Principles of Assessment Chapter 21 The Abdomen

Infants and Children

In the newborn the umbilical cord shows prominently on the abdomen. The liver takes up proportionately more space in the abdomen at birth than in later life. In a healthy term neonate the lower edge may be palpated 0.5 to 2.5 cm below the right costal margin. urinary bladder is located higher in the abdomen than in the adult. It lies between the symphysis and the umbilicus. during early childhood the abdominal wall is less muscular; therefore the organs may be easier to palpate.

Costovertebral Angle Tenderness

Indirect fist percussion causes the tissues to vibrate instead of producing a sound. To assess the kidney place one hand over the 12th rib at the costovertebral angle on the back (Fig. 21-17). Thump that hand with the ulnar edge of your other fist. The person normally feels a thud but no pain. (Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.)

Hyperactive Bowel Sounds

Loud, gurgling sounds, "borborygmi," signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus

borborygmi

Loud, gurgling sounds.

normally palpable structures

Mild tenderness normally is present when palpating the sigmoid colon. Any other tenderness should be investigated

Culture and genetics

Millions of American adults have the potential for lactose-intolerance symptoms; traditional estimated rates were that 15% of Whites, 50% of Mexican Americans, and 80% of African Americans had the condition.

Aortic Aneurysm

Most aortic aneurysms (>95%) are located below the renal arteries and extend to the umbilicus. A focal bulging >5 cm is palpable in about 80% of cases during routine physical examination and feels like a pulsating mass in the upper abdomen just to the left of midline. You will hear a bruit. Femoral pulses are present but decreased.

The Pregnant Woman

Nausea and vomiting, or "morning sickness," is an early sign of pregnancy for most pregnant women, starting between the 1st and 2nd missed periods. The cause may be the result of hormonal changes such as the production of human chorionic gonadotropin (hCG) "acid indigestion" or heartburn (pyrosis) caused by esophageal reflux. Gastrointestinal (GI) motility decreases, which prolongs gastric emptying time. The decreased motility causes more water to be resorbed from the colon, which leads to constipation.

Vascular Sounds Venous hum

Occurs rarely. Heard in periumbilical region. Originates from inferior vena cava. Medium pitch, continuous sound, pressure on bell may obliterate it. May have palpable thrill. Occurs with portal hypertension and cirrhotic liver.

Splenic Dullness

Often the spleen is obscured by stomach contents, but you may locate it by percussing for a dull note from the 9th to 11th intercostal space just behind the left midaxillary line (Fig. 21-16). 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.

Rebound Tenderness (Blumberg Sign)

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. Refer the person with suspected appendicitis for computed tomography (CT) scanning

Pancreas

Pancreatitis has acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank, severe nausea, and vomiting.

Left Lower Quadrant (LLQ)

Part of descending colon Sigmoid colon Left ovary and tube Left ureter Left spermatic cord

among women obesity rates

-32.2% of White women are obese -whereas 58.5% of Black women -44.9% of Mexican-American women are obese.

causes of abdominal pain and location

Abdominal pain may be: -visceral: from an internal organ (dull, general, poorly localized) -parietal: from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement) -referred from a disorder in another site. Acute pain requiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel obstruction, or a perforated organ.

Palpation infant

Aid palpation by flexing the baby's knees with one hand while palpating with the other. Alternatively you may hold the upper back and flex the neck slightly with one hand. Offer a pacifier to a crying baby.

Hooking Technique

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

Enlarged Nodular Liver

An enlarged and nodular liver occurs with late portal cirrhosis, metastatic cancer, or tertiary syphilis. Often with cirrhosis the liver is smaller, but the edge is firmer than normal, and the edge is easily palpable.

hepatomegaly

An enlarged liver span indicates liver enlargement

Enlarged Liver

An enlarged, smooth, nontender liver occurs with fatty infiltration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia.The liver feels enlarged and smooth but is tender to palpation with early heart failure, acute hepatitis, or hepatic abscess.

Enlarged Gallbladder

An enlarged, tender gallbladder suggests acute cholecystitis. Feel it behind the liver border as a smooth and firm mass like a sausage, although it may be difficult to palpate because of involuntary rigidity of abdominal muscles. The area is exquisitely painful to fist percussion, and inspiratory arrest (Murphy sign) is present.An enlarged, nontender gallbladder also feels like a smooth, sausagelike mass. It occurs when the gallbladder is filled with stones, as with common bile duct obstruction.

obturator test

An inflamed appendix irritates the obturator muscle, and this leg movement produces pain.

Midline aorta

Aorta Uterus (if enlarged) Bladder (if distended)

Appendix

Appendicitis typically starts as dull, diffuse pain in periumbilical region that later shifts to severe, sharp, persistent pain and tenderness localized in RLQ (McBurney point). Pain is aggravated by movement, coughing, deep breathing; associated with anorexia, then nausea and vomiting, fever.

Vascular Sounds

As you listen to the abdomen, note the presence of any vascular sounds or bruits.

Which table foods have you introduced?

Consider a new food as a possible allergen. Adding only one new food at a time to the infant's diet helps identify allergies.

General Tympany

First percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness. Move clockwise. Tympany should predominate because air in the intestines rises to the surface when the person is supine.

Fluid Wave

First test for a fluid wave by standing on the person's right side. Place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen in the midline (Fig. 21-18). (This stops transmission across the skin of the upcoming tap.) Place your left hand on the person's right flank. With your right hand reach across the abdomen and give the left flank a firm strike.

Stomach

Gastric ulcer pain is dull, aching, gnawing epigastric pain, usually brought on by food and radiates to back or substernal area. Pain of perforated ulcer is burning epigastric pain of sudden onset that refers to one or both shoulders.

Small intestine

Gastroenteritis has diffuse, generalized abdominal pain with nausea, diarrhea.

Esophagus

Gastroesophageal reflux disease (GERD) is a complex of symptoms of esophagitis, including burning pain in midepigastrium or behind lower sternum that radiates upward or "heartburn." Occurs 30 to 60 minutes after eating; aggravated by lying down or bending over

liver referred pain

Hepatitis may have mild-to-moderate dull pain in right upper quadrant (RUQ) or epigastrium, along with anorexia, nausea, malaise, low-grade fever.

costovertebral angle

The 12th rib forms an angle with the vertebral column.

What should the abdomen of the infant show?

The abdomen shows respiratory movement. The only other abdominal movement you should note is occasional peristalsis, which may be visible because of the thin musculature. abnormal findings: Marked peristalsis with pyloric stenosis .

The Infant inspection

The contour of the abdomen is protuberant because of the immature abdominal musculature. The skin contains a fine, superficial venous pattern. This may be visible in lightly pigmented children up to the age of puberty. Scaphoid shape occurs with dehydration. Dilated veins. (illustrated on image)

Shifting Dullness

The second test for ascites is percussing for shifting dullness. In a supine person ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel to the periumbilical space. You will hear a tympanitic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid (Fig. 21-19). Then percuss down the side of the abdomen. If fluid is present, the note will change from tympany to dull as you reach its level. Mark this spot. This shifting level of dullness indicates the presence of fluid.

Umbilical Hernia

This is a soft, skin-covered mass, the protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring. It is accentuated by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining; but the bowel rarely incarcerates or strangulates. More common in premature infants. Most resolve spontaneously by 1 year; parents should avoid affixing a belt or coin at the hernia because this will not help closure and may cause contact dermatitis. In an adult it occurs with pregnancy, chronic ascites, or chronic intrathoracic pressure (e.g., asthma, chronic bronchitis).

The Alvarado Score

This scoring system combines findings to assist evaluation in patients with RLQ pain. Also called the MANTRELS score, from the mnemonic in the following list, a score of 4 or less significantly decreases the probability of appendicitis. An Alvarado score of ≥7 increases the probability of appendicitis

Iliopsoas Muscle Test

When the iliopsoas muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the RLQ.

Inspiratory Arrest (Murphy Sign)

When the test is positive, as the descending liver pushes the inflamed gallbladder onto the examining hand, the person feels sharp pain and abruptly stops inspiration midway.

positive spleen percussion sign

a change in percussion from tympany to a dull sound with full inspiration indicating splenomegaly.

anorexia nervosa

a serious psychosocial disorder that includes loss of appetite, voluntary starvation, and grave weight loss. This person may augment weight loss by purging (self-induced vomiting) and use of laxatives.

The Aging Adult abdomen

abnormal findings : Abdominal rigidity with acute abdominal conditions is less common in aging. With an acute abdomen the aging person often complains of less pain than a younger person would.

Bowel sounds

are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from 5 to 30 times per minute.

Hyperactive sounds

are loud, high-pitched, rushing, tinkling sounds that signal increased motility.

The bean-shaped kidneys

are retroperitoneal, or posterior to the abdominal contents. They are well protected by the posterior ribs and musculature. The left kidney lies here at the 11th and 12th ribs. Because of the placement of the liver, the right kidney rests 1 to 2 cm lower than the left kidney and sometimes may be palpable

solid viscera

are those that maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus)

Pigmented nevi (moles)

circumscribed brown macular or papular areas—are common on the abdomen.

diastasis recti

common: a separation of the rectus muscles with a visible bulge along the midline Refer diastasis recti lasting more than 6 years

Dysphagia

difficulty swallowing. occurs with disorders of the throat or esophagus.

The liver in the infant

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 and 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.

Hypoactive or absent sounds

follow abdominal surgery or with inflammation of the peritoneum

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 they flex the vertebral column.

Red blood

in stools occurs with GI bleeding or localized bleeding around the anus.

dairy foods crucial nutritional requirements

including calcium magnesium potassium proteins vitamins A, D, B12 riboflavin.

Pyloric stenosis

is a congenital defect and appears in the 2nd or 3rd week. After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. Then one can palpate an olive-size mass in the RUQ midway between the right costal margin and umbilicus. Refer promptly because of risk for weight loss.

Involuntary rigidity

is a constant, boardlike hardness of the muscles. It is a protective mechanism accompanying acute inflammation of the peritoneum. It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up.

Sister Mary Joseph nodule

is a hard nodule in umbilicus that occurs with metastatic cancer of stomach, large intestine, ovary. or pancreas.

abdomen

is a large, oval cavity extending from the diaphragm down to the brim of the pelvis.

Anorexia

is a loss of appetite from GI disease as a side effect to some medications, with pregnancy, or with mental health disorders.

spleen

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

pancreas

is a soft, lobulated gland located behind the stomach. It stretches obliquely across the posterior abdominal wall to the left upper quadrant.

aorta

is just to the left of midline in the upper part of the abdomen. It descends behind the peritoneum, and at 2 cm below the umbilicus it bifurcates into the right and left common iliac arteries opposite the 4th lumbar vertebra. You can palpate the aortic pulsations easily in the upper anterior abdominal wall.

Hyperresonance

is present with gaseous distention.

Obesity

is the accumulation of excess body fat. -Currently 35.7% of U.S. adults are obese (BMI ≥30 kg/m2).10

Pica

is the persistent craving and compulsive eating of nonfood substances. Although a toddler may attempt nonfoods at some time, he or she should recognize edibles by age 2 years.

Food intolerance

lactase deficiency resulting in bloating or excessive gas after taking milk products

Black stools

may be tarry due to occult blood (melena) from GI bleeding or nontarry from iron medications. Gray stools occur with hepatitis.

Cutaneous angiomas (spider nevi)

occur with portal hypertension or liver disease. Lesions, rashes

Prominent, dilated veins

occur with portal hypertension, cirrhosis, ascites, or vena caval obstruction.

Dullness

occurs over a distended bladder, adipose tissue, fluid, or a mass.

Chronic pain of gastric ulcers

occurs usually on an empty stomach

Voluntary guarding

occurs when the person is cold, tense, or ticklish.

Tenderness

occurs with local inflammation, inflammation of the peritoneum or underlying organ, and with an enlarged organ whose capsule is stretched.

hypogastric

or suprapubic for the area above the pubic bone.

palpate the abdomen of the child

position the young child on the parent's lap as you sit knee-to-knee with the parent. Flex the knees up and elevate the head slightly. The child can "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 his or her hand under your own as you palpate or apply the stethoscope and palpate around it.

Peptic ulcer disease

refers to painful sores or ulcers in the lining of the stomach or first part of the small intestine, called the duodenum. occurs with frequent use of nonsteroidal antiinflammatory drugs (NSAIDs), alcohol, smoking, and Helicobacter pylori infection.

The liver in the child

remains easily palpable 1 to 2 cm below the right costal margin The edge is soft and sharp and moves easily.

borborygmus

stomach growling A perfectly "silent abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding if bowel sounds are completely absent.

the linea alba

tendinous seam

The Child abdomen

the abdomen looks flat when supine. Normal movement on the abdomen includes respirations, which remain abdominal until 7 years of age. abnormal finding : A scaphoid abdomen is associated with dehydration or malnutrition. Younger than 7 years, the absence of abdominal respirations occurs with inflammation of the peritoneum.

Right Upper Quadrant (RUQ)

Liver Gallbladder Duodenum Head of pancreas Right kidney and adrenal Hepatic flexure of colon Part of ascending and transverse colon

ascites

(free fluid in the peritoneal cavity) Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

Pyrosis

(heartburn), a burning sensation in esophagus and stomach, from reflux of gastric acid. Eructation (belching).

striae

(lineae albicantes)—silvery white, linear, jagged marks about 1 to 6 cm long. They occur when elastic fibers 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.

The shape of the hollow viscera

(stomach, gallbladder, small intestine, colon, and bladder) depends on the contents. They usually are not palpable, although you may feel a colon distended with feces or a bladder distended with urine.

Clinical Portrait of Intestinal Obstruction

- history of previous abdominal surgery with adhesion -vomiting -absence of stool or gas passage -distended abdomen (after 2nd day) -x-ray shows dilated air-filled loops of small bowel with multiple air-fluid levels -hyperactive bowel sounds in early obstruction; hypoactive or silent in late obstruction -dehydration and loss of electrolytes - colicky pain from strong peristalsis above the obstruction -fever -pressure from excess fluid and gas may -> leaking fluid into peritoneum -hypovolemic shock (hypertension, tachycardia, cool skin if left untreated)

The Aging Adult

-with aging the appearance of the abdominal wall changes. -women accumulate fat in the suprapubic area do to estrogen levels. -the faces and extremities losses adipose tissue. -the abdominal muscles relax. -salivation decreases -Esophageal emptying is delayed. -Gastric acid secretion decreases with aging -The incidence of gallstones increases -Liver size decreases by 25% between the ages of 20 and 70 years -Aging people frequently report constipation. Constipation is not a physiologic consequence of aging.

Common Sites of Referred Abdominal Pain

...

Palpate Surface and Deep Areas Perform palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness. Review comfort measures on p. 545. Because most people are naturally inclined to protect the abdomen, you need to use additional measures to enhance complete muscle relaxation.

1. Bend the person'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. Teach the person to breathe slowly (in through the nose and out through the mouth). 4. Keep your own voice low and soothing. Conversation may relax the person. 5. Try "emotive imagery." For example, you might say, "Now I want you to imagine that 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 person, keep the person's hand under your own with your fingers curled over his or her 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 do not perceive a stethoscope as a ticklish object. You can slide the stethoscope out when the person is used to being touched.

If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following:

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

pain of duodenal ulcers occurs

2 to 3 hours after a meal and is relieved by more food.

Among men the obesity rates

36.2% of Whites 38.8% of Blacks 36.6% of Mexican Americans are obese.

Vascular Sounds Arterial

A bruit indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels. Listen with the bell. Occurs with the following: • Aortic aneurysm—Murmur is harsh, systolic, or continuous and accentuated with systole. Note in person with hypertension. • Renal artery stenosis—Murmur is midline or toward flank, soft, low-to-medium pitch. • Partial occlusion of femoral arteries.

Incisional Hernia

A bulge near an old operative scar that may not show when person is supine but is apparent when the person increases intra-abdominal pressure by a sit-up, by standing, or by the Valsalva maneuver.

Diastasis Recti

A midline longitudinal ridge that is a separation of the abdominal rectus muscles. Ridge is revealed when intra-abdominal pressure is increased by raising head while supine. Occurs congenitally (here), and as a result of pregnancy or marked obesity in which prolonged distention or a decrease in muscle tone has occurred. It is not clinically significant.

Peritoneal Friction Rub

A rough, grating sound, like two pieces of leather rubbed together, indicates peritoneal inflammation. Occurs rarely. Usually occurs over organs with a large surface area in contact with the peritoneum. Liver—Friction rub over lower right rib cage from abscess or metastatic tumor. Spleen—Friction rub over lower left rib cage in left anterior axillary line from abscess, infection, or tumor.

Auscultation of the abdomen in the infant

Auscultation yields only bowel sounds, the metallic tinkling of peristalsis. No vascular sounds should be heard. abnormal sounds : Bruit or Venous hum

Enlarged Spleen

Because any enlargement superiorly is stopped by the diaphragm, the spleen enlarges down and to the midline. When extreme, it can extend down to the left pelvis. It retains the splenic notch on the medial edge. When splenomegaly occurs with acute infections (mononucleosis), it is moderately enlarged and soft, with rounded edges. When the result of a chronic cause, the enlargement is firm or hard, with sharp edges. An enlarged spleen is usually not tender to palpation; it is tender only if the peritoneum is also inflamed.

Light and Deep Palpation

Begin with light palpation. With the first four fingers close together, depress the skin about 1 cm. Make a gentle rotary motion, sliding the fingers and skin together. Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen. The objective here is not to search for organs but to form an overall impression of the skin surface and superficial musculature. Save the examination of any identified tender areas until last. This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination. looking for : Muscle guarding.Rigidity.Large masses.Tenderness.

Right Lower Quadrant (RLQ)

Cecum Appendix Right ovary and tube Right ureter Right spermatic cord

Gallbladder

Cholecystitis is biliary colic, sudden pain in RUQ that may radiate to right or left scapula and that builds over time, lasting 2 to 4 hours, after ingestion of fatty foods, alcohol, or caffeine. Associated with nausea and vomiting and with positive Murphy sign or sudden stop in inspiration with RUQ palpation.

Hypoactive Bowel Sounds

Diminished or absent bowel sounds signal decreased motility as a result of inflammation as seen with peritonitis; from paralytic ileus as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia

Duodenum

Duodenal ulcer typically has dull, aching, gnawing pain; does not radiate; may be relieved by food; and may awaken the person from sleep.

Enlarged Kidney

Enlarged with hydronephrosis, cyst, or neoplasm. May be difficult to distinguish an enlarged kidney from an enlarged spleen because they have a similar shape. Both extend forward and down. However, the spleen may have a sharp edge, whereas the kidney never does. The spleen retains the splenic notch, whereas the kidney has no palpable notch. Percussion over the spleen is dull, whereas over the kidney it is tympanitic because of the overriding bowel.

viscera

Inside the abdominal cavity all the internal organs

Wharton's jelly

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. Skin covers the area by 3 to 4 weeks. The presence of only one artery signals the risk for congenital defects. Inflammation. Drainage after cord falls off.

Ovarian Cyst (Large)

Inspection. Curve in lower half of abdomen, midline. Everted umbilicus. Auscultation. Normal bowel sounds over upper abdomen where intestines pushed superiorly. Percussion. Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness. Palpation. Transmits aortic pulsation, whereas ascites does not.

Tumor

Inspection. Localized distention. Auscultation. Normal bowel sounds. Percussion. Dull over mass if reaches up to skin surface. Palpation. Define borders. Distinguish from enlarged organ or normally palpable

Feces

Inspection. Localized distention. Auscultation. Normal bowel sounds. Percussion. Tympany predominates. Scattered dullness over fecal mass. Palpation. Plastic-like or ropelike mass with feces in intestines.

Ascites

Inspection. Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin; recent weight gain; increase in abdominal girth. Auscultation. Normal bowel sounds over intestines. Diminished over ascitic fluid. Percussion. Tympany at top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness. Palpation. Taut skin and increased intra-abdominal pressure limit palpation.

Pregnancy*

Inspection. Single curve. Umbilicus protruding. Breasts engorged. Auscultation. Fetal heart tones. Bowel sounds diminished. Percussion. Tympany over intestines. Dull over enlarging uterus. Palpation. Fetal parts. Fetal movements.

abdominal distention Air or Gas

Inspection. Single round curve. Auscultation. Depends on cause of gas (e.g., decreased or absent bowel sounds with ileus); hyperactive with early intestinal obstruction. Percussion. Tympany over large area. Palpation. May have muscle spasm of abdominal wall.

abdominal distention Obesity

Inspection. Uniformly rounded. Umbilicus sunken (it adheres to peritoneum, layers of fat are superficial to it). Auscultation. Normal bowel sounds. Percussion. Tympany. Scattered dullness over adipose tissue. Palpation. Normal. May be hard to feel through thick abdominal wall.

How often does your toddler/child eat?

Irregular eating patterns are common and a source of parental anxiety. As long as the child shows normal growth and development and only nutritious foods are offered, parents may be reassured.

Kidney

Kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain.

lactose intolerant

Lactase is the digestive enzyme necessary for absorption of the carbohydrate lactose (milk sugar). In some racial groups lactase activity is high at birth but declines to low levels by adulthood. -abdominal pain, bloating, and flatulence when milk products are consumed.

Colon

Large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen and bloating. Irritable bowel syndrome (IBS) has sharp or burning cramping pain over a wide area; does not radiate. Brought on by meals; relieved by bowel movement.

Palpate the liver

Next palpate for specific organs, beginning with the liver in the RUQ . Place your left hand under the person's back parallel to the 11th and 12th 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 person to breathe slowly. With every exhalation, move your palpating hand up 1 or 2 cm. 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. Often the liver is not palpable and you feel nothing firm. Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is enlarged. Record the number of centimeters it descends and note its consistency (hard, nodular) and tenderness

Spleen palpation

Normally the spleen is not palpable and must be enlarged 3 times its normal size to be felt. The spleen enlarges with mononucleosis, trauma, leukemias and lymphomas, portal hypertension, and HIV infection (see Table 21-7). If you feel an enlarged spleen, refer the person but do not continue to palpate it. An enlarged spleen is friable and can rupture easily with overpalpation. Describe the number of centimeters that it extends below the left costal margin.

Percussion infant

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

Epigastric Hernia

Protrusion of abdominal structures presents as a small, fatty nodule at epigastrium in midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing.

Hernia of abdominal viscera

Protrusion of abdominal viscera through abnormal opening in muscle wall

umbilical hernia in the infant

Refer any umbilical hernia larger than 2.5 cm , continuing to grow after 1 month; or lasting for more than 2 years in a White child or for more than 7 years in a Black child.should disappear after the year.

Kidneys palpation

Search for the right kidney by placing your hands together in a "duck-bill" position at the person's right flank . Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask the person to take a deep breath. In most people you will feel no change. Occasionally you may feel the lower pole of the right kidney as a round, smooth mass that slides between your fingers. Either condition is normal. you are searching for : Enlarged kidney. Kidney mass.

Symmetry of abdomen

Shine a light across the abdomen toward you or lengthwise across the person. The abdomen should be symmetric bilaterally (Fig. 21-8). Note any localized bulging, visible mass, or asymmetric shape. Even small bulges are highlighted by shadow. Step to the foot of the examination table to recheck symmetry.

Left Upper Quadrant (LUQ)

Stomach Spleen Left lobe of liver Body of pancreas Left kidney and adrenal Splenic flexure of colon Part of transverse and descending colon

Scratch Test

This traditional technique uses auscultation to detect the lower border of the liver. Place the stethoscope over the xiphoid while lightly stroking the skin with one finger up the MCL from the RLQ and parallel to the liver border. When you reach the liver edge, the sound is magnified in the stethoscope. However, there are many variations in the technique, and evidence is mixed as to its value.One recent study found moderate agreement between the results by scratch test and ultrasound.They recommend the scratch test if the abdomen is distended, obese, or too tender for palpation or if muscles are rigid or guarded.

Deep palpation in obese patient

To overcome the resistance of a very large or obese abdomen, use a bimanual technique. Place your two hands on top of one another. The top hand does the pushing; the bottom hand is relaxed and can concentrate on the sense of palpation. With either technique note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal

Succussion Splash

Unrelated to peristalsis, this is a very loud splash auscultated over the upper abdomen when the infant is rocked side to side. It indicates increased air and fluid in the stomach, as seen with pyloric obstruction or large hiatus hernia.

auscultation of the abdomen

Use the diaphragm endpiece because bowel sounds are relatively high-pitched. Begin in the RLQ at the ileocecal valve area because bowel sounds normally are always present here.

Aorta palpate pulsation

Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline. Normally it is 2.5 to 4 cm wide in the adult and pulsates in an anterior direction. Widened with aneurysm Prominent lateral pulsation with aortic aneurysm pushes the examiner's two fingers apart.

when examining the abdomen, preparation.

the abdomen so it is fully visible. Drape the genitalia and female breasts. The following measures enhance abdominal wall relaxation: • The person should have emptied the bladder, saving a urine specimen if needed. • Keep the room warm to avoid chilling and tensing of muscles. • Position the person supine, with the head on a pillow, the knees bent or on pillow, and the arms at the sides or across the chest. • To avoid abdominal tensing, the stethoscope endpiece must be warm, your hands must be warm, and your fingernails must be very short. • Inquire about any painful areas. Examine such an area last to avoid any muscle guarding. • Finally learn to use distraction: Enhance muscle relaxation through breathing exercises; emotive imagery; your low, soothing voice; engaging in conversation; or having the person relate his or her abdominal history while you palpate.

umbilical

the area around the umbilicus

epigastric

the area between the costal margins

one assessment for which you should NOT use auscultation of the abdomen is for

the correct placement of nasogastric feeding tubes.

Hematemesis

the vomit of blood occurs with stomach or duodenal ulcers and esophageal varices.

Marked peristalsis

together with projectile vomiting in the newborn suggests pyloric stenosis, an obstruction of the pyloric valve of the stomach.

deep palpation

using the technique described earlier but push down about 5 to 8 cm (2 to 3 inches).Moving clockwise, explore the entire abdomen.