The Abdomen-PD

What does the aorta bifurcate into?

Aorta, descending(abdominal)--> L/R Common iliac-- L/R External iliac--> L/R Femoral

How does a PA check splenic percussion?

Percuss the lowest interspace in the left anterior axillary line. This area is usually tympanitic. Then ask the patient to take a deep breath, and percuss again. When spleen size is normal, the percussion note usually remains tympanitic

If resistance is present upon palpation, the PA should?

-If resistance is present, try to distinguish voluntary guarding from involuntary rigidity or muscular spasm. Voluntary guarding usually decreases with the techniques listed below. •Palpate after asking the patient to exhale, which usually relaxes the abdominal muscles. •Ask the patient to mouth-breathe with the jaws wide open.

Hooking technique

Standing to the right of the patient's chest, place the fingers of both hands below the border of liver dullness and press in and up toward the costal margin. Ask the patient to take another deep breath.

Why is it important to be careful to no palpate to close to the right coastal margin?

Starting palpation too close to the right costal margin risks missing the lower edge of an enlarged liver that extends into the RLQ.

Prior to examination, what should the PA ask the patient?

Before you begin, ask the patient to point to any areas of pain so that you can examine these areas last.

what does gentle palpation accomplish?

aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses.

Before the examination make sure...

the patient has an empty bladder

What age group would you assess the aortic width, and what is considered within normal limits?

• 50 y/o •<3cm wide, average 2.5cm

What are the two possible ways, the abdomen may be divided for descriptive purposes? Name all of the respective regions.

• For descriptive purposes the abdomen is divided by imaginary lines that cross at the umbilicus. These lines form the right upper, left upper, right lower, and left lower quadrants. The abdomen may also be divided into nine areas. The three mid-line areas are the epigastric, umbilical, and hypogastric (or suprapubic) areas.

What are normal measurements of liver span?

•4-8cm in midsternal line •6-12cm in right midclavicular line

Why should the physician assistant auscultate the abdomine before percussion or palpation?

•Auscultate the abdomen before performing percussion or palpation, maneuvers which may alter the characteristics of the bowel sounds.

What abdominal structures can be found in the LUQ?

•Body and Tail of Pancreas •Stomach •Spleen •Splenic Flexure of colon •Transverse colon

What should the physician assistant note about the contour of the abdomen?

•Is it flat, rounded, protuberant, or scaphoid (markedly concave or hollowed)? • Do the flanks bulge, or are there any local bulges? Also survey the inguinal and femoral areas. •Is the abdomen symmetric? •Are there visible organs or masses? An enlarged liver or spleen may descend below the rib cage.

What abdominal structures can be found in the R.U.Q.?

•Liver •Gallbladder •Hepatic Flexure of colon •head of pancreas •Pylorus •Duodenum

What are the three techniques to evaluate for ascites?

•Percuss for dullness outward in several directions from the central area of tympany. •Test for shifting dullness •Test for a fluid wave.

How does does the PA percuss the left lower anterior chest wall?

•Percuss the left lower anterior chest wall roughly from the border of cardiac dullness at the 6th rib to the anterior axillary line and down to the costal margin, an area termed Traube space. •As you percuss along this route, note the lateral extent of tympany. If tympany is prominent, especially laterally, splenomegaly is not likely.

What are the two techniques that may help a PA detect an enlarged spleen?

•Percuss the left lower anterior chest wall. •Check for a splenic percussion sign.

How to measure the vertical span of the liver dullness.

•Percuss the span of the liver. First, locate the midclavicular line. Use a light to moderate percussion strike. Starting at a level below the umbilicus in the right lower quadrant, in an area of tympany, percuss up toward the liver. Identify the lower border of dullness in the midclavicular line. •Next, identify the upper border of liver dullness. Starting at the nipple line, lightly percuss from lung resonance down toward liver dullness. Measure the span of liver dullness between those two points.

What abdominal structures can be found in the LLQ?

•Sigmoid colon •Descending colon •Left ovary

Most organs palpable in the abdominal cavity except the

•Stomach •Much of the liver •spleen

What should the physician assistant note about the skin of the abdomen?

•Temperature. Check if the skin is warm, or cool and clammy. •Color. Note any bruises, erythema, or jaundice. •Scars. Describe or diagram their location. •Striae. Old silver striae or stretch marks are normal. •Dilated veins. A few small veins may be visible normally •Rashes or ecchymoses

What should the physician assistant note about the pulsations of the abdomen?

•The normal aortic pulsation is frequently visible in the epigastrium.

How does a PA assess a patient's kidney's for tenderness?

•To assess for kidney tenderness, locate the costovertebral angles. They are posterior to and below, the 12th ribs lateral to the vertebrae.

How does the PA palpate the right kidney?

•To capture the patient's right kidney, return to the patient's right side, and use your left hand to lift up from the back and your right hand to feel deep in the right upper quadrant. Proceed as before. •A normal right kidney may be palpable, especially when the patient is thin and the abdominal muscles are relaxed.

What percentage of normal adults are able to have the tip of there spleen palpated?

5%

Which Kidney is lower?

•The right kidney is slightly lower than the left

how do you palpate the liver?

•To palpate the liver, place your left hand behind the lower thorax, lifting up the 11th and 12th ribs overlying soft tissues. Place your right hand just below the right upper quadrant lateral to the rectus abdominus muscles and well below the lower border of liver dullness. •Ask the patient to "Breathe deeply for me, please." • Press gently into the abdomen and, as the patient breathes in deeply, try to feel for the liver edge as it moves down to meet your fingertips. If possible, let the liver slip under your finger pads as you feel its anterior surface You often need to try again, moving your fingertips closer to the costal margin.

How does a PA palpate the spleen?

•To palpate the spleen to assess its size, reach over and around the patient with your left hand to support the left lower posterior rib cage and overlying structures. •Place your right hand below the left costal margin and press in with your fingers toward the spleen. •Ask the patient to "Take another deep breath." •Then ask the patient to take a deep breath and percuss again. When spleen size is normal, the percussion note usually remains tympanitic. When the spleen is enlarged, tympany often changes to dullness. Dullness is a positive sign. It may be falsely positive, but its presence means you should perform careful palpation.

What are two special techniques a PA can perform as they gain experience?

•Two additional techniques are testing for shifting dullness... percussing the border of tympany and dullness with the patient supine...then turning the patient onto one side and percussing again. •And testing for a fluid wave, by tapping one flank sharply with your fingertips while you feel on the opposite flank for an impulse transmitted through the fat. Individuals with more body fat will need two sets of hands for this test.

What findings suggest that peritoneal inflammation or obstruction?

•Variations in normal bowel sounds and bruits, which are vascular sounds resembling heart murmurs over the aorta or other arteries in the abdomen.

What happens when the spleen enlarges?

•When a spleen enlarges, it expands anteriorly, downward and medially, often replacing the tympany of stomach and colon with the dullness of a solid organ. •It then becomes palpable below the costal margin.

What does "Deep Palpation" accomplish?

•delineate the liver edge, the kidneys, and abdominal masses. •Again using the palmar surfaces of your fingers, press down in all four quadrants

Signs of peritonitis include a

•positive cough test •guarding, rigidity •rebound tenderness •percussion tenderness.

What is borborygmi?

•prolonged gurgles of hyperperistalsis from "stomach growling,"

What abdominal structures can be found in the RLQ?

•right ovary •appendix •ascending colon •Cecum

Approxiametly how accurate is percussion in detecting splenomegaly? (sensitivity/specificity)

(sensitivity, 60% to 80%; specificity, 72% to 94%)

Estimates of liver span by percussion have a ______________ correlation with actual span.

60% to 70%

At what volume does a bladder produce dullness?

400-600mL

If percussion dullness is found, how accurate is palpation in detecting splenomegaly?

If percussion dullness is present, palpation correctly detects splenomegaly more than 80% of the time.

why is it important to tell the patient how to have his/her hands during the examination?

Ask the patient to keep the arms at the sides or folded across the chest. When the arms are above the head, the abdominal wall stretches and tightens, which hinders palpation.

What would you do if you suggest the spllen may be enlarged, but you were not able to palpate it while the patient was suspine?

Ask the patient to turn onto the right side, with the legs somewhat flexed at the hips. In that position, gravity may bring the spleen forward and to the right into a palpable location.

Appeendicitis Assessment

Assess carefully for the peritoneal signs of acute abdomen and the additional signs of McBurney point tenderness, Rovsing sign, the psoas sign, and the obturator sign.

Where should the PA auscultate for bruits?

Auscultate for bruits over the aorta, the iliac arteries, and the femoral arteries

Where should you auscultate for friction rubs?

Auscultate over the liver and spleen for friction rubs.

What pattern should a PA auscultate bowel sounds?

Bowel sounds are widely transmitted through the abdomen, listening in one spot, such as the RLQ, is usually sufficient.

what does depp palpation accomplish?

Deep palpation is usually required to delineate the liver edge, the kidneys, and abdominal masses. Again using the palmar surfaces of your fingers, press down in all four quadrants (Fig. 11-12). Identify any masses; note their location, size, shape, consistency, tenderness, pulsations, and any mobility with respiration or pressure from the examining hand.

What special consideration, as far as the auscultation of the abdomen, should the PA consider for hypertensive patients?

If the patient has hypertension, auscultate the epigastrium and in each upper quadrant for bruits. Later in the examination, when the patient sits up, listen also in the CVAs.

What is the proper way to assess a patient with possible peritonitis?

Even before palpation, ask the patient to cough and identify where the cough produces pain. Then palpate gently, starting with one finger then with your hand, to localize the area of pain. As you palpate, check for the peritoneal signs of guarding, rigidity, and rebound tenderness.

What are the only palpable pelvic organs?

Except for a pregnant or gravid uterus, or a distended bladder, normal pelvic organs are not palpable through the abdominal wall.

If you can't see but suspect a incisional hernia or umbilical hernia, ask the patient to?

If you suspect but do not see an umbilical or incisional hernia, ask the patient to raise both head and shoulders off the table.

During inspection of the abdomen where should you position yourself, and what are you looking for?

From the right side of the bed, inspect the surface, contours, and movements of the abdomen. Watch for bulges or peristalsis. Try to sit or bend down so that you can view the abdomen tangentially.

What does abdominal wall gentle palpation aid in?

Gentle palpation aids detection of abdominal tenderness, muscular resistance, and some superficial organs and masses.

What is guarding?

Guarding is a voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted.

When RUQ pain and tenderness suggest acute cholecystitis, assess Murphy sign.

Hook your left thumb or the fingers of your right hand under the costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Alternatively, palpate the RUQ with the fingers of your right hand near the costal margin. If the liver is enlarged, hook your thumb or fingers under the liver edge at a comparable point. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Watch the patient's breathing and note the degree of tenderness.

How should a PA position his hands to perform gentle palpate of the abdomen?

Keeping your hand and forearm on a horizontal plane, with fingers together and flat on the abdominal wall, palpate the abdomen with a light gentle dipping motion. If resistance is present, try to distinguish voluntary guarding from involuntary rigidity or muscular spasm. Voluntary guarding usually decreases with the techniques listed below.

What do normal bowels sounds, sound like?

Normal sounds consist of clicks and gurgles, occurring at an estimated frequency of 5 to 34 per minute.

What should the physician assistant note about the umbilicus?

Observe its contour and location and any inflammation or bulges suggesting a ventral hernia.

What should the physician assistant note about the Peristalsis of the abdomen?

Observe the abdomen for several minutes if you suspect intestinal obstruction. Normally, peristalsis is visible in very thin people.

How does the PA palpate the Aorta?

Okay, I'm going to examine the aorta. Can you take a deep breath in, slowly, and let it out for me? To assess the aorta, press the upper abdomen slightly left of mid line and feel for the aorta's pulsations. Now, try to assess the width of the aorta, especially in older smokers at risk for abdominal aortic aneurysm. Pressing gently with a hand on each side of the aorta, try to estimate its width. Normally it should be less than 3 centimeters. Okay, we're almost done. Now if I can get you to sit up for me, please. With the patient sitting up, assess for costovertebral angle tenderness (or CVAT), seen in pyelonephritis. Place the ball of your left hand on each costovertebral angle in turn and strike it with the ulnar surface of your fist. Normally there is no tenderness over normal kidneys.

On inspiration the liver is......

On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line.

What percussion finding would the PA find near the costal margins?

On the right, you will usually find the dullness of the liver; on the left, the tympany that overlies the gastric air bubble and the splenic flexure of the colon.

What kind of percussion is normal in abdominal examination?

Percuss the abdomen lightly in all four quadrants to determine the distribution of tympany and dullness. Tympany usually predominates because of gas in the GI tract, but scattered areas of dullness from fluid and feces are also common.

What does percussion help the PA assess in the abdomen exam?

Percussion helps you assess the amount and distribution of gas in the abdomen, viscera and masses that are solid or fluid-filled, and the size of the liver and spleen.

What is the medical term for an enlarged spleen?

Splenomegaly

Where would a PA feel the aortic pulsations?

Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations.

What is rebound tenderness?

Rebound tenderness refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand. To assess rebound tenderness, ask the patient "Which hurts more, when I press or let go?" Press down with your fingers firmly and slowly, then withdraw your hand quickly. The maneuver is positive if withdrawal produces pain. Percuss gently to check for percussion tenderness.

What is rigidity?

Rigidity is an involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations.

Which side of a patient does the book tell you to stand at, and what systematic approach did it mention?

Stand at the patient's right side and proceed in a systematic fashion with •inspection •auscultation •percussion •palpation. --Visualize each organ in the region you are examining. Watch the patient's face for any signs of pain or discomfort.

Where can you palpate the aorta and what does it bifurcate to?

The abdominal aorta usually palpable in the epigastrium and bifurcates into the common iliac arteries below the umbilicus then the external iliac arteries as it passed under the inguinal ligaments, they become the femoral arteries.

What is the name of the membrane that lines the abdominal cavity, and what are the two continuous layers that compose it?

The abdominopelvic cavity is covered by a serous membrane known as the peritoneum which has two layers, •Parietal-outlines the outside of the abdominopelvic cavity. •Visceral- outlines the organs

Which part of the stethoscope should a PA auscultate bowel sounds with?

The diaphragm

The rectus abdominus muscles are more predominate when the patient is in what position?

The rectus abdominis muscles become more prominent when the patient raises the head and shoulders or lifts the legs from the supine position.

What would the next step be if you note a dull area suggesting an underlying mass or enlarged organ?

This observation will guide subsequent palpation.

Why is it beneficial for the PA to ask the patient to breathe with the abdomen?

This practice brings the liver, as well as the spleen and kidneys, into a palpable position during inspiration.

How does a PA assess for tenderness when the liver is not palpable?

To assess for tenderness when the liver is not palpable, place your left hand flat on the right lower rib cage and gently strike it with the ulnar surface of your right fist. Ask the patient to compare the sensation.

How should the PA place the drapes on the patient?

To expose the abdomen, place the drape or sheet at the level of the symphysis pubis, then raise the gown to below the nipple line just above the xiphoid process.

What are hernias in the abdominal wall exclusive of groin hernias?

Ventral hernias

what is McBurney's point, and what assessment is it associated with?

You should also be able to assess for possible appendicitis by searching carefully for an area of local tenderness called McBurney's point, which lies two centimeters from the anterior superior spinous process of ilium on a line drawn down from the umbilicus.

what is the abnormal enlargement of a liver called?

hepatomegaly

what is peritonitis?

parietal peritoneum

How does the PA palpate the left kidney?

•To palpate the left kidney, move to the patient's left side and place your right hand behind the patient, just below and parallel to the right 12th rib with your fingertips just reaching the costovertebral angle. Lift trying to displace the kidney anteriorly. •Place your left hand gently in the left upper quadrant, lateral and parallel to the rectus muscle. •Now ask the patient to take a deep breath. At the peak of inspiration, press your left hand firmly and\ deeply into the left upper quadrant, just below the costal margin and try to capture the kidney between your hands. •Ask the patient to breathe out and then stop breathing. Slowly release the pressure of your left hand feeling at the same time for the kidney to slide back into its expiratory position. •If the kidney is palpable, assess its size, contour, and any tenderness.