parts of ascending and
transverse colon

Left Upper Quadrant (LUQ): Stomach, Spleen, Left lobe of liver, Body of pancreas , Left kidney and adrenal gland, Splenic flexure of colon, Parts of transverse and descending colon

Right Lower Quadrant (RLQ): Cecum, Appendix, Right ovary and fallopian tuve, right ureter, right spermatic cord

Left Lower Quadrant (LLQ): Part of descending colon, Sigmoid colon, Left ovary and fallopian tube, Left ureter, Left spermatic cord

Midline: Aorta, Uterus (If enlarged), Bladder (If enlarged)

Question 11

What are some developemental considerations for infants and children ?

Answer 11

In newborns, the umbilical cord shows prominently on the abdomen - It contains two arteries and one vein

The liver takes up proportionately more space in the abdomen at birth than in later life - In healthy full-term newborns, the lower edge may be palpated 0.5 to 2.5 cm below the right costal margin

The urinary bladder is located higher in the abdomen in newborns than in adults - It
lies between the symphysis and the umbilicus

During early childhood, the abdominal wall is less muscular, which may
make the organs easier to palpate

Children with gastroenteritis, particularly those younger than 1 year of age, are at increased risk for dehydration because of their relatively small body weights and high turnover of water and electrolytes

Signs of clinical dehydration that indicate increased risk for progression to shock include altered responsiveness (irritability, lethargy), sunken eyes, tachycardia, tachypnea, and reduced skin turgor

Question 12

What are developemental considerations for pregnant women ?

Answer 12

Nausea and vomiting, or “morning sickness,” is an early sign of pregnancy in many pregnant women, starting between the first and second missed periods

Another symptom is “acid indigestion,” or heartburn, caused by esophageal reflux

Elevated levels of progesterone relax all smooth muscle, which leads to a decrease in gastro-intestinal motility and prolongation of gastric emptying time

As a result of decreased motility, more water is reabsorbed from the colon, which leads to constipation

Constipation as well as increased venous pressure in the lower pelvis, may lead to formation of hemorrhoids.

The enlarging uterus displaces the intestines upward and posteriorly - Bowel sounds are diminished

Although the appendix may move during pregnancy, causing appendicitis-related pain in an atypical location - most pregnant women with appendicitis experience RLQ pain

Skin changes on the abdomen, such as striae and linea nigra

Question 13

What are some developemental changes for older adults ?

Answer 13

Aging alters the appearance of the abdominal wall

During and after middle age, some fat accumulates in the suprapubic area in women as a result of decreased estrogen levels

Men also show some fat deposits in the abdominal area, resulting in the “big belly.”

This development is accentuated in adults with a sedentary lifestyle -With further aging, adipose tissue is redistributed away from the face and extremities to the abdomen and hips, and the abdominal musculature relaxes

Changes of aging occur in the gastro-intestinal system but do not significantly affect function as long as no disease is present
• Salivation decreases, causing dryness of the mouth and a decrease in the sense of taste
• Esophageal emptying is delayed. Feeding an older adult in the supine position increases the risk for aspiration
• Gastric acid secretion decreases with aging. As a result, the absorption of orally administered medications may be impaired or delayed. This may cause pernicious
anemia (as a result of impaired vitamin B12 absorption), iron deficiency anemia, and malabsorption of calcium.

• Older adults are more susceptible to dehydration because the ability to conserve water is reduced, as are the ability to respond to changes in temperature and the acuteness of thirst
• Liver size decreases with age, particularly after 80 years, although most liver function remains normal - Age-related reductions in liver blood flow and medication-metabolizing enzyme content influences medication metabolism and the variability in response to beneficial and adverse medication effects seen in older adults
• Renal function decreases with age, contributing to the increased risk for adverse or toxic medication effects, as most medications are eventually cleared through the kidneys after metabolism in the liver. Older adults who drink alcohol and take medications are at even greater risk, including exacerbation of therapeutic and adverse effects and interference with medication effectiveness
• The incidence of gallstones increases with age, occurring in up to 20% of Canadian women and 10% of Canadian men by age 60.5
• Age-related changes alone do not account for the frequent reports of constipation by older adults. Common risk factors in older adults include functional impairments such as decreased mobility, pathological conditions such as hypothyroidism, adverse medication effects, and poor dietary habits, including inadequate intake of fluids and fibre
• Additional lifestyle factors that contribute to constipation include prolonged use and overuse of laxatives; ignoring the defecation urge; sedentary lifestyle; and polypharmacy
• Medications associated with constipation include opioids, nonsteroidal anti-inflammatory drugs (NSAIDs), antacids containing aluminum or calcium,anticholinergics (e.g., anticonvulsants, antidepressants,antiparkinson agents) diuretics, calcium channel blockers, and calcium or iron supplements
• The risk for colorectal cancer increases with age

Question 14

Who is affected by obesity the most ? what is GERD ?

Answer 14

Prevalence of obesity in women in low income households is higher compatred to women in higher income households

Obesity increases the risk of diabetes, cncer (esophageal cancer), digestive problems such as gallstones, fatty liver, cirrhosis, and Gastroesophageal reflux disease (GERD)

Risk factors for GERD incluce age, obesity, hiatus herbia, smoking, pregnancy, food choices, and family history with GERD

Question 15

What is Lactose Intolerance ?

Answer 15

Lactose Intolerance - these individuals have lower levels of lactase that is the intestinal enzyme that digests lactose - avoidance of milk products can compromise calcium and vitamin D intakes - research has found that lactose-intolerant individuals can consume moderate amounts of lactose without perceptible symptoms

Question 16

What is Celiac Disease ?

Answer 16

Celiac disease is an inherited autoimmune condition in which intestinal tissue is damaged in response to eating gluten, which prevents nutrients from being properly absorbed

Untreated celiac disease can lead to medical problems such as lactose intolerance, malnutrition, osteoporosis, colon cancer, and lymphoma

Question 17

What are gastro-intestinal Ulcers ?

Answer 17

Canada has the highest incidence of gastro-intestinal ulcers in the world

Peptic ulcer disease increases with age and occurs with frequent use of NSAIDS, alcohol, smoking, and infection with Helicobacter pylori

Eight to 10 million Canadians have H. pylori infection, which is also associated
with development of stomach cancer; approximately 75% of First Nations people are infected with H. pylori

Question 18

What is Inflammatory Bowel Disease (IBD) and Irritable Bowel Syndrome (IBS)?

Answer 18

Canada also has among the highest prevalence and incidence rates of inflammatory bowel disease (IBD) and irritable bowel syndrome (IBS) in the world

IBD can be diagnosed at any age, but usual onset is in the 20s for Crohn’s disease and throughout adulthood for ulcerative colitis; incidence for both diseases peaks by age 30 and does not decline until age 80

A diagnosis of IBD is associate with a higher risk for colorectal cancer

Infectious diseases such as hepatitis A and gastro-intestinal illnesses are often related to socioeconomic factors such as inadequate housing, sewage, and water-treatment facilities

These conditions are often present in Indigenous communities

The most common gastro-intestinal and parasitic infections in refugee populations are Giardia, worm infections (e.g., roundworm [Ascaris], whipworm [Trichuris], and hookworm), and parasites of the Strongyloides and Schistosoma species

Question 19

What are self-management measures to maintain the liver ?

Answer 19

The liver is largest organ in the body - it has an immense capacity to heal and regenerate

1. Practice Safe Sex
2. Do not share items that have may have bodily fluids on them
3. Be aware of your environment (be carefule of aersols,make sure rooms are well ventilated)
4. Monitor diet and weight
5. Travel Wisely
6. Use medications wisely
7. Do not mix medication
8. Drink alcohol in moderation
9. Do not mix mediction & alcohol
10. Do not use illegal drugs
11. Get vaccinated
12. Be aware of your risks for hepatitis

Question 20

What is HAV ? what are the risk factors for HAV ?

Answer 20

Hepatitis A virus which is spread primarily through food or water contaminated by feces - the risk factors for HAV infection include the following:

• Eating food prepared by someone who has HAV infectionand poor hygiene
• Eating raw or undercooked shellfish (such as oysters or clams)
• Eating uncooked food, including unpeeled fruits and vegetables
• Travelling to HAV-endemic areas
• Having homosexual relations
• Sharing a household with an HAV-infected patient HBV is spread primarily through contact with infected blood or bodily fluids. Risk factors for HBV infection include the following:
  
  • Having unprotected sex, especially with someone with HBV infection or whose sexual history is unknown
  • sharing needles or other drug use equipment, including spoons, water, and cotton, to inject illegal drugs
  • Handling blood or bodily fluids as a routine part of your job (e.g. nurses and other health care providers; morticians and embalmers)
  • Getting body piercings or tattoos from a site in which infection control practices are poor
  • Travelling to HBV-endemic areas
  • Sharing a household with an HBV-infected patient
  • Receiving dialysis treatment HCV is spread primarily through contact with infected blood
  • • Risk factors for HCV infection include the following:
  • Having received a transfusion before 1992 or clotting factors before 1987
  • Using illegal intravenous drugs or intranasal cocaine
  • Handling blood or bodily fluids as a routine part of a job
  • Receiving dialysis treatment
  • Getting body piercings or tattoos from a site in which infection control practices are poor
  • Sharing a household with an HCV-infected patient

Question 21

What are health history questions to ask regarding the abdomen ?

Answer 21

1. Appetite: Any change in appetitie ? increased or decreased ? (Anorexia: is a loss of appetite that occurs with GI disease - can occur with medications, pregnany, psychological disorders - loss of appetite - unexplained weight loss may be a sign of GI cancers)
2. Dyspahgia: Any difficult swallowing ? (Dysphagia occurs with disorders of the throat or esophagus)
3. Food Intolerance: Are there any foods you cannot eat ? (lactose intolerance, allergies etc) - (Pyrosis: heartburn, burning sensation in the esophagus and stomach caused by gastric acid reflux) - (Excessive Belching: may occur with food intolerance or hiatal hernia)
4. Abdomial Pain: do you have any abdominal pain? abdominal pain may be visceral (internal organs) or pareital or referred
5. Nauseau/Vomitting: Any nauseau or vomitting ? (Hematemesis: blood in vomit, occurs with stomach or duodenal ulcers and esophageal varices)
6. Bowel Habits: how often do you have bowel movements ?
7. Past Abdominal History: Any history of GI problems ? (Abdominal Adhesions: scar tissue in the abdomen, from previous abdominal surgeries or infections can cause pain vomitting, cramping, etc)
8. Medications: What medicatio are you currently taking ?
9. Alcohol and tobacco: how much alcohol fo you drink ? do you smoke ?
10. Nutritional Assesment: ask about their diet ? 24 hour recall what they ate -

Question 22

What are some additional history questions for infants and children ?

Answer 22

1. Schedule & Content: what do you eat at regular meals ? do you eat breakfast? what do you eat for snacks ?
2. Exercise: What is your exercise pattern ?
3. Underweight: How much weight have you lost ? By diet, exercise, how ? what is your activity pattern ?

Question 23

What are additional history questions for older adults ?

Answer 23

1. Food Access: how do you acquire groceries ad prepare your meals ?
2. Emotional Characteristics: do you eat alone or share meals with others ?
3. Recall
4. Bowel Movements

Question 24

How does one inspect the abdomen ?

Answer 24

Inspect Contour: Stand on the patient’s right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen - Your head should be slightly higher than the abdomen - Determine the profile from the rib margin to the pubic bone -
The contour describes the nutritional state and normally ranges from flat to rounded

Inspect Symmetry: Shine a light across the abdomen toward you or lengthwise across the patient - The abdomen should be symmetrical bilaterally -Note any localized bulging,visible mass, or asymmetrical shape - Even small bulges are highlighted by shadow - Step to the foot of the examination table to recheck symmetry - Ask the patient to take a deep breath to further highlight any change - The abdomen should stay smooth and symmetrical - You can also ask the patient to perform a sit-up without the hands to push up

Question 25

How does one inspect the abdomen ? (cont'd)

Answer 25

***Inspect Umbilicus:*** Normally the umbilicus is midline and inverted, with no sign of discoloration, inflammation, or hernia - It becomes everted and pushed upward during pregnancy - The umbilicus is a common site for piercings in young women - The site should not be red or crusted ***Inspect Skin***: The surface is smooth and even, with homogeneous colour -This area is helpful for judging pigment because it is often protected from sun - One common pigment change is striae (lineae albicantes), which are silvery white, linear, jagged marks approximately 1 to 6 cm long - They occur when elastic fibres in the reticular layer of the skin are broken after rapid or prolonged stretching, as in pregnancy or excessive weight gain - Recent striae are pink or blue; then they turn silvery white - Pigmented nevi (moles), which are circumscribed brown macular or papular areas, are common on the abdomen - Normally, no lesions are present - If a scar is present, ask about it and draw its location in the patient’s record, indicating the length in centimetres - A surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue

Question 26

How does one inspect the abdomen ? (cont'd)

Answer 26

Inspect pulsation or movement: Normally, you may see the pulsations from the aorta beneath the skin in the epigastric area, particularly in thin patients with good muscle wall relaxation - Respiratory movement also shows in the abdomen, particularly in men - Waves of peristalsis are sometimes visible in very thin patients. They ripple slowly and obliquely across the abdomen Inspect hair distribution Inspect Demeanour

Question 27

How to asculate bowel sounds and vascular sounds ?

Answer 27

auscultation is done next b/c percussion and palpatation increases peristalsis which can give false intepretation of bowel sounds if you hear bruit during auscultation avoid palpation and percussion do not push too hard - listen to all four quadrants - start at the RLQ at the ileocecal valve b/c bowels souds are always present here

Question 28

What is important to note regarding bowel sounds ?

Answer 28

Note the character and frequency of bowel sounds Bowel sounds originate from the movement of air and fluid through the small intestine Depending on the time elapsed since eating, normal sounds range widely Bowel sounds are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute Judge whether they are normal, hyperactive, or hypoactive

Question 29

What are hyperactive sounds and hypoactive sounds or absent sounds ?

Answer 29

Abnormal bowel sounds have two distinct patterns: 1. Hyperactive sounds are loud, high-pitched, rushing, tinkling sounds that signal increased motility and may indicate bowel obstruction 2. Sounds may be hypoactive or absent after abdominal surgery or with inflammation of the peritoneum

Question 30

what are important things to note regarding vascular sounds ?

Answer 30

Using firmer pressure, listen with the bell of the stethoscope to check over the aorta and the renal, iliac, and femoral arteries, especially in patients with hypertension Note the presence of any vascular sounds or bruits - Usually, no such sound is present

Question 31

How to percuss the abdomen ?

Answer 31

***General Tympany***: First, percuss lightly in all four quadrants to determine the prevailing amountof tympany and dullness - Move clockwise. Tympany should predominate because air in the intestines rises to the surface when the patient is supine - Dullness is heard over solid structures (e.g., liver), a distended bladder, adipose tissue, fluid, or a mass. - Hyper-resonance is heard with gaseous distension

Question 32

How does one palpate the surface areas of the abdomen ?

Answer 32

Perform light palpation to assess surface characteristics such as texture, temperature, moisture, swelling, rigidity, pulsation, and presence of tenderness or pain 1. Bend the patient’s knees. 2. Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up. 3. Coach the patient to breathe slowly (in through the nose, and out through the mouth). 4. Keep your own voice low and soothing. Conversation may relax the patient. 5. Try “emotive imagery.” For example, you might say, “Imagine you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep. Let yourself relax.” 6. With a very ticklish patient, keep the patient’s hand under your own with your fingers curled over the patient’s fingers. Move both hands around as you palpate; people are not ticklish to themselves. 7. Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate. People generally do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the patient is used to being touched.

Question 33

What is Voluntary Guarding ?

Answer 33

***Voluntary guarding*** occurs when the patient is cold, tense, or ticklish - It is bilateral, and you will feel the muscles relax slightly during exhalation.

Question 34

What are developemental considerations for infants ? (Inspection)

Answer 34

***Inspection***: The contour of the abdomen is protuberant because of the immature abdominal musculature - The skin exhibits a fine, superficial venous pattern that may be visible in lightly pigmented children until puberty - Inspect the umbilical cord throughout the neonatal period - At birth, it is white and contains two umbilical arteries and one vein surrounded by mucoid connective tissue, called ***Wharton’s jelly*** The umbilical stump dries within a week, hardens, and falls off by 10 to 14 days after birth - Skin covers the area by 3 to 4 weeks - The abdomen should be symmetrical, although two bulges are common You may note an ***umbilical hernia*** (It appears 2 to 3 weeks after birth and is especially prominent when the infant cries - The hernia reaches maximum size at 1 month of age (up to 2.5 cm) and usually disappears by 1 year of age) Another common variation is ***diastasis recti***, a separation of the rectus muscles with a visible bulge along the midline -The condition is more common in infants of African descent, and it usually disappears by early childhood The abdomen shows respiratory movement. The only other abdominal movement you should note is occasional peristalsis, which may be visible because of thin musculature

Question 35

What are developemental considerations for infants ? (Auscultation)

Answer 35

***Auscultation:*** Auscultation yields only bowel sounds—the metallic tinkling of peristalsis No vascular sounds should be heard

Question 36

What are developemental considerations for infants ? (Percussion)

Answer 36

Percussion reveals tympany over the stomach (the infant swallows some air with feeding) and dullness over the liver The spleen is not percussedin infants The abdomen sounds tympanitic, although it is normal to percuss dullness over the bladder - This dullness may extend up to the umbilicus.

Question 37

What are developemental considerations for infants ? (Palpation)

Answer 37

Aid palpation by flexing the baby’s knees with one hand while palpating with the other Alternatively, hold the upper back and flex the neck slightly with one hand Offer a pacifier to a crying baby The liver fills the RUQ. It is normal to feel the liver edge at the right costal margin or 1 to 2 cm below Normally, you may palpate the spleen tip, both kidneys, and the bladder Also easily palpated are the cecum in the RLQ and the sigmoid colon, which feels like a sausage in the left inguinal area Make note of the newborn’s first stool, a sticky, greenish black meconium stool within 24 hours of birth By the fourth day, stools of breastfed babies are golden yellow, pasty, and smell like sour milk, whereas those of formula-fed babies are brown-yellow, firmer, and more fecal smelling

Question 38

What are developemental considerations for children ?

Answer 38

At ages younger than 4 years, the abdomen looks protuberant when the child is both supine and standing - After age 4 years, the potbelly remains when the child stands because of lumbar lordosis, but the abdomen looks flat when the child is supine - Normal movement on the abdomen includes respirations, which remain abdominal until 7 years of age To palpate the abdomen, position a young child on the parent’s lap as you sit knee to knee with the parent - Flex the child’s knees up, and elevate the head slightly. You can ask the child to “pant like a dog” to further relax abdominal muscles - Hold your entire palm flat on the abdominal surface for a moment before starting palpation - This accustoms the child to being touched - If the child is very ticklish, hold the child’s hand under your own as you palpate, or apply the stethoscope and palpate around it The liver remains easily palpable 1 to 2 cm below the right costal margin - The edge is soft and sharp and moves easily - On the left, the spleen also is easily palpable as a soft, sharp, movable edge - Usually you can feel 1 to 2 cm of the right kidney and the tip of the left kidney - Percussion of the liver span reveals measurements of approximately 3.5 cm at age 2 years, 5 cm at age 6 years, and 6 to 7 cm during adolescence Many adolescents are easily embarrassed by exposure of the abdomen, and adequate draping is necessary - The physical findings are the same as those listed for adults.

Question 39

What are developemental considerations for older adults ?

Answer 39

On inspection, you may note increased deposits of subcutaneous fat on the abdomen and hips because it is redistributed away from the extremities Abdominal musculature is thinner and has less tone than that of younger adults; therefore, in the absence of obesity, you may note peristalsis Because the abdominal wall is thinner and softer, organs may be easier to palpate (in the absence of obesity) The liver is easier to palpate Normally, you can feel the liver edge at or just below the costal margin When the lungs are distended and the diaphragm is depressed, the liver is palpated lower, descending 1 to 2 cm below the costal margin with inhalation The kidneys are easier to palpate

Question 40

How to percuss the liver span ?

Answer 40

Percuss to map out boundaries of certain organs Measure height of the liver in the right midclavicular line. (For a consistent placement of the midclavicular line landmark, remember to palpate the acromioclavicular and the sternoclavicular joints, and judge the line at a point midway between the two.) Begin in the area of lung resonance, and percuss down the intercostal spaces until the sound changes to a dull quality Mark the spot on the patient’s body, usually in the fifth intercostal space Then find abdominal tympany and percuss up in the midclavicular line Mark the spot on the patient’s body where the sound changes from tympany to a dull sound, normally at the right costal margin - Measure the distance between the two marks; the normal liver span in adults ranges from 6 to 12 cm The height of the liver span is correlated with the height of the patient; taller people have longer livers - Also, men have a longer liver span than women of the same height Overall, the mean liver span is 10.5 cm in men and 7 cm in women One variation occurs in people with chronic emphysema, in which the liver is displaced downward by the hyperinflated lungs - Although you hear a dull percussion note well below the right costal margin, the overall span is still within normal limits Clinical estimation of liver span is important in screening for hepatomegaly and in monitoring changes in liver size - However, this measurement is a gross estimate; the liver span may be underestimated because of inaccurate detection of the upper border.

Question 41

What is the scratch test ?

Answer 41

Another assessment technique is the scratch test, which may help define the liver border when the abdomen is distended or the abdominal muscles are tense Place your stethoscope over the liver -With one fingernail, scratch short strokes over the abdomen, starting in the RLQ and moving progressively up toward the liver When the scratching sound in your stethoscope becomes magnified, you will have crossed the border from over a hollow organ to over a solid one

Question 42

What is Splenic Dullness ?

Answer 42

Often the spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from the ninth to eleventh intercostal spaces just behind the left midaxillary line The area of splenic dullness normally is not wider than 7 cm in the adult and should not encroach on the normal tympany over the gastric air bubble Now percuss in the lowest intercostal space in the left anterior axillary line - You should hear tympany -Ask the patient to take a deep breath - Normally,tympany remains through full inspiration. A dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma, and infection In the anterior axillary line, a change in percussion from tympany to a dull sound with full inspiration is a positive spleen percussion sign, indicating splenomegaly - This method helps detect mild to moderate splenomegaly before the spleen becomes palpable, as in mononucleosis, malaria, or hepatic cirrhosis

Question 43

What is Costoverbral Angel Tenderness ?

Answer 43

Indirect fist percussion causes the tissues to vibrate instead of producing a sound To assess the kidney, place one hand over the twelfth rib at the costovertebral angle on the back (Fighump that hand with the ulnar edge of your other fist. The patient normally feels a thud but no pain. Perform the assessment bilaterally (Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the patient is sitting up and you are standing behind the patient.)

Question 44

How to palpate deep areas ?

Answer 44

If appropriate, perform deep palpation following light palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness Perform deep palpation using the same technique described earlier for light palpation, but push down approximately 5 to 8 cm - Moving clockwise, palpate the entire abdomen To overcome the resistance of a very large or obese abdomen, use a bimanual technique. - Place your two hands on top of each other - The top hand does the pushing; the bottom hand is relaxed and can concentrate on the sense of palpation - With either a single-handed or bimanual technique - note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses Making sense of what you are palpating is more difficult than it seems. Inexperienced examiners complain that the abdomen “all feels the same,” as if they are pushing their hand into a soft sofa cushion *It helps to memorize the anatomy and visualize what is under each quadrant as you palpate.*

Question 45

What is important to note when mild tenderness and a mass is found ?

Answer 45

1. Location 2. Size 3. Shape 4. Consistency (soft, firm, hard) 5. Surface (smooth, nodular) 6. Mobility (including movement with respirations) 7. Pulsatility 8. Tenderness

Question 46

How does one asses the liver ?

Answer 46

Next, palpate for specific organs, beginning with the liver in the RUQ Place your left hand under the patient’s back, parallel to the eleventh and twelfth ribs, and lift up to support the abdominal contents Place your right hand on the RUQ, with fingers parallel to the midline - Push deeply down and under the right costal margin Ask the patient to take a deep breath - It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation It feels like a firm, regular ridge - the liver is often not palpable, and you feel nothing firm.

Question 47

What is the Hooking technique ?

Answer 47

An alternative method of palpating the liver is to stand at the patient’s right shoulder and swivel your body to the right so that you face the patient’s feet Hook your fingers over the costal margin from above Ask the patient to take a deep breath. Try to feel the liver edge bump your fingertips.

Question 48

How does one asses the spleen ?

Answer 48

Normally, the spleen is not palpable and must be enlarged to three times its normal size to be felt. To search for it, reach over the abdomen with your left hand and behind the left side at the eleventh and twelfth ribs Lift up for support Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin Push your hand deeply down and under the left costal margin, and ask the patient to take a deep breath You should feel nothing firm When enlarged, the spleen slides out and bumps your fingertips It can grow so large that it extends into the lower quadrants When this condition is suspected, start low on the abdomen so that you will not miss it An alternative position is to roll the patient onto the right side to displace the spleen more forward and downward

Question 49

What are some critical findings for the nurse ?

Answer 49

The spleen becomes enlarged with mononucleosis and trauma If you feel enlargement of the spleen, refer the patient, but do not continue to palpate it An enlarged spleen is friable and can rupture easily with overpalpation Describe the number of centimetres that the spleen extends below the left costal margin

Question 50

How does one asses the kidney ?

Answer 50

Search for the right kidney by placing your hands together in a “duck bill” position at the patient’s right flank Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen), and ask the patient to take a deep breath In most people, you will feel no change - On occasion, you may feel the lower pole of the right kidney slide between your fingers as a round, smooth mass Either condition is normal The left kidney sits 1 cm higher than the right kidney and is normally not palpable Search for it by reaching your left hand across the abdomen and behind the left flank for support Push your right hand deep into the abdomen, and ask the patient to breathe deeply You should feel no change with the inhalation

Question 51

How does one asses the Aorta ?

Answer 51

Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline In adults, it is normally 2.5 to 4 cm wide and pulsates in an anterior direction

Question 52

What is the rebound tenderness (Blumbergs sign) ?

Answer 52

Assess rebound tenderness when the patient reports abdominal pain or when you elicit tenderness during palpation. Choose a site away from the painful area Hold your hand 90 degrees, or perpendicular, to the abdomen Push down slowly and deeply then lift up quickly - This makes structures that are indented by palpation rebound suddenly A normal, or negative, response is no pain on release of pressure Perform this test at the end of the examination, because it can cause severe pain and muscle rigidity Pain on release of pressure confirms rebound tenderness, which is a reliable sign of peritoneal inflammation Peritoneal inflammation accompanies appendicitis - Cough tenderness that is localized to a specific spot also signals peritoneal irritation

Question 53

What are inspiratory Arrest (Murphys sign) ?

Answer 53

Normally, palpating the liver causes no pain In a patient with inflammation of the gallbladder, or cholecystitis, pain occurs Hold your fingers under the liver border Ask the patient to take a deep breath A normal response is to complete the deep breath without pain

Question 54

What is the Iliopsoas muscle test ?

Answer 54

Perform the iliopsoas muscle test when the acute abdominal pain is suspect for appendicitis With the patient supine, lift the right leg straight up, flexing at the hip; then push down over the lower part of the right thigh as the patient tries to hold the leg up When the test result is negative, the patient feels no change When the iliopsoas muscle is inflamed pain is felt in the RLQ.