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Abdomen
STUDENT NOTES
What are (^) • Onset and duration: when it began; sudden or gradual; persistent, recurrent, intermittent
- Character: dull, sharp, burning, gnawing, stabbing, cramping, aching, colicky - Location: of onset, change in location over time, radiating to another area, superficial or deep - Associated symptoms: vomiting, diarrhea, constipation, passage of flatus, belching, jaundice, change in abdominal girth, weight loss or weight gain - Relationship to: menstrual cycle, abnormal menses, intercourse, urination, defecation, inspiration, change in body position, food or alcohol intake, stress, time of day, trauma - Recent stool characteristics: color, consistency, odor, frequency - Urinary characteristics: frequency, color, volume congruent with fluid intake, force of stream, ease of starting stream, ability to empty bladder - Medications: high doses of aspirin, steroids, nonsteroidal anti-inflammatory drugs (NSAIDs) examples of appropriate history of present illness (HPI) questions you may ask a patient with a chief complaint of an abdominal issue? Describe how you would inspect the abdomen. Proper steps to examine abdomen: inspection, auscultation, percussion, and palpation Using tangential lighting, inspect the abdomen for 4 surface characteristics
- Observe the skin color. It may vary greatly but should have no jaundice, cyanosis, redness, bruises, or discoloration
- Check for nodules and other lesions, which should not be present
- Note any scars and draw their location, configuration, and relative size on an
illustration of the abdomen
- Assess the venous return. Above the umbilicus, venous return should be toward the head. Below the umbilicus, it should be toward the feet Inspect the abdominal contour and symmetry - The contour is the abdominal profile from the rib margin to the pubis. It normally may be flat, rounded, or scaphoid. The umbilicus should be centrally located and may be inverted or may protrude slightly. - Contralateral areas of the abdomen should be symmetrical in appearance and contour and should have no distention of bulges - To elicit hidden masses or bulges, have the patient take a deep breath and hold it. The abdomen should remain smooth and symmetrical. Next, have the supine patient raise their head from the table as you inspect the abdomen. Note any masses, hernia, or muscle separation. With the patient’s head at rest, observe for 3 types of abdominal movement
- Inspect for smooth, even movement with respiration
- Assess for surface motion from peristalsis. In a thin patient, it normally may be visible. Otherwise, it may signal an intestinal obstruction
- Note any aortic pulsation in the upper midline. Although pulsation may be visible
Key Point
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Abdomen
STUDENT NOTES
Describe how and where you auscultate the abdomen. What are the three additional sounds you assess? What is normal Using the diaphragm of a warmed stethoscope, listen for bowel sounds and note their frequency and character Expect to hear clicks and gurgles at a rate of 5 – 35 per minute. Note unexpected findings, such as increased or decreased bowel sounds or high-pitched tinkling sounds. Auscultate for three additional sounds (friction rubs, bruits, and venous hum)
- Use the stethoscope diaphragm to detect high-pitched friction rubs over the liver and spleen
- Use the stethoscope bell to check for bruits over the aortic, renal, iliac, and femoral arteries
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Abdomen
STUDENT NOTES
when you auscultate the abdomen? What is abnormal?
- Use the stethoscope bell to assess for a soft, continuous, low-pitched venous hum in the epigastric area and around the umbilicus Abnormal: - Borborygmic: loud prolonged gurgles - Increased bowel sounds: gastroenteritis, early obstruction, hunger - High-pitched tinkling: intestinal fluid and air under pressure, early obstruction - Decreased bowel sounds: peritonitis, paralytic ileus
Abdomen
Describe how you palpate the abdomen. What are you assessing when you perform light, moderate and deep palpation? What are the normal and abnormal findings? What do the abnormal findings indicate as possible differential diagnoses? Using light palpation, systematically assess all quadrants. But first, try to relax the abdominal muscles. For example, place a small pillow under the patient’s head and slightly flexed knees, warm your hands, take a slow and gentle approach, and save any tender areas for last. Press in no more than 1 cm with the palmar surface of your fingers
- Expect the abdomen to feel smooth and soft - Note any resistance or tenderness. And watch for guarding, which should alert you to proceed with caution Using moderate palpation, systematically assess all quadrants in two ways.
- Palpate with the palmar surface of your fingers. This may elicit tenderness that was not produced by light palpation
- Palpate with the side of your hand throughout the respiratory cycle. As the patient inhales, you may feel the liver and spleen bump gently against your hand. Using deep palpation, systematically assess all quadrants with the palmar surface of your fingers. If a patient’s obesity or muscular resistance make deep palpation difficult, try bimanual palpation with one hand on top of the other. With either technique, feel for the rectus abdominis muscles, aorta, and portions of the colon. Note any tenderness. If you detect a mass, evaluate its location, size, shape, consistency, tenderness, pulsation, mobility, and movement with respiration. To see if the mass is superficial or intraabdominal, palpate as the patient lifts his or her head off the table. A superficial mass will remain palpable; an intraabdominal mass will not.
Palpate the umbilical ring and periumbilical area. The umbilical ring should feel round and regular. The area should have no bulges, nodules, or granulation. Light Palpation:
- Avoid problem spot areas - Palpate all 4 quadrants or all 9 regions Moderate Palpation: - Useful in assessing organs that move with respirations, liver, and spleen Deep Palpation: - Useful to detect less obvious masses, may use bimanual with one hand on top of the other for obese individuals
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Abdomen
STUDENT NOTES
Describe how and where you percuss the abdomen. What are normal and abnormal findings? What do the findings indicate? Systematically percuss for tone in all abdominal quadrants
- Tympany is heard over the stomach and intestines - Dullness is heard over organs and solid masses Percuss to estimate the liver span, using 3 steps.
- Determine the lower border of the liver by percussing up from an area of tympany along the right midclavicular line. Mark the point where tympany changes to dullness, which usually occurs at or slightly below the costal margin
- Determine the upper border of the liver by percussing down from an area of resonance along the right midclavicular line. Mark the pint where resonance changes to dullness, which usually is in the fifth intercostal space.
- Measure the distance between the marks. The vertical liver span usually ranges from 6 to 12 cm To assess liver descent, ask the patient to take a deep breath and hold it while you percuss the lower border again. With this maneuver, the area of dullness at the lower border should shift down to 2 to 3 cm.
FYI 1. A tense abdomen could be a sign of inflammation.
- Rigidity of the abdomen is a sign of peritoneal irritation.
- A palpable tender gallbladder indicates cholecystitis, nontender enlargement suggests common bile duct obstruction.
- As an inflamed gallbladder comes in contact with the examining fingers, the patient will experience pain and abruptly halt inspiration (Murphy’s sign).
- Be careful when palpating the spleen. Patients with splenomegaly from infectious mononucleosis have a small risk for spontaneous splenic rupture.
- A prominent lateral pulsation of the aorta suggests aortic aneurysm. How do you palpate for the various abdominal structures? What are the normal and abnormal findings? What do the findings indicate as possible differential diagnoses? Palpate for specific abdominal structures. - For the liver, press in and feel for its edge at the right costal margin as the patient takes a deep breath. If palpable, the liver should feel firm, smooth, even, and nontender. - For the gallbladder, palpate below the liver margin at the lateral border of the rectus abdominus muscle. A healthy gallbladder is not palpable. - For the spleen, press in over the left costal margin as the patient takes a deep breath. The spleen is not usually palpable. - For the kidneys, assess the right and left organs separately, placing one hand on the flank and the other hand on the costal margin. As the patient inhales deeply, lift the flank and palpate deeply. The right kidney is more commonly palpable than the left kidney. - For the aorta, palpate deeply for the aortic pulsation slightly left of the midline. If the pulsation is prominent, try to determine its direction. - For the bladder, palpate above the symphysis pubis. If the bladder is distended with urine, it feels like a smooth, round, tense mass. Normal: - Spleen, kidneys, and healthy gallbladder are not palpable Abnormal: - Cholecystitis: palpable tender gallbladder - Common bile duct obstruction: nontender enlarged gallbladder
How do you assess for ascites? If a patient has ascites, what may that indicate?
- If you suspect ascites, percuss the supine patient’s abdomen for dullness in the dependent parts and tympany in the upper parts. Also assess for shifting dullness or fluid wave. - Ascites: pathologic increase in fluid in peritoneal cavity. Most sensitive maneuvers for detecting ascites are flank dullness and presence of bulging flanks - If you suspect ascites, percuss the supine patient’s abdomen for dullness in the dependent parts and tympany in the upper parts. Also assess for shifting dullness or fluid wave suggests ascites.
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Abdomen
STUDENT NOTES
- If the patient reports abdominal pain, assess it thoroughly, especially its quality and location. When examining the abdomen, be sure to watch the patient’s face for clues to pain. If needed, assess for rebound tenderness and perform the iliopsoas muscle and obturator muscle tests. - If you suspect a freely movable abdominal mass, perform ballottement.
healing, may develop from infection – H. Pylori, abdominal pain
- Crohn Disease: chronic inflammatory disorder that can affect any part of GI tract,
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Abdomen
STUDENT NOTES
terminal ileum and colon most common, unpredictable flares and remissions, RLQ pain, perianal skin tags are common and good clue for diagnosis
- Ulcerative colitis: chronic inflammatory disorder of colon and rectum that produces mucosal friability and areas of ulceration: unknown cause but immunologic and genetic factors have been implied, bloody frequent watery stools, 20-30 diarrhea episodes a day, weight loss, fatigue - Stomach cancer: arises from epithelial cells of mucous membrane, most common in lower half of stomach, vague and nonspecific symptoms, loss of appetite, feeling full, eight loss, dysphagia, persistent epigastric pain, enlarged supraclavicular nodes - Diverticular disease: diverticula are saclike mucosal outpouching through colonic muscle, sigmoid is most common affected location. Diverticulitis: LLQ pain, anorexia, N/V, constipation - Colon Cancer: rectum, sigmoid, proximal, and descending colon, 2 nd^ most common cancer in US, abdominal pain, bloody stool Hepatobiliary System Abnormalities: - Hepatitis: inflammatory process characterized by diffuse or patchy hepatocellular necrosis, caused by viral infection, alcohol, drugs, toxins, abnormal LFTs, asymptomatic or reports of jaundice, anorexia, abdominal pain, clay-colored stools - Cirrhosis: diffuse hepatic process characterized by fibrosis and alteration of normal liver architecture into structurally abnormal nodules, liver enlarged on exam, asymptomatic or some report jaundice, anorexia, abdominal pain, clay- colored stools - Primary Hepatocellular Carcinoma: associated with cirrhosis frequently, 6 months survival, jaundice, anorexia, fatigue, abdominal fullness, clay-colored stools, hard irregular liver palpated - Cholelithiasis: stone formation in gallbladder, crystals produced - Cholecystitis: inflammatory process of the gallbladder most commonly due to
Abdomen
constant abdominal pain, weight loss, steatorrhea Spleen
- Spleen laceration/rupture: most commonly injured organ, LUQ pain radiating to shoulder Kidney: - Acute glomerulonephritis: inflammation of the capillary loops of the renal glomeruli, edema, hypertension, oliguria or may have unremarkable findings, flank pain - Hydronephrosis: dilation of renal pelvis d/t obstruction of urine flow - Pyelonephritis: infection of kidney and renal pelvis: fever, dysuria, flank pain - Renal abscess: localized infection in medulla or cortex, same symptoms as pyelonephritis - Renal calculi: stones in pelvis of kidney, associated with obstruction and infections in the urinary tract, fever, dysuria, flank pain, hematuria - Acute Renal Failure: sudden impairment of renal function, urine output may be normal, decreased, or absent, may see fluid overload or dehydration
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Abdomen
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