-
questions to ask on subjective data/history
- surgical history
- change of appetite (anorexia, early satiety, heartburn, gas)
- diet
- weight change
- foreign travel
- relevant fam hisotry- esp colon cancer
- pain
- nausea/vom/diarrhea
- blood in stool- red or black tarry (upper gi or older bleed)
- odynophagia/dysphagia- when and how often
- food intolerace- what happens, antacid use?
-
odynophagia
painful swallowing
-
questions about abdominal pain
- affected by food, menses etc
- cramping, colic, sharp, dull etc quality
- pain scale
- location and radiation
- interfering with activity
- onset (sudden/gradual) worsening and reliving factors
- duration/frequency
- anxiety/stress
- last BM and its quality
- abx use
-
what to consider with nausea and vomiting
- peptic ulcer
- gastritis
- esophageal lesions/varicies
- stomach cancer
- benign tumors
- swallowed blood from upper gi/resp
-
-
hematochezia
blood in stool
-
questions about diarrhea
- color, consistancy
- laxative use
- abx
- travel
- onset
- acute/chronic/recurrent
-
past abdominal history questions
- ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia?
- abdominal surgery?
- fam history- autoimmune disease/cancer
-
how can alcohol affect the abdomen
- can lead to liver disease
- irritates lining of intestinal wall
-
how can recreational drugs affect abdomen
- opiods= constipation
- hep C from IV drug use
-
landmarks of the abdominal wall
- costal margin: lower edge of the chest (thorax) formed by the bottom edge of the ribcage
- Xiphoid process: end of sternum
- Rectus Abdominus Muscle: costal cartilages of ribs 5-7
- anterior superior iliac spine: bony projection of the iliac bone by the pelvis
- inguinal ligament: from ant. sup. iliac crest to the pubic turbucle of the pubic bone
- linea alba: a fibrous structure that runs down the midline of the abdomen in humans and other vertebrates. In humans linea alba runs from the xiphoid process to the pubic symphysis
- symphysis pubis
-
anatomy of abdominal wall- picture to label
-
what are solid visceral organs
and name them
- organs that maintain characteristic shape
- SOUP KAL
- Spleen
- Ovaries
- Uterus
- Pancreas
- Kidneys
- Adrenal glands
- Liver
-
what are hollow visceral organs and name them
- shape of organ depends on its contents
- Galbladder
- Stomach
- Small Intestine
- Large intestine
- Bladder
-
-
functions of the liver
- phagocytosis and detox of bacteria and foreign material
- hemopoesis and synthesis of clotting factors
- bile production for digestion of fatty acids
- glycogen storage
- storage of ADEK fat sol vitamins
- metabolism of C, H, O, Fat proteins
- fills most of Right Upp. quadrant and extends over to left. mid clav. line
-
functions of pancreas
- produces digestive enzymes
- produces and secretes hormones insulin and glucagon
-
functions of spleen
- destroys old RBCs
- produces antibodies
- stores and filters blood
-
Is the spleen palpable?
normally is not palpable but when its enlarged, its lower pole moves downward and midline
-
function of ovaries
- store mutrue and expel ova
- produce feminizing hormones
-
are the ovaries palpable
only by binmanual exam during pelvic exam
-
functions of kidneys
- channels through which blood is filtered
- collect body waste products for excretion
- prevent excess fluid loss
-
examining the kidney
- examine mostly from the back
- they are bean shaped and protected by the posterior ribs
- they are at the costovertebral angle
-
where is the costovertebral angle
- 12th rib and vertebral column
- angle formed by the last rib and the spine
- the kidny is behind ribs 11 and 12
-
function of gallbladder
- stores bile
- emulsifies fat substances
-
functions of stomach
- receives ingested substances
- secretes juices, HCl and digestive enzymes necessary for initial catabolism of ingested substances
- stores ingested substances and controls emptying rate of contents into duodenum
-
functions of large intestine
- aka colon
- absorbs high % of fluid reminaing in bulk content of intestine
- synthesizes vitamin K at proximal end
- serves as storage area for feces
-
aorta location
located left of midline in upper part of abdomen
-
where does the aorta biforcate
- 2cm below umbillicus
- biforcates into the left and right iliac arteries and become the femoral arteries
-
where are the renal arteries
branch off the aorta right before where it biforcates into iliac arteries
-
divisions of the abdomen
- 4 quadrants
- order of examination: RLQ, RUQ, LUQ, LLQ
-
what are the sections of the abdomen when split 9 ways
- line down each mid clavicular line, line at the costal margin and line at the anterior symphysis pubis. belly button in the middle
- epigastric
- umbillical
- hypogastric/surpapubic
- each section also has a left and right one so 3 per name
-
setting up for the abdominal physical exam
- stand on right side- easier to feel spleen liver and other organs
- good lighting, centimeter ruler
- warm environment, hands, stethescope, patient
- short nails
- empty bladder
- avoid quick unexpected movements
- distract person with convo or questions
-
during the abdominal physical exam
- watch facial expressions: they may say no pain but grimace
- examine painful area last: patient may not let you continue otherwise
- patient in supine position with knees flexed: pillow under knees to relax abdomen
-
patient position during abdominal exam
- supine, knees flexed with pillow under them
- lower back relaxed and flat on table (arched will tighten ab muscles)
- arms at sides or folded across chest (overhead wil tighten ab wall)
-
order of assessment on abdominal exam
- inspect
- auscultate
- percuss
- palpate
- done bc auscultation provides important information about bowel mobility
- percussion/palpation alter frequency of bowel sounds
-
inspecting the abdomen
- skin
- umbilicus
- abdomen
- dystention
- pulsations
-
inspecting abdominal skin
- scars, striae, rashes, lesions
- old silver straie (stretchmarks) may be normal but pink-purple ones may be cushings
- few small dilated veins may be normal, while larger ones may suggest hepatic cirrhosis or obstruction of inferior vena cava
- look for diaphoesse
-
-
what to inspect the abdomen for
- countour
- flat, round proturband (protrudent), scaphoid (boat shaped)
- bulginf flank or local bulges (including the inguinal and femoral areas)
-
what do different types of bulges suggest
- bulging flank: ascites
- suprapubic bulge: distended bladder or pregnant uterus
- localized bulge: hernia
-
Assessing for distention
- look for symmetry, masses, peristalsis and pulsations
- paristalsis may be visible normally in those who are very thin
-
what could different types of distentions suggest
- distension: could be due to ascities, cancer, gas, post laproscopic surgery
- assymmetry: enlarged organ or mass
- visible masses: enlarged liver or spleen extending below rib cage
- lower abd. masses: ovarian/uterine tumors
- increased peristaltic waves: bowel obstruction
-
how to inspect for bulges
at eye level
-
aortic pulsation in abdomen
- pulsation is frequently visible in the epigastrum (upper abd. immediately over the stomach)- this is normal
- increased pulsation may suggest aortic aneurysm or increased pulse pressure
-
reasons for distention/proturbant abdomen
- you should give 7 F***s about a distended abdomen
- Fat
- Flatus
- Fluid
- Feces
- Fetus
- Fibroid Tumor
- Fatal growth
-
auscultating the abdomen
- always prior to percussion/palp
- listen in all 4 quadrants for frequency and character of bowel sounds
- start in RL quadrant because if there are sounds there, there are likely sounds in the other ones as well
-
why would the RLQ have sounds
- its where the cecum meets the large bowel
- bowel sounds are widely transmitted throughout the abd, so listening in one spot is often sufficient
-
normal bowel sounds
- clicks and gurgles
- 5-34/min
-
how long to listen before saying no bowel sounds
a full 5 min at least
-
what can alter bowel sounds
- diarrhea
- intestinal obstruction
- paralytic ileus
- peritonitis
-
borborygmi
- long prolonged gurgles of peristalsis
- aka stomach growling
-
what to listen for on auscultation besides bowel sounds
- bruits (swooshing sound of turbulent blood) on the aorta, renal arteries, iliac arteries and femoral arteries
- vascular sounds resembling heart murmurs over aorta or other abd arteries
- may suggest vascular occlusive disease
-
where are the abdominal arteries on the body (label)
-
what part of the stethoscope should you use to listen to vascular sounds in the abdomen
diaphragm- book may say different but this is correct.
-
percussing the abdomen
- percuss lightly in all 4 quads
- press hard down with middle finger and use the tip of your other finger to tap ontop of that finger
-
what does percussion of the abdomen tell us
- amount and distribution of gas in abd
- possible masses that are solid or fluid filled
- size of liver and spleen
-
sounds when percussing the abdomen
- tympany: usually predominates. gas in gi tract
- dullness: in scattered areas may suggest fluid and feces
- protrubant tympanic throughout abdomen: may suggest intestinal obstruction
-
what can dullness suggest in different areas
- dull areas: may suggest underlying mass or enlarged organ (preggo, ovarian tumor, distended bladder, large liver, large spleen)
- lower anterior chest, between lungs and costal margin (12th rib) on the right: dullness of liver
-
tympany on left lower anterior chest
gastric air bubble and splenic flexure of colon
-
palpations of the abdomen
- aorta
- do lightly- pads of fingertips in the 4 quadrants
- hand and forarm on horizontal plane, fingers together and flat on abdomen
- use light gentle dipping motion
- when moving hand, raise it just off skin
-
why do we palpate the abdomen
- to assess abd. tenderness, muscle resistance, superficial organs and masses
- make sure to reassure and relax patient
-
how to have the patient relax their abdomen for palpation
ask to mouth breathe, with jaw dropped open
-
what if you palpate involuntary rigitidy of abdomen
- this is a muscle spasm
- may suggest peritoneal inflammation
-
order of palpation
shallow then deep
-
other things to note when palpating
- for horizontal and verticle inguinal lymph nodes- you shouldnt feel
- Costovertebral angle- tenderness (checked during resp. exam)
-
organs to palpate
- SH... BLACK
- Spleen
- Horizontal and vertical lymph nodes
- ...
- Bladder
- Liver
- Aorta
- CVA tenderness
- Kidneys
-
where are the horizontal lymph nodes
near the femoral artery going horizontally across
-
where are the vertical lymph nodes
going up and down by where the femoral vein meets the great saphenous vein
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