Abdominal Exam 2023 PDF

Examination of the Abdomen PAT KENNEY‐MOORE EdD, PA‐C PHYSICAL DIAGNOSIS BLOCK II Abdominal Anatomy Depiction of the digestive system – 17th Century Persia 2 organs for alimentry system mooch 7 pharynx digestive food esophagus stomach smell inter teak Abdominal Anatomy gallbladder Line near tucked u...

Examination of the Abdomen PAT KENNEY‐MOORE EdD, PA‐C PHYSICAL DIAGNOSIS BLOCK II Abdominal Anatomy Depiction of the digestive system – 17th Century Persia 2 organs for alimentry system mooch 7 pharynx digestive food esophagus stomach smell inter teak Abdominal Anatomy gallbladder Line near tucked underneath Stomach I intestine smell Food Jesquest stomach 3 Abdominal Anatomy sit top of kidneys on 4 Abdominal Anatomy 5 Quadrants of the Abdomen 6 Nine Regions of the Abdomen http://www.studyblue.com/notes/note/n/quandrants-and-planes/deck/5155776. Accessed July 21, 2014. 7 Structures in Quadrants 8 Abdominal Exam: IAPP Inspection Auscultation Percussion Palpation 9 Abdominal Exam: The Basics Warm hands Short fingernails Wash hands before touching the patient Drape appropriately Pt supine Gown brought up to costal margin Drape low on hips All four quadrants must be exposed 10 Abdominal Exam: The Basics In the event of a painful abdomen, have the patient point to painful area Examine that area LAST Examining the painful area first can elicit tenderness and cause patient to “guard” making the remainder of the exam hard to complete 11 Positioning the Patient Cover upper body with gown Cover lower extremities with drape Expose area xyphoid process to symphysis pubis Knees extended for inspection, flexed for palpation Arms to the patient’s sides http://meded.ucsd.edu/clinicalmed/abdomen.htm. Accessed July 21, 2014. 12 Abdominal Exam Inspection Auscultation Percussion Palpation 13 Abdominal Exam: Inspection Symmetry Shape and Contour: Scaphoid Flat Rounded Protuberant Deformities: Herniation, bulges, masses 14 Abdominal Exam: Inspection Movement: Aortic pulsation Increased peristalsis Skin: Scars Striae Pigmentation skin Moles Venous patterns pr Lesions Jaundice issue liver gut GI infection 15 Abdominal Exam: Inspection A: Normal B: Caput Medusae / Portal Hypertension C: Inferior Vena Cava Obstruction 16 Abdominal Exam: inspection Scars: Old or new? Well‐healed? Signs of infection or compromise? Striae: tearing in the tissue Silver striae Purple striae 17 Abdominal Exam: inspection Umbilicus Everted or inverted? Discolored? 18 Abdominal Exam Inspection Auscultation Percussion Palpation 19 Abdominal Exam: Auscultation The exception to the IPPA rule – the abdominal exam sequence is IAPP Warm stethoscope (diaphragm) Gentle pressure in all four quadrants 20 Abdominal Exam: Auscultation Listen for bowel sounds: Borborygmi (rumbling/stomach growling) Frequency: (5 ‐ 35 per minute) Character: High pitched Low‐pitched Gurgles 21 Abdominal Exam: Auscultation Listen for bowel sounds: Document: Hypoactive Normoactive Hyperactive Absent Absent Bowel Sounds: Must not hear anything after 5 minutes of continuous listening 22 Abdominal Exam: Auscultation Bruits: sound of turbulent blood flow Keep in mind that this is a peripheral vascular examination done over the abdominal area, not an examination of the abdomen! 23 Abdominal Exam Inspection Auscultation Percussion Palpation 24 Abdominal Exam: Percussion Follows a pattern Percussion of the 4 quadrants Percussion of the liver Percussion of the spleen Blunt percussion of the costovertebral angle (CVA) 25 Abdominal Exam: Percussion Percuss in all 4 quadrants Tympanic over air (expected) Stomach Intestines Dullness over solid areas (expected) Stool Organs Fluid Masses Should not be tender 26 Abdominal Exam: Percussion Location of abdominal dullness rightside right below nippe 27 line Abdominal Exam: Percussion Liver Span resonance to dullness Percuss in right mid‐ clavicular line (MCL) Patient to hold breath Percuss down from above nipple level Listen for resonance  dullness Mark border http://www.easynotecards.com/print_list/7313. Accessed July 21, 2014. 28 Abdominal Exam: Percussion Liver span cont… Have patient breathe, then hold breath again Percuss up from R lumbar area of abdomen Should hear tympany  dullness Mark border http://www.easynotecards.com/print_list/7313. Accessed July 21, 2014. 29 Abdominal Exam: Percussion Liver span cont… 30 Abdominal Exam: Percussion Spleen Percuss in lowest ICS (9th), left anterior axillary line (AAL), before and after patient takes a deep breath Percussion over the area of a non enlarged spleen will be tympanic in both cases Dullness is diagnostic for an enlarged spleen 31 Abdominal Exam: Percussion Costovertebral angle (CVA) tenderness Patient in a seated position Advise them you are going to tap on their back Place your palm over the CVA Use heel of closed fist to strike your hand Compare the left and right sides for tenderness palm is flat http://quizlet.com/18653018/abdominal-gi-gu-assmt-flash-cards/. Accessed July 21, 2014. 32 Abdominal Exam Inspection Auscultation Percussion Palpation 33 Abdominal Exam: Palpation Follows a pattern Light Deep Liver Spleen Kidneys Abdominal Aorta (a peripheral vascular component) 34 Abdominal Exam: Palpation The Basics Leave painful area for last, but assess O all four quadrants – do not skip painful areas! rightside Additionally, palpate the epigastric, periumbilical and suprapubic areas Watch the face, not the belly 35 Abdominal Exam: Palpation Light Palpation one Assess for Abdominal tenderness Muscular resistance guarding – voluntary or involuntary Superficial organs Superficial masses hand pads 3 fingers I 36 Abdominal Exam: Palpation Light Palpation Flat of the hand Fingers together Using one hand Light and gentle pressure Circular motion “Dipping” motion 37 Abdominal Exam: Palpation Light Palpation 38 Abdominal Exam: Palpation Deep Palpation Assess for Delineation of abdominal organs Less obvious masses Often mistaken for masses Feces sacral promontory thin rectus abdominis wall 39 Abdominal Exam: Palpation Sacral promontory is atthe base of thesacrum 40 Dom hand first Two handed few Abdominal Exam: Palpation cm deep Deep Palpation Left hand superimposed on flat of right (or vice versa) Left exerts pressure Right appreciates tactile input Warm hands prevent guarding Deep can be uncomfortable but should not be painful access what you are feeling 41 Abdominal Exam: Palpation Liver Goes up down with breathing Patient takes deep breath Right hand press inward and upwards The edge of the liver may slide under your hand If not, move your hand up and repeat the maneuver Healthy liver has smooth, firm, regular surface and can be mildly tender when pressed p 42 Abdominal Exam: Palpation Liver 43 Abdominal Exam: Palpation Liver 44 Abdominal Exam: Palpation Spleen Patient on right side or supine Patient takes deep breath Examiner’s left hand reaches across to support the ribcage 45 Abdominal Exam: Palpation Spleen Begin left of the umbilicus – start Move to the LUQ Palpate inward with right hand toward axilla If enlarged, the spleen may brush the tips of the examiners hand or may extend into the abdominal cavity 46 Abdominal Exam: Palpation 47 Abdominal Exam: Palpation Kidney Patient supine Left hand on right flank, right hand resting lightly below the costal margin cartilages of the 7 10th ribs Patient takes deep breath – then examiner presses palms together to “capture” the kidney below level of hands If enlarged, you will feel it slip through your fingers as the patient exhales Repeat maneuver for left kidney, reaching across the patient 48 Abdominal Exam: Palpation Kidney Right kidney is sometimes palpable in a healthy, thin person Left kidney is never palpable unless abnormal we can do it but its not palpable 49 Abdominal Exam: Palpation Kidney 50 Abdominal Exam: Palpation Abdominal Aorta Position fingers to span width of aorta Measure width in centimeters o Normal < 2.5 cm > 2.5 cm consider ultrasound 51 Abdominal Exam: Palpation 52 Abdominal Exam: GU system The genitourinary system is adjacent to gastrointestinal system Several symptoms (pain, bleeding, enlarging abdomen etc.) necessitate examining these adjacent systems in addition to the GI system 53 Abdominal Exam: The Rectum Rectal exam Assess for sphincter tone GI bleeding Referred pain Prostate Fecal Occult Blood Test (FOBT) – examining finger is wiped on treated test strip and observed for color change indicating the presence of blood (guaiac test) Fecal Immunochemical Test (FIT) – no dietary requirements 54 Abdominal Exam: GU system Genitourinary exam Assess for referred pain from pelvis or external genitalia Assess prostate Pelvic exam Assess for uterine bleeding Assess for referred pain 55 Abdominal Exam: Problem – Oriented Tests Test for inflammation around the liver or spleen ◦ Auscultate for friction rubs Tests for ascites ◦ Shifting Dullness ◦ Fluid wave Test for gallbladder irritation ◦ Murphy sign Tests for peritoneal irritation ◦ Rebound ◦ Psoas ◦ Obturator ◦ Markle / Heel jar Guarding ◦ Voluntary guarding – the patient contracts muscles to prevent discomfort or tickling ◦ Involuntary guarding – reflex contraction or spasm of the abdominal muscles due to peritoneal inflammation – “rigid” abdomen = surgical abdomen 56 Auscultate for Friction Rubs Inflammation around liver or spleen can cause a friction rub Rubs are typically high‐ pitched sounds – use the diaphragm Have patient inhale while listening over costal margin 57 Shifting Dullness for Ascites Tpresent SOAP 58 Shifting Dullness for Ascites Patient supine Begin percussing at umbilicus (tympany) ‐ percuss to the patient’s left side until dullness is located Mark the border Turn patient to left lateral decubitus position Begin percussing at the patient’s right flank – downward to where dullness is located If ascites is present, dullness will shift to dependent position This is not measured specifically, just noted that the location shifted – i.e. shifting dullness is present 59 Shifting Dullness for Ascites 60 present Fluid Wave for Ascites Patient supine Patient’s own hand as a barrier in mid abdomen Examiner taps one side while palpating the other Wave transmitted across to other hand is positive for ascites 61 Murphy Sign for Gallbladder Tucked underneath liver Patient exhales Examiner places hand below costal margin (right mid‐clavicular) Patient inhales Positive = patient stops inhalation abruptly 62 Peritoneal Signs: Dothis at the end Rebound Tenderness Press gently and deeply into abdomen in region remote from focus of pain start where from Rapidly withdraw hand / fingers it hurts the most Return to position (i.e. rebound) of structures displaced by hand causes stabbing pain at irritated site If positive, suggests peritoneal inflammation/ irritation as seen with appendicitis Perform at end of exam; may be quite painful No need for repeated exams once a positive test is obtained 63 Peritoneal Signs: Psoas Sign Option 1 Patient supine Hand above right knee Patient flex hip against resistance RLQ Pain = possible peritoneal irritation (appendicitis) 64 Peritoneal Signs: Psoas Sign Option 2 Patient in lateral decubitus position Extend right leg at hip against resistance RLQ Pain = possible peritoneal irritation (appendicitis) 65 Peritoneal Signs: Obturator Sign Patient supine Patient flex right leg at hip at knee to 90 degrees Grasp leg just above knee and at ankle Internally rotate hip Tests for irritation of obturator muscle RLQ Pain = possible peritoneal irritation (appendicitis) http://www.studyblue.com/notes/note/n/4-acute-abdomen-/deck/5090745. Accessed July 21, 2014. 66 Peritoneal Signs: Heel Jar (Markle Test) Option 1 Option 2 Patient stands on tiptoes Patient supine Patient drops to heels Examiner strikes patient’s heel with their fist Abdominal pain = positive test 67 where does append lira I McBurney Point ‐ Palpation Between the umbilicus and right anterior superior iliac spine (ASIS) Pain with palpation indicative of appendicitis (or other peritoneal inflammation) If tender, document as “McBurney pt. tenderness present” 0 68 Referred Pain 69 Pain Descriptions Burning – peptic ulcer disease (PUD) Tearing – dissecting aneurysm Colicky – cholecystitis (biliary colic) Commons and gas Severe – renal colic or stones General Appearance – ◦ Writhing = renal or biliary colic ◦ Holding completely still = peritonitis 70 QUESTIONS? 71