module 12 NGR5003 Exam III

Irritable bowel syndrome

pain - Hypogastric pain; crampy, variable, infrequent; associated with bowel function s/s - Unremarkable physical examination - Pain associated with gas, bloating, distention; relief with passage of flatus, feces

kehr sign

- Abdominal pain radiating to left shoulder - associated with Spleen rupture; renal calculi; ectopic pregnancy

Murphy sign

- Abrupt cessation of inspiration on palpation of gallbladder - associated with cholecystitis

dance sign

- Absence of bowel sounds in right lower quadrant - associated with intussusception

clinical pearl: assessing liver size

- It is best to report the size of the liver in two ways: liver span as determined from percussing the upper and lower borders, and the extent of liver projection below the costal margin. - When the size of a patient's liver is important in assessing the clinical condition, projection below the costal margin alone will not provide enough comparative information. - Be sure to specify which landmarks were used for future measurement comparison (e.g., midclavicular line).

risk factors for colon cancer

- Age older than 50 years - Family history of colorectal cancer or adenomatous polyps in one or more first-degree relatives and family history of syndromic colon cancer, including familial adenomatous polyposis (FAP), hereditarynonpolyposis colorectal cancer (HNPCC), Turcot syndrome (also associated with brain tumors), Peutz-Jeghers syndrome, and MUYTH-associated polyposis (MAP; mutation in the gene MUYTH) - Personal history of colon cancer, adenomatous polyps, inflammatory bowel disease (Crohn disease, ulcerative colitis), FAP, HNPCC - Race: African American - Ethnic background: Ashkenazi Jewish - Diet: low-fiber, high in red meat, processed meats, and foods fired, broiled, grilled increases risk; diet high in fruits and vegetable decreases risk - Obesity - Smoking cigarettes - Physical inactivity - Heavy alcohol use - Type 2 diabetes

alternative liver palpation techniques

- An alternative technique is to hook your fingers over the right costal margin below the border of liver dullness, as shown in Fig. 18.17. - Stand on the patient's right side facing his or her feet. - Press in and up toward the costal margin with your fingers, and ask the patient to take a deep breath. - Try to feel the liver edge as it descends to meet your fingers. - If the abdomen is distended or the abdominal muscles tense, the usual techniques for determining the lower liver border may be unproductive, and the scratch test may be useful (Fig. 18.18). - This technique uses auscultation to detect the differences in sound transmission over solid and hollow organs. - Place the diaphragm of the stethoscope over the liver and with the finger of your other hand scratch the abdominal surface lightly, moving toward the liver border. - When you encounter the liver, the sound you hear intensifies. - To check for liver tenderness when the liver is not palpable, use indirect fist percussion. - Place the palmar surface of one hand over the lower right rib cage, and then strike your hand with the ulnar surface of the fist of your other hand. - The healthy liver is not tender to percussion.

Right Lumbar

- Ascending colon - Lower half of right kidney - Portion of duodenum and jejunum

ballottement

- Ballottement is a palpation technique used to assess an organ or a mass. - To perform abdominal ballottement with one hand, place your extended fingers, hand, and forearm at a 90-degree angle to the abdomen. - Push in toward the organ or mass with the fingertips (Fig. 18.28, A). - If the mass is freely movable, it will float upward and touch the fingertips as fluid and other structures are displaced by the maneuver. - To perform bimanual ballottement, place one hand on the anterior abdominal wall and one hand against the flank. - Push inward on the abdominal wall while palpating with the flank hand to determine the presence and size of the mass

inspection

- Begin by inspecting the abdomen from a seated position at the patient's right side. - This position allows a tangential view that enhances shadows and contouring - When abdominal vessels appear distended or more pronounced, use the following procedure to determine the direction of venous return. - Place the index fingers of both hands side by side perpendicularly over a vein. - Press and separate the fingers, milking empty a section of vein. - Release one finger and time the refill. Release the other finger and time the refill. - The flow of venous blood is in the direction of the faster filling. - Flow patterns are altered in some disease states unexpected findings: - A glistening, taut appearance suggests ascites. Inspect for bruises and localized discoloration. - Areas of redness may indicate inflammation. - A bluish periumbilical discoloration (Cullen sign) suggests intraabdominal bleeding. - Striae often result from pregnancy or weight gain. - Striae of recent origin are pink or blue in color but turn silvery white over time. - Abdominal tumors or ascites can produce striae. - The striae of Cushing disease remain purplish. - A pearl-like, enlarged and sometimes painful umbilical nodule from cancer metastasis, known as Sister Mary Joseph's nodule, may be the first sign of an intraabdominal malignancy

liver span

- Begin liver percussion at the right midclavicular line over an area of tympany. - Always begin with an area of tympany and proceed to an area of dullness because that sound change is easiest to detect. - Percuss upward along the midclavicular line, as shown in Fig. 18.8, to determine the lower border of the liver. - The area of liver dullness is usually heard at the costal margin or slightly below it. - Mark the border with a marking pen. - A lower liver border that is more than 2 to 3 cm (.75 to 1 inch) below the costal margin may indicate organ enlargement or downward displacement of the diaphragm because of emphysema or other pulmonary disease. - To determine the upper border of the liver, begin percussion on the right midclavicular line at an area of lung resonance around the third intercostal space. - Continue downward until the percussion tone changes to one of dullness; this marks the upper border of the liver. - Mark the location with the pen. - The upper border is usually in the fifth intercostal space. - An upper border below this may indicate downward displacement or liver atrophy. - Dullness extending above the fifth intercostal space suggests upward displacement from abdominal fluid or masses. - Measure the distance between the marks to estimate the vertical span of the liver. - The usual span is approximately 6 to 12 cm (2.5 to 4.5 inches). - A span greater than this may indicate liver enlargement, whereas a lesser span suggests atrophy. - If liver enlargement is suspected, additional percus- sion maneuvers can provide further information. Percuss upward and then downward over the right midaxillary line. - Liver dullness is usually detected around the seventh intercostal space. You can also percuss along the midsternal line to estimate the midsternal liver span (see Fig. 18.8). - The usual span at the midsternal line is 4 to 8 cm (1.5 to 3 inches). Spans exceeding 8 cm suggest liver enlargement. - To assess the descent of the liver, ask the patient to take a deep breath and hold it while you percuss upward again from the abdomen at the right midclavicular line. - The area of lower border dullness should move downward 2 to 3 cm. This maneuver will guide subsequent palpation of the organ

Right Inguinal

- Cecum - Appendix - Lower end of ileum - Right ureter - Right spermatic cord - Right ovary

moderate palpation

- Continue palpation with the same hand position and technique used for light palpation, exerting moderate pressure as an intermediate step to gradually approach deep palpation. - An additional maneuver of moderate palpation is performed with the side of your hand (Fig. 18.12). - This maneuver is useful in assessing organs that move with respiration, specifically the liver and spleen. - Palpate during the entire respiratory cycle. - As the patient inspires, the organ is displaced downward, and you may be able to feel it as it bumps gently against your hand.

inspection of infants and children

- It should be rounded and dome- shaped because the abdominal musculature has not fully developed. - Note any localized fullness. - Abdominal and chest movements should be synchronous, with a slight bulge of the abdomen at the beginning of respiration. - Note whether the abdomen protrudes above the level of the chest or is scaphoid. - A distended or protruding abdomen can result from feces, a mass, or organ enlargement. - A scaphoid abdomen in a newborn suggests that the abdominal contents are displaced into the thorax.

contour

- Contour is the abdominal profile from the rib margin to the pubis, viewed on the horizontal plane. - The expected contours can be described as flat, rounded, or scaphoid. - A flat contour is common in well-muscled, athletic adults. - The rounded or convex contour is characteristic of young children, but in adults it is the result of subcutaneous fat or poor muscle tone. - The abdomen should be evenly rounded with the maximum height of convexity at the umbilicus. - The scaphoid or concave contour is seen in thin adults. - Note the location and contour of the umbilicus. -- It should be centrally located without displacement upward, downward, or laterally. -- The umbilicus may be inverted or protrude slightly, but it should be free of inflammation, swelling, or bulge that may indicate a hernia. Examination methods - Inspect for symmetry from a seated position at the patient's side, then move to a standing position behind the patient's head, if possible. - Ask the patient to take a deep breath and hold it. The contour should remain smooth and symmetric. -- This maneuver lowers the diaphragm and compresses the organs of the abdominal cavity, which may cause previously unseen bulges or masses to appear. - Next, ask the patient to raise his or her head from the table. -- This contracts the rectus abdominis muscles, which produces muscle prominence in thin or athletic adults. -- Superficial abdominal wall masses may become visible. -- If a hernia is present, the increased abdominal pressure may cause it to protrude.

Left Lumbar

- Descending colon - Lower half of left kidney - Portions of jejunum and ileum

GI changes in pregnancy

- Due to relaxation of the lower esophageal sphincter, heartburn (gastroesophageal reflux) often occurs. - Gallstones are more common in the second and third trimesters. - The kidneys enlarge slightly (by about 1 cm in length) during pregnancy. - The bladder has increased sensitivity and compression during pregnancy, leading to frequency and urgency of urination during the first and third trimesters. - The colon is displaced laterally upward and posteriorly, peristaltic activity may decrease, and water absorption is increased. -- As a result, bowel sounds are diminished, and constipation and flatus are more common. - The appendix is displaced upward and laterally, away from McBurney point, an anatomic landmark one-third of the distance from the anterior superior iliac spine to the umbilicus. - In the postpartum period, the uterus involutes rapidly. Immediately after delivery, the uterus is approximately the size of a 20-week pregnancy (palpable at the level of the umbilicus). - By the end of the first week, it is about the size of a 12-week pregnancy, palpable at the symphysis pubis. - The muscles of the pelvic floor and the pelvic supports gradually regain tone during the postpartum period and may require 6 to 7 weeks to recover. - Stretching of the abdominal wall during pregnancy may result in persistent striae.

Cullen sign

- Ecchymosis around umbilicus - associated with Hemoperitoneum; pancreatitis; ectopic pregnancy

gray turner sign

- Ecchymosis of flanks - associated with Hemoperitoneum; pancreatitis

balance

- Fixed dullness to percussion in left flank and dullness in right flank that disappears on change of position - associated with peritoneal irrigation

regions of the abdomen

- For the purposes of examination, the abdomen is commonly divided into four quadrants, first by drawing an imaginary line from the sternum to the pubis through the umbilicus. - Draw a second imaginary line perpendicular to the first, horizontally across the abdomen through the umbilicus (Fig. 18.3). - Alternatively, the abdomen is divided into nine regions using following imaginary lines: two horizontal lines, one across the lowest edge of the costal margin and the other across the edge of the iliac crest, and two vertical lines running bilaterally from the midclavicular line to the middle of the Poupart ligament, approximating the lateral borders of the rectus abdominis muscles

preparation for an abdominal exam

- Have the patient empty his or her bladder before the examination begins; a full bladder interferes with accurate examination of nearby organs and makes the examination uncomfortable. - Place the patient in a supine position with arms at the sides. - Approach the patient from the right side. - The patient's abdominal musculature should be relaxed to allow access to the underlying structures. - It may be helpful to place a small pillow under the patient's head and another under slightly flexed knees. - Drape a towel or sheet over the patient's chest for warmth and privacy. - Make your approach slow and gentle, avoiding sudden movements. - Ask the patient to point to any tender areas, and examine those last.

Hypogastric (Pubic)

- Ileum - Bladder - Uterus (if enlarged)

findings in peritoneal irritation

- Involuntary rigidity of abdominal muscles - Tenderness and guarding - Absent bowel sounds - Positive obturator test - Positive iliopsoas test - Rebound tenderness (Blumberg sign and McBurney sign; see Table 18.5) - Abdominal pain on walking - Positive heel jar test (Markle sign; see Table 18.5) - Right lower quadrant pain intensified by left lower quadrant abdominal palpation

Markle (heel jar)

- Patient stands with straightened knees, then raises up on toes, relaxes, and allows heels to hit floor, thus jarring body; action will cause abdominal pain if positive - associated with Peritoneal irritation; appendicitis

light palpation

- Lay the palm of your hand lightly on the abdomen, with the fingers extended and held together (Fig. 18.11). - With the palmar surface of your fingers, depress the abdominal wall no more than 1 cm, using a light and even pressing circular motion. - Avoid short, quick jabs. - Light palpation is useful in identifying muscular resis- tance and areas of tenderness. - A large mass or distended structure may be appreciated on light palpation as a sense of resistance. - If resistance is present, determine whether it is voluntary or involuntary in the following way: -- Place a pillow under the patient's knees and ask the patient to breathe slowly through the mouth as you feel for relaxation of the rectus abdominis muscles on expiration. -- If the tenseness remains, it is probably an involuntary response to localized or generalized rigidity. - Rigidity is a board-like hardness of the abdominal wall overlying areas of peritoneal irritation.

organs in the LEFT UPPER QUADRANT (LUQ)

- Left lobe of liver - Spleen - Stomach - Body of pancreas - Left adrenal gland - Portion of left kidney - Splenic flexure of colon - Portions of transverse and descending colon

additional sounds and bruits

- Listen with the diaphragm for friction rubs over the liver and spleen. - Friction rubs are high pitched and are heard in association with respiration. - Although friction rubs in the abdomen are rare, they indicate inflammation of the peritoneal surface of the organ from tumor, infection, or infarct. - A bruit is a harsh or musical intermittent ausculta- tory sound, which may reflect blood flow turbulence and indicate vascular disease. - Listen with the bell of the stethoscope in the epigastric region and in the aortic, renal, iliac, and femoral arteries. - Vascular sounds are usually well localized. - Keep their specific locations in mind as you listen at those sites (Fig. 18.7). - Auscultate with the bell of the stethoscope in the epigastric region and around the umbilicus for a venous hum, which is soft, low pitched, and continuous. - A venous hum occurs with increased collateral circulation between the portal and systemic venous systems.

organs in the RIGHT UPPER QUADRANT (RUQ)

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

organs in LEFT LOWER QUADRANT (LLQ)

- Lower pole of left kidney - Sigmoid colon - Portion of descending colon - Bladder (if distended) - Ovary and salpinx - Uterus (if enlarged) - Left spermatic cord Left ureter

organs in RIGHT LOWER QUADRANT (RLQ)

- Lower pole of right kidney - Cecum and appendix - Portion of ascending colon - Bladder (if distended) - Ovary and salpinx - Uterus (if enlarged) - Right spermatic cord Right ureter

movement

- Males exhibit primarily abdominal movement with respiration, whereas females show mostly costal movement. - Limited abdominal motion associated with respiration may indicate peritonitis in an ill-appearing adult male. - Surface motion from peristalsis, seen as a rippling movement across the abdomen, may be seen in thin individuals but can also be a sign of intestinal obstruction. - Abdominal aortic pulsations seen in the upper midline are often visible in thin adults. - Marked pulsations may occur as the result of increased pulse pressure or abdominal aortic aneurysm.

risk factors for hepatitis A

- Men who have sex with men - Travelers to countries with intermediate or high prevalence - Household family members and close contacts of children adopted from countries with high rates of infection - Children in day care, employees, and household contacts - People with clotting factor disorders - Injection and noninjection drug users

clinical pearl: scars

- Note any scars and draw their location, configuration, and relative size on an illustration of the abdomen. - If the cause of a scar was not explained during the history, now is a good time to pursue that information. - The presence of scarring should alert you to the possibility of intraabdominal adhesions.

Umbilical

- Omentum - Mesentery - Lower part of duodenum - Jejunum and ileum

Romberg-Howship

- Pain down the medial aspect of the thigh to the knees - Strangulated obturator hernia

Aron sign

- Pain or distress occurs in area of patient's heart or stomach on palpation of McBurney point - associated with appendicitis

palpation of the gallbladder

- Palpate below the liver margin at the lateral border of the rectus abdominis muscle for the gallbladder. - A healthy gallbladder will not be palpable. - A palpable, tender gallbladder indicates cholecystitis, whereas nontender enlargement suggests common bile duct obstruction. - If you suspect cholecystitis, have the patient take a deep breath during deep palpation. - As the inflamed gallbladder comes in contact with the examining fingers, the patient will experience pain and abruptly halt inspiration (Murphy sign).

aorta palpation

- Palpate deeply slightly to the left of the midline, and feel for the aortic pulsation. - If the pulsation is prominent, try to determine the direction of pulsation. - A prominent lateral pulsation suggests an aortic aneurysm. - If you are unable to feel the pulse on deep palpation, an alternate technique may help. - Place the palmar surface of your hands with fingers extended on the midline. - Press the fingers deeply inward on each side of the aorta, and feel for the pulsation. - In thin individuals, you can use one hand, placing the thumb on one side of the aorta and the fingers on the other side - In general palpation has a moderate sensitivity for detecting aneurysms large enough to be referred for surgery. - The U.S. Preventive Services Task Force currently recommends a one-time screening ultrasound for AAA in men 65 to 75 years of age who have ever smoked.

risk factors for hepatitis C

- People who have sex with an infected individual - Men who have sex with men - People who have multiple sex partners (e.g., >1 sex partner in the previous 6 months) - Infants born to infected mothers - people with human immunodeficiency virus infection - People who received blood transfusions or solid organ transplants before July 1992 - people who received clotting factors concentrates made before 1987 - hemodialysis patients - Injection drug users - Healthcare and public safety workers at risk for occupational exposure to blood or blood-contaminated products

risk factors for hepatitis B

- People who have sex with an infected individual - Men who have sex with men - People who have multiple sex partners (e.g., >1 sex partner in the previous 6 months) - People who live with chronically infected individuals - Travelers to countries with intermediate or high prevalence - Infants born to infected mothers - hemodialysis patients - Injection drug users - Healthcare and public safety workers at risk for occupational exposure to blood or blood-contaminated products - Residents and staff of facilities for developmentally disabled persons

gastric bubble

- Percuss for the gastric air bubble in the area of the left lower anterior rib cage and left epigastric region. - The tympany produced by the gastric bubble is lower in pitch than the tympany of the intestine.

palpation of the liver

- Place your left hand under the patient at the 11th and 12th ribs, pressing upward to elevate the liver toward the abdominal wall. - Place your right hand on the abdomen, fingers pointing toward the head and extended so the tips rest on the right midclavicular line below the level of liver dullness, as shown in Fig. 18.16, A. - Alternatively, you can place your right hand parallel to the right costal margin, as shown in Fig. 18.16, B. - In either case, press your right hand gently but deeply, in and up. Have the patient breathe regularly a few times and then take a deep breath. - Try to feel the liver edge as the diaphragm pushes it down to meet your fingertips. - Ordinarily, the liver is not palpable, although it may be felt in some thin persons without pathologic conditions. - If the liver edge is felt, it should be firm, smooth, even, and nontender. - Feel for nodules, tenderness, and irregularity. - If the liver is palpable, repeat the maneuver medially and laterally to the costal margin to assess the liver contour and surface

epigastric

- Pylorus - Duodenum - Pancreas - Portion of liver

Right Hypochondriac

- Right lobe of liver - Gallbladder - Portion of duodenum - Hepatic flexure of colon - Portion of right kidney - Right adrenal gland

Rovsing

- Right lower quadrant pain intensified by left lower quadrant abdominal palpation - associated with Peritoneal irritation; appendicitis

Left Inguinal

- Sigmoid colon - Left ureter - Left spermatic cord - Left ovary

Left Hypochondriac

- Stomach - Spleen - Tail of pancreas - Splenic flexure of colon - Upper pole of left kidney Left adrenal gland

Anatomy and Physiology

- The abdominal cavity contains several of the body's vital organs (Fig. 18.1). - The peritoneum, a serous membrane, lines the cavity and forms a protective cover for many of the abdominal organs. - Double folds of the peritoneum around the stomach constitute the greater and lesser omentum. - The mesentery, a fan-shaped fold of the peritoneum, covers most of the small intestine and anchors it to the posterior abdominal wall.

vasculature

- The abdominal portion of the descending aorta travels from the diaphragm through the abdominal cavity, just to the left of midline (Fig. 18.1, D). - At about the level of the umbilicus, the aorta branches into the two common iliac arteries. - The splenic and renal arteries, which supply their respective organs, also branch off within the abdomen.

gallbladder

- The gallbladder is a saclike, pear-shaped organ about 4 inches long, lying recessed in the inferior surface of the liver. It concentrates and stores bile from the liver. - In response to cholecystokinin, a hormone produced in the duodenum, the gallbladder releases bile into the cystic duct. - The cystic duct and hepatic duct join to form the common bile duct. - Contraction of the gallbladder propels bile along the common duct and into the duodenum at the duodenal papilla. - Composed of cholesterol, bile salts, and pigments, bile serves to maintain the alkaline pH of the small intestine, permitting emulsification of fats so that absorption of lipids can be accomplished.

anatomy of the liver

- The liver lies in the right upper quadrant of the abdomen (Fig. 18.1, C), just below the diaphragm and above the gallbladder, right kidney, and hepatic flexure of the colon. - The heaviest organ in the body, the liver weighs about 3 pounds in the adult. - It is composed of four lobes containing lobules, the functional units. - Each lobule is made up of liver cells radiating around a central vein. - Branches of the portal vein, hepatic artery, and bile duct penetrate to the periphery of the lobules. - Bile secreted by the liver cells drains from the bile ducts into the hepatic duct, which joins the cystic duct from the gallbladder to form the common bile duct. - The hepatic artery transports blood to the liver directly from the aorta, and the portal vein carries blood from the digestive tract and spleen to the liver.

pancreas

- The pancreas lies behind and beneath the stomach, with its head resting in the curve of the duodenum and tip extending across the abdominal cavity to almost touch the spleen (Fig. 18.1, C). - As an exocrine gland, the acinar cells of the pancreas produce digestive juices containing inactive enzymes for the breakdown of proteins, fats, and carbohydrates. - Collecting ducts empty the juice into the pancreatic duct (duct of Wirsung), which runs the length of the organ. - The pancreatic duct empties into the duodenum at the duodenal papilla, alongside the common bile duct. - Once introduced into the duodenum, the digestive enzymes are activated. - As an endocrine gland, islet cells scattered throughout the pancreas produce the hormones insulin and glucagon.

detecting splenomegaly

- The prevalence of palpable splenomegaly in healthy individuals is low and the physical examination is more specific than sensitive (i.e., the inability to detect the spleen with palpation and/or percussion does not rule out splenomegaly). - In general, when suspicion for splenomegaly is at least 10% based on history and other physical examination findings, begin with percussion of Traube space. - If dullness is appreciated, palpation should follow. For thin patients, palpation may be more useful than percussion. - If clinical suspicion is high, and splenomegaly is not appreciated on examination, radiologic imaging may be necessary.

Musculature and Connective Tissues

- The rectus abdominis muscles anteriorly and the internal and external oblique muscles laterally form and protect the abdominal cavity (Fig. 18.1, A). - The linea alba, a tendinous band, is located in the midline of the abdomen between the rectus abdominis muscles. - It extends from the xiphoid process to the symphysis pubis and contains the umbilicus. - The inguinal ligament (Poupart ligament) extends from the anterior superior spine of the ilium on each side to the pubis.

spleen

- The spleen is in the left upper quadrant, lying above the left kidney and just below the diaphragm. - White pulp (lymphoid tissue) constitutes most of the organ and functions as part of the reticuloendothelial system to filter blood and manufacture lymphocytes and monocytes. - The red pulp of the spleen contains a capillary network and venous sinus system that allow for storage and release of blood, permitting the spleen to accommodate up to several hundred milliliters at once.

anatomy of the stomach

- The stomach lies transversely in the upper abdominal cavity, just below the diaphragm. - It consists of three sections: the fundus, lying above and to the left of the cardiac orifice; the middle two-thirds, or body; and the pylorus, the most distal portion that narrows and terminates in the pyloric orifice.\ - pepsin digest proteins, whereas gastric lipase acts on emulsified fats. Little absorption takes place in the stomach.

examining the abdomen of a ticklish patient

- The ticklishness of a patient can sometimes make it difficult to palpate the abdomen satisfactorily; however, there are ways to overcome this problem. - Ask the patient to perform self-palpation, and place your hands over the patient's fingers, not quite touching the abdomen itself. - After a time, let your fingers drift slowly onto the abdomen while still resting primarily on the patient's fingers. - You can still learn a good deal, and ticklishness might be less of a problem. - You might also use the diaphragm of the stethoscope (making sure it is warm enough) as a palpating instrument. - This serves as a starting point, and again your fingers can drift over the edge of the diaphragm and palpate without eliciting an excessively ticklish response. - Applying a stimulus to another, less sensitive part of the body with your nonpalpating hand can also decrease a ticklish response. - In some instances, a patient's ticklishness cannot be overcome and you just have to palpate as best you can.

urinary bladder palpation

- The urinary bladder is not palpable in a healthy patient unless the bladder is distended with urine, at which time you will feel it as a smooth, round, tense mass. - You can determine the distended bladder outline with percussion; a distended bladder will elicit a lower percussion note than the surrounding air-filled intestines.

bowel sounds

- They are usually heard as clicks and gurgles that occur irregularly and range from 5 to 35 per minute. - Bowel sounds are generalized so most often they can be assessed adequately by listening in one place. - Loud prolonged gurgles are called borborygmi (stomach growling). - Increased bowel sounds may occur with gastroenteritis, early intestinal obstruction, or hunger. - High-pitched tinkling sounds suggest intestinal fluid and air under pressure, as in early obstruction. - Decreased bowel sounds occur with peritonitis and paralytic ileus. - Auscultate in all four quadrants if you have a concern. - Absent bowel sounds, referring to an inability to hear any bowel sounds after 5 minutes of continuous listening, is typically associated with abdominal pain and rigidity and is a surgical emergency.

obturator muscle test

- This test can be performed when you suspect a ruptured appendix or a pelvic abscess due to irritation of the obturator muscle. - While in the supine position, ask the patient to flex the right leg at the hip and knee to 90 degrees. - Hold the leg just above the knee, grasp the ankle, and rotate the leg laterally and medially (Fig. 18.27). - Pain in the right hypogastric region is a positive sign, indicating irritation of the obturator muscle.

illiopsoas muscle test

- This test is performed when you suspect appendicitis because an inflamed appendix may cause irritation of the lateral iliopsoas muscle. - Ask the patient to lie supine and then place your hand over the lower right thigh. - Ask the patient to raise the right leg, flexing at the hip, while you push downward (Fig. 18.26). - An alternative technique is to position the patient on the left side and ask that the right leg be raised from the hip while you press downward against it. - A third technique is to hyperextend the right leg by drawing it backward while the patient is lying on the left side. - Pain with any of these techniques is considered a positive psoas sign, indicating irritation of the iliopsoas muscle.

masses

- To determine whether a mass is superficial (i.e., located in the abdominal wall) or intraabdominal, have the patient lift his or her head from the examining table, thus contracting the abdominal muscles. - Masses in the abdominal wall will continue to be palpable, but those located in the abdominal cavity will be more difficult to feel because they are obscured by abdominal musculature. - The presence of feces in the colon, often mistaken for an abdominal mass, can be felt as a soft, rounded, boggy mass in the cecum and in the ascending, descending, or sigmoid colons.

deep palpation

- Use the palmar surface of your extended fingers, pressing deeply and evenly into the abdominal wall (Fig. 18.13). - Palpate all four quadrants or nine regions, moving the fingers back and forth over the abdominal contents. - Often you are able to feel the borders of the rectus abdominis muscles, the aorta, and portions of the colon. - Deep pressure may also evoke tenderness in the healthy person over the cecum, sigmoid colon, aorta, and in the midline near the xiphoid process. - If deep palpation is difficult because of obesity or muscular resistance, you can use a bimanual technique with one hand atop the other, as shown in Fig. 18.14. - Exert pressure with the top hand while concentrating on sensation with the other hand. - Some examiners prefer to use the bimanual technique for all patients.

an enlarged spleen of an enlarged left kidney?

- When an organ is palpable below the left costal margin, it may be difficult to differentiate an enlarged spleen from an enlarged left kidney. - Percussion should help distinguish between the organs. - The percussion note over an enlarged spleen is dull because the spleen displaces the bowel. - The usual area of splenic dullness will be increased downward and toward the midline. - The percussion note over an enlarged kidney is resonant because the kidney is deeply situated behind the bowel. - In addition, the edge of the spleen is sharper than that of the kidney. - A palpable notch along the medial border suggests an enlarged spleen rather than an enlarged kidney.

clinical pearl: abdominal distension

- You are with a patient whose abdomen is significantly distended and whose bowel sounds are hypoactive or even absent. - There is no particular pain, and you feel no masses. - The deep tendon reflexes are diminished. - You know that the patient is on diuretics for treatment of hypertension. - Think of hypokalemia as a cause of a paralytic ileus (intestinal pseudoobstruction): --diuretics/distention/deficiency of potassium. - Narcotics and hypothyroidism can do the same thing.

rebound tenderness

- blumberg sign which indicates peritonitis - Rebound tenderness over McBurney point in the lower right quadrant suggests appendicitis (positive McBurney sign)

Tympany

- musical note of higher pitch than resonance - located over air filled viscera

Hyperresonance

- pitch lies between tympany and resonance - located in base of left lung

alimentary tract

- runs from the mouth to the anus and includes the esophagus, stomach, small intestine, and large intestine. - It functions to ingest and digest food; absorb nutrients, electrolytes, and water; and excrete waste products. - Food and the products of digestion are moved along the length of the alimentary tract by peristalsis under autonomic (involuntary) nervous system control.

dullness

- short, high-pitched note with little resonance - located over solid organs adjacent to air filled structures - A distended bladder produces dullness in the suprapubic area

resonance

- sustained note of moderate pitch - located over lung tissue and sometimes over the abdomen

examination of the abdomen

1. Inspect the abdomen for: - Skin characteristics - Venous return patterns - Symmetry - Surface motion 2. Inspect abdominal muscles as patient raises head to detect presence of: - Masses - Hernia - Separation of muscles 3. Auscultate with stethoscope diaphragm for bowel sounds 4. Auscultate with stethoscope bell for bruits over aorta, renal, iliac, and femoral arteries 5. Percuss the abdomen for: - Tone in all four quadrants (or nine regions) - Liver borders to estimate span - Splenic dullness in left midaxillary line - Gastric air bubble 6. Lightly palpate in all quadrants or regions for: - Muscular resistance - Tenderness - Masses 7. Deeply palpate for: - Bulges and masses around the umbilicus and umbilical ring - Liver border in right costal margin - Gallbladder below liver margin at lateral border of the rectus muscle - Spleen in left costal margin - Right and left kidneys - Aortic pulsation in midline - Other masses 8. With patient sitting, percuss the left and right costovertebral angles for kidney tenderness.

clues in diagnosing abdominal pain

1. Patients may give a "touch-me-not" warning—that is, not to touch in a particular area; however, these patients may not actually have pain if their faces seem relaxed and unconcerned, even smiling. When you touch they might recoil, but the unconcerned face persists. (This sign is helpful in other areas of the body, as well as the abdomen.) 2. Patients with an organic cause for abdominal pain are generally not hungry. A negative response to the "Do you want something to eat?" question is probable, particularly with appendicitis or intra- abdominal infection. 3. Ask the patient to point a finger to the location of the pain. If it is not directed to the umbilicus but goes immediately to a fixed point, there is a greater likelihood that this has significant pathologic importance. The farther from the umbilicus the pain, the more likely it will be organic in origin (Apley rule). If the finger goes to the umbilicus and the patient seems otherwise well to you, you should include psychosomatic causes in the differential diagnosis. 4. Patients with nonspecific abdominal pain may keep their eyes closed during abdominal palpation, whereas patients with organic disease usually keep their eyes open. 5. Patients with nonsignificant pain will have abdominal pain when you manually palpate the abdomen. However, if you then tell the patient you want to listen to the painful area and push just as hard with the stethoscope and elicit no pain response, the pain is likely not significant.

quality and onset of abdominal pain

Burning---Peptic ulcer Cramping---Biliary colic, gastroenteritis Colicky---Appendicitis with impacted feces; renal stone Aching ---Appendiceal irritation Knifelike ---Pancreatitis Ripping, tearing---Aortic dissection Gradual onset---Infection Sudden onset---Duodenal ulcer, acute pancreatitis, obstruction, perforation

Lactose intolerance

pain - Crampy pain after drinking milk or eating milk products - Associated diarrhea; unremarkable physical examination

Hernia

pain - Localized pain that increases with exertion or lifting s/s - Hernia on physical examination

Uterine fibroids

pain - Pain related to menses, intercourse s/s - Palpable myoma(s)

Perforated gastric or duodenal ulcer

pain - Abrupt RUQ; may be referred to shoulders s/s - Abdominal free air and distention with increased resonance over liver; tenderness in epigastrium or RUQ; rigid abdominal wall, rebound tenderness

Intestinal obstruction

pain - Abrupt, severe, colicky, spasmodic; referred to epigastrium, umbilicus s/s - Distention, minimal rebound tenderness, vomiting, localized tenderness, visible peristalsis; bowel sounds absent (with paralytic obstruction) or hyperactive high pitched (with mechanical obstruction)

Peptic ulcer

pain - Burning or gnawing pain s/s - May have epigastric tenderness on palpation

Esophagitis/gastroesophageal reflux disease

pain - Burning or gnawing pain in midepigastrium, worsens with recumbency and certain foods - Unremarkable physical examination

Constipation

pain - Colicky or dull and steady pain that does not progress and worsen s/s - Fecal mass palpable, stool in rectum

gastritis

pain - Constant burning pain in epigastrium s/s - May be accompanied by nausea, vomiting, diarrhea, or fever Unremarkable physical examination

pancreatitis

pain - Dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present in one or both flanks; may be referred to left shoulder and penetrates to back s/s - Epigastric tenderness, vomiting, fever, shock; + Grey Turner sign; + Cullen sign: both signs occur 2-3 days after onset

Diverticulitis

pain - Epigastric, radiating down left side of abdomen especially after eating; may be referred to back s/s - Flatulence, borborygmus, diarrhea, dysuria, tenderness on palpation

Biliary stones, colic

pain - Episodic, severe, RUQ, or epigastrium lasting 15 minutes to several hours; may be lower s/s - RUQ tenderness, soft abdominal wall, anorexia, vomiting, jaundice, subnormal temperature

appendicitis

pain - Initially periumbilical or epigastric; colicky; later becomes localized to RLQ, often at McBurney point associated s/s - Guarding, tenderness; + iliopsoas and + obturator signs, RLQ skin hyperesthesia; anorexia, nausea, or vomiting after onset of pain; low-grade fever; + Aaron, Rovsing, Markle, and McBurney signs*

splenic rupture

pain - Intense; LUQ, radiating to left shoulder; may worsen with foot of bed elevated s/s - Shock, pallor, lowered temperature

Renal calculi

pain - Intense; flank, extending to groin and genitals; may be episodic s/s - Fever, hematuria; + Kehr sign

Diverticular disease

pain - Localized pain s/s - Abdominal tenderness, fever

pelvic inflammatory disease

pain - Lower quadrant, increases with activity s/s - Tender adnexa and cervix, cervical discharge, dyspareunia

ruptured ovarian cyst

pain - Lower quadrant, steady, increases with cough or motion s/s - Vomiting, low-grade fever, anorexia, tenderness on pelvic examination

salpingitis

pain - Lower quadrant, worse on left s/s - Nausea, vomiting, fever, suprapubic tenderness, rigid abdomen, pain on pelvic examination

Ectopic pregnancy

pain - Lower quadrant; referred to shoulder; with rupture is agonizing s/s - Hypogastric tenderness, symptoms of pregnancy, spotting, irregular menses, soft abdominal wall, mass on bimanual pelvic examination; ruptured: shock, rigid abdominal wall, distention; + Kehr and Cullen signs

peritonitis

pain - Onset sudden or gradual; pain generalized or localized, dull or severe and unrelenting; guarding; pain on deep inspiration s/s - Shallow respiration; + Blumberg, Markle, and Ballance signs; reduced or absent bowel sounds, nausea and vomiting; + obturator + iliopsoas signs

volvulus

pain - Referred to hypogastrium and umbilicus s/s - Distention, nausea, vomiting, guarding; sigmoid loop volvulus may be palpable

cholecystitis

pain - Severe, unrelenting RUQ or epigastric pain; may be referred to right subscapular area s/s - RUQ tenderness and rigidity; + Murphy sign, palpable gallbladder, anorexia, vomiting, fever, possible jaundice

Leaking abdominal aneurysm

pain - Steady throbbing midline over aneurysm; may penetrate to back, flank s/s - Nausea, vomiting, abdominal mass, bruit

ascites assessment

shifting dullness - after identifying the borders between tympany and dullness, have the patient lie on one side and again percuss for tympany and dullness and mark the borders. - In the patient without ascites, the borders will remain relatively constant. With ascites, the border of dullness shifts to the dependent side (approaches the midline) as the fluid resettles with gravity fluid wave - This procedure requires three hands, so you will need assistance from the patient or another examiner (Fig. 18.24). - With the patient supine, ask him or her or another person to press the edge of the hand and forearm firmly along the vertical midline of the abdomen. - This positioning helps stop the transmission of a wave through adipose tissue. - Place your hands on each side of the abdomen and strike one side sharply with your fingertips. - Feel for the impulse of a fluid wave with the fingertips of your other hand. - An easily detected fluid wave suggests ascites. - However, a fluid wave can sometimes be felt in people without ascites and, conversely, may not occur in people with early ascites. - The most sensitive maneuvers for detecting ascites are flank dullness (84%) and the presence of bulging flanks (81%), both of which have a specificity of 59%. - The most specific test is the presence of a fluid wave (90%), although its sensitivity is fair (62%). - Because these maneuvers may miss smaller amounts of peritoneal fluid, radiologic studies may be necessary.