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Advanced Physical Assessment

Etoh and the abdomen use the CAGE questionnaire- cirrhosis
1 Standard etoh Drink 2 oz of regular beer, or wine cooler, 8 oz of malt liquor, 5 oz of wine, 1.5 oz of 80-proof spirits
Hepatitis A: Transmission is fecal-oral- food poisoning- Advise hand wash after bathroom-vaccine @age of 1 year, chronic liver disease, travelers to endemic areasep B
Hep C no vaccine- post exposure
Screening for colorectal CA age 50-75, easisest-High-sensitivity fecal occult (FOBT) annually, Sigmoidoscopy q5 years with FOBT every 3 years,BEST- colonoscopy every 10, Adults age 76 to 85 years – do NOT screen routinely (individual), Adults older the age 85 – do NOT screen at all
Visceral abdominal pain deep organ, hollow organ (intestine), distended, stretched- pt cannot localize, Varies in quality; may be gnawing, burning, cramping, aching, severe associated w/sweating, pallor, n/v. RUQ from liver distension against its capsule in alcoholic hepatitis
Parietal Pain in abdomen superficial- localized-inflammation, Steady, aching, more severe, more nerve endings- periumbilical pain in early appendicitis from distension-gradually changes to parietal pain in the RLQ from inflammation of the adjacent parietal peritoneum
Classic condition that has both visceral and parietal pain appendicitis
Referred Pain in abdomen Pain of duodenal or pancreatic referred to the back; pain from biliary tree rt shoulder or rt posterior chest, also the chest, spine, or pelvis  abdomen, and pleurisy or MI  epigastric
Pain d/t Stretching of encapsulated organs (liver, spleen, kidney)- swelling/ inflammation of organ itself- constant, dull or moderate-RUQ pain secondary to liver congestion (CHF), LUQ d/t splenic enlargement- flank pain (pyelonephritis).
Pain due to Irritation of the mucosal lining stomach-h.pylori (gastritis or peptic ulcer) or NSAIDS, esophagus (esophagitis), stomach or duodenum (duodenitis or peptic ulcer)
Pain in abdomen d/t Smooth muscle spasm viral gastroenteritis or irritable bowel syndrome- is one of the most common causes for abdominal pain-crampy or colicky
Peritoneal irritation causes severe abdominal discomfort that usually sharp stabbing pain associated with marked tenderness on palpation. Examples include acute appendicitis, diverticulitis, and acute cholecystitis.
Direct splanchnic nerve stimulation causes compresses over the nerve- pain of moderate severity. Retroperitoneal processes such as pancreatic cancer or an expanding aortic aneurysm may compress adjacent splanchnic nerves
Gall bladder RUQ/ epigastric pain; radiates to R shoulder, colicky (gas or obstruction) in nature
Pancreas mid-epigastric, radiates straight through to the back WORSE WHEN PT LYING DOWN
Esophagus retrosternal/ mid-epigastric. r/t swallowing and reflux of gastric acid
Small intestine crampy peri-umbilical discomfort d/t spasm of the smooth ms
Appendix initially, nausea and peri-umbilical, poorly localized visceral pain that peaks in intensity in 4-6 hrs and then may subside, only later to reappear in the RLQ at McBurney’s point.
Colon usually in the LLQ and RLQ. May be constant or occur in spasms. r/t defecation (diverticulitis on the left mostly) sigmoid is the widest
Rectum deep within the pelvis, very poorly localized. Can be intense, associated with the need to defecate
Kidney RUQ, LUQ, left flank, right flank, or either costovertebral angle. It is constant and moderately severe when due to pyelonephritis with systemic signs (fever, chills, and malaise)
Ureter RLQ/LLQ, radiates to testicles or labia. It is excruciatingly severe when due to passing a stone.
Stomach epigastric, may radiate to the left shoulder. Gets worse w eating if due to gastric ulcer
Duodenum epigastric. Occurs due to peptic ulcer, the pain develops during fasting & is relieved with eating
RUQ (Liver, kidney, gall bladder) Acute cholecystitis, biliary colic, acute hepatitis, duodenal ulcer, right lower lobe pneumonia
RLQ (ascending, colon, appendix, ovary, fallopian tube) Appendicitis, cecal diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion
LUQ- pancreas, spleen and kidney Gastritis, acute pancreatitis, splenic pathology, left lower lobe pneumonia
LLQ (sigmoid and descending colon, ovary, fallopian tube) Diverticulitis, ectopic pregnancy, tubo-ovarian abscess, ruptured ovarian cyst, ovarian torsion, constipation
Midline or periumbilical Appendicitis (early), gastroenteritis, mesenteric lymphadenitis, myocardial, ischemia or infarction, pancreatitis
Flank pain Abdominal aortic aneurysm, renal colic, pyelonephritis
Front to back pan acute pancreatitis, ruptured abdominal aortic aneurysm, retrocecal appendicitis, posterior duodenal ulcer
Suprapubic or lower abdominal Ectopic pregnancy, mittelschmerz, ruptured ovarian cyst, pelvic, inflammatory disease, endometriosis, urinary tract infection
Referred- Diaphragmatic goes to supraclavicular area-kehrs sign
Referred- ureter Hypogastrium, groin, inner thigh
Referred- cardiac pain Epigastrium, jaw, shoulder
Referred pain from appendix Periumbilical via T10 nerve
Referred pain from duodenum Umbilical region via greater thoracic splanchnic nerve
Referred pain from hiatal hernia epigastrium via T7 and T8 nerves
Referred pain from gallbladder epigastrium
Referred pain from gallbladder and duct Epigastric pain that wraps around to the scapula
The term acute abdomen is used to describe the sudden onset of severe abdominal pain and an acute abdomen indicates urgent surgical intervention. 1. Peritonitis (infx peritoneal cavity) 2. Bowel infarction 3. Perforation hollow organ (perforated ulcer, appendix) 4. Ruptured AAA
Signs of an acute abdomen (peritonitis) 1. Abdominal distention (protuberance) with tympany on percussion 2. Tenderness 3. Rebound tenderness 4.↑↓ bowel sounds 5. Cutaneous hypersensitivity
Rigidity involuntary spasm of abdominal wall musculature
Abdominal fullness diabetic gastroparesis
Belching, bloating, abdominal distention lactose intolerance
RLQ PID, ectopic, appendicitis
LLQ diverticulitis
Irritable bowel syndrome not d/t d/c but a pain syndrome
n/v. loss of appetite Pregnancy, DKA, adrenal insufficiency, hypercalcemia, uremia, liver disease, Induced vomiting w/out nausea in anorexia/ bulimia
coffee ground emesis/ hematemesis Esophageal or gastric varices, Mallory-Weiss tears w/frequent vomitting, peptic ulcer disease
Dysphagia is difficulty swallowing- with liquids, solids or both- structural abnormalities or motility d/o
Odynophagia pain with swallowing- ulcerations of the esophagus, caustic agents, infections, herpes simplex and candidiasis of the esophagus.
Diarrhea is defined as stool in excess of 200 grams per day- an increase in frequency of stools (usually >3 per day), and increased liquid content of stools*.Acute is < two weeks. Chronic is > four weeks.
Constipation CCB and iron can cause this
Constipation is defined as fewer than three bowel movements per week
* Black tarry stools (melena) points to GI bleed need antibiotic because organism is now inside the cell
Inflammatory bowel vs inflammatory bowel inflammatory has blood in stool- abdominal discomfort and diarrhea for both- but inflammatory has blood- alarming
When cause of jaundice is intrahepatic (not hemolytic) or extra hepatic damaged for the extra hepatic hepatocytes,damaged biliary ducts- viral hepatitis, cirrhosis, primary biliary cirrhosis, drug-induced cholestasis within the liver- or extrahepatic- bile ducts, cystic& common bile ducts.
To differentiate between intra and extra hepatic jaundice- ask about urine and the stool- Dark urine and clay color stool
Pencil-like stool or blood in stool in colon cancer
Dark tarry stool: in polyps, carcinoma, GI bleeding
Mucus in the stool: villous adenoma, IBD, IBS
Pain with defecation, rectal bleeding or tenderness Hemorrhoids, Proctitis from STIs
BPH s/s Hesitancy, straining to void, reduced stream, dribbling, irritated bladder, nocturia
A scaphoid abdomen presents as a concavity to the horizontal plane-malnourished individuals.
TestGrey Turner’s sign ecchymosis in one or both flanks-described 1st in pancreatitis, retroperitoneal intraperitoneal bleeding includes ovarian cyst hemorrhage, hemorrhagic ascites secondary to metastatic cancer, bilateral salpingitis, and strangulated bowel w/hemorrhage.
Test Cullen’s sign is periumbilical ecchymosis 1st described for ruptured ectopic pregnancy but indicates retroperitoneal or intraperitoneal bleeding.Blood travels to the periumbilical area
Test- venous pattern is normally up and down, what is SVC obstruction the normal direction of flow is reversed, such that blood flow in the upper abdomen is downward.
Test- venous pattern is normally up and down, what is IVC obstruction blood flow in the lower abdomen is upward with collaterals being especially prominent in the flanks.
Test- venous pattern is normally up and down, what is intrahepatic portal vein obstruction (as seen in cirrhosis) the veins appear to radiate outward from the umbilicus. This prominent venous pattern is called a caput medusa. Flow above the umbilicus is cephalad↑, while flow below the umbilicus is caudad↓
Portal vein thrombosis, the blood direction goes which way towards the belly button- press it and it fills (towards it) more- in portal hypertension, you press it and it empties away from (same direction it’s going)
Visible peristalsis occurs early in mechanical bowel obstruction
A Spigelian hernia presents as a tender mass in the abdominal wall 3 - 5 cm above the inguinal ligaments.
Small bowel mechanical obstruction (centrally) may occur because of scar tissue (adhesions), hernia,, volvulus (twisting of the small bowel onitself), intussusception (small bowel invaginating or telescoping on itself) or gallstone ileus (gallstone impacted in the ileum
Large bowel (laterally) mechanical obstruction can be caused by tumor (colon cancer), volvulus (twisting of the large bowel on itself, usually the sigmoid), hernias, diverticulitis or intussusception.
Absence of bowel sounds could be caused by hypokalemia
Arterial bruits most commonly come from celiac artery
Epigastric systolic bruits midline between the xiphoid and umbilicus- found in those with abdominal aortic aneurysms.
Renal artery bruits anterior abdomen 2 inches up from the umbilicus, often radiating into the flank-The finding of an abdominal bruit having both systolic and diastolic components is virtually diagnostic of renal artery stenosis(which is an important cause of secondary HTN)
Peritoneal friction rubs most often originate from the spleen or liver when their capsules rub against the peritoneum Splenic infarction, liver metastasis, hepatoma
Tympany air- normally occurs over the gastric air bubble in the LUQ.
Generalized tympany however is a consistent finding in mechanical and paralytic ileus, and in the presence of a perforated hollow organ (intestine, stomach etc.).
Dullness to percussion occurs over solid organs, fecal-filled bowel, and laterally over the flanks in abdominal distention due to ascites fluid shifts to more dependent area (not the organ)
Light palpation is used to assess the abdominal wall for intramural (muscle) masses- about 1 cm with palm-having the pt raise his/her head- if mass becomes more, then it is intramural (such as hernias or diastasis recti), if less= intra-abdominal
Boas' sign, cutaneous hypersensitivity over the posterior right lower ribs, inflammation of the gallbladder (acute cholecystitis).
Kehr’s sign describes cutaneous hypersensitivity over the left shoulder secondary to diaphragmatic irritation from splenic rupture.
Guarding and rigidity voluntary and involuntary both seen in peritoneal irritation
Test Direct tenderness is appreciated on deep palpation just beneath the examining hand- appendicitis- hurts when you press over a single point over the RLQ
Test Indirect tenderness develops at a location distant to the site of underlying pathology as a result of peritoneal irritation you have appendicitis but press over the LLQ and hurts over the right side Rovsing’s sign
Rebound tenderness (Blumberg's sign) is a transient, sharp, knife-like pain that results when pressure is suddenly released during deep palpation- d/t peritoneal irritation and inflammation.
The cough test (coughing produces a sharp pain in the abdomen) appears to be a more compassionate way of establishing peritoneal inflammation and is probably of equal or more value (+LR 2.4) than rebound tenderness (+LR 2.1) for detecting peritoneal irritation.
When taken together, a positive cough test (+LR 2.4), rigidity (+LR 5.1) and guarding (+LR 2.4) argue strongly for the presence of peritonitis- inflammation of the peritoneum
Murphy's sign hooking the fingers under the right costal margin and asking the patient to inspire deeply- a "catch" in inspiration is found when there is acute cholecystitis.
Costovertebral angle tenderness pyelonephritis
Percuss of the liver dullness in the MCL will tell you it is displaced- COPD- dullness- lower- pushed down by lungs (9-12 cm) is normal, if 15-20 it is enlarged- DO U/S
Palpation of the spleen can be contraindicated with infectious mononucleosis- can burst- barely palpable is 2x normal- palpate with them on their right side
Test- Splenomegaly with jaundice points to hepatic disease with portal hypertension (such as cirrhosis).
Test- Splenomegaly and pallor points to leukemia and lymphoma.
Test Splenomegaly with lymphadenopathy
Spleen or kidney spleen is coming down from above- has notch, extends beyond midline- dull to percussion-cannot probe between the mass and costal margin w/the spleen- and the kidney is growing upward- so you can put your fingers beneath costal margin
Pain with pressure or fist percussion over the costovertebral angle (CVA) supports the diagnosis of pyelonephritis if associated with fever and dysuria, but may also be musculoskeletal
RLQ masses feces in the right colon, right colon or cecal carcinoma, ovarian cysts, appendiceal abscess, thickened ileum of Crohn's disease, and ectopic pregnancy
LLQ mass feces in the left colon, colon carcinoma, diverticular abscess, ovarian cysts, or ectopic pregnancy.
RUQ hepatomegaly, an enlarged right kidney, an enlarged gallbladder, or an enlarged or inflamed pancreas.
LUQ an enlarged spleen, enlarged left kidney, an inflamed or enlarged pancreas or stool in the splenic flexure of the colon
Epigastric masses an enlarged left lobe of the liver, pancreatic enlargement, masses of the stomach, and aortic aneurysms.
Hypogastric mass increased uterine size (pregnancy, fibroids), abdominal hernias, an enlarged bladder, ovarian cysts, and aortic aneurysms.
AAA risk age ≥65 years, smoking, male gender, 1st degree relative with Hx of AAA repair. A periumbilical or upper abdominal mass with expansile pulsations that is ≥3 cm in diameter suggests an AAA.
Ascites centrally you feel tympanny but laterally feel dullness- fluid goes to the dependent sides- go to the right and it shifts to the rt. A protuberant abdomen with bulging flanks suggests ascites
Test Differentiation between ascites and a large ovarian cyst same s/s BUT percussion of the abdomen yields dullness and lateral tympany. The large ovarian cyst forces air-filled bowel laterally toward the flanks.
Iliopsoas sign and obturator sign did in lab- straight leg and leg flex to check for appendicitis
Distended bladder 400-600 ml
TEST Rosving sign Press deeply evenly in the LLQ, then quickly withdraw your fingers- pain will be at RLQ- pain will always be at sign of inflammation
Test Murphy sign cholesistitis- hook your thumb under the right costal margin at edge of rectal muscle, take a deep breath- Sharp tenderness and a sudden stop in inspiratory effort
Test- Intussusception red color jelly appearance- blood and mucous in stool- acute intermittent abdominal pain with distention/onstruction, absent bowel sounds- sausage shaped mass- younger than 6 yrs- more in females-
Test- Pyloric stenosis Hypertrophy (narrowing) of the circular muscle of the pylorus leading to obstruction of the pyloric sphincter- males- olive shaped mass- projectile vomiting- failure to thrive-
Biliary atresia Congenital obstruction or absence of some or all of the bile duct system (mostly the extrahepatic bile ducts) resulting in bile flow obstruction- jaundice, clay-colored stool- dark urine- failure to thrive- full term infant- progressive- abdominal u/s
Test Meckel Diverticulum Outpouching of the ileum (s. interstine) that varies in size- most common congenital anomaly- asymptomatic- inflamed- discovered same time as appendicitis
Wilms Tumor (Nephroblastoma): Most common intraabdominal tumor of childhood (2-3 yrs old)- painless abdominal tumor- abdominal pain, vomiting, and hematuria, htn
Hirschsprung Disease Primary absence of parasympathetic ganglion cells in a segment of the colon, which interrupts intestinal motility- gut not moving- failure to thrive- severe constipation
Hemolytic Uremic Syndrome (HUS) Triad of microangiopathic hemolytic anemia, thrombocytopenia, and uremia-common causes of acute renal failure in children, generally occurring in those younger than 4 years- shiga-like toxin E-coli
Acute Salpingitis bilateral, the tenderness (inflammation of the fallopian tubes) is usually maximal just above the inguinal ligaments-Rebound tenderness and rigidity may be present- motion of the cervix
Acute Pleurisy Abdominal from acute pleural inflammation- mimic acute cholecystitis or acute appendicitis-Rebound tenderness and rigidity are less common-Chest signs present
Variation in liver shape elongation, sometimes called Riedel lobe, represents a variation in shape, not an increase in liver volume or size
Irregular large liver An enlarged liver that is firm or hard with an irregular edge or surface suggests hepatocellular carcinoma
Smooth large liver Cirrhosis (firm, nontender edge- scarred and contracted), hemochromatosis, amyloidosis, and lymphoma- smooth, tender edge= inflammation (hepatitis, or venous congestion in right-sided heart)
Created by: arsho453