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Heath Assessment CH 21
Terms in this set (139)
is a large, oval cavity extending from the diaphragm down to the brim of the pelvis. It is bordered in back by the vertebral column and paravertebral muscles, and at the sides and front by the lower rib cage and abdominal muscles
Four layers of large, flat muscles form the ventral abdominal wall. These are joined at the midline by a tendinous seam, the __ __
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.
are those that maintain a characteristic shape (liver, pancreas, spleen, adrenal glands, kidneys, ovaries, and uterus)
right; midclavicular; right; bimanual
The liver fills most of the ___ upper quadrant and extends over to the left __ line (MCL). The lower edge of the liver and the ___ kidney normally may be palpable. The ovaries normally are palpable only on ___ examination during the pelvic examination.
(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.
stomach; gallbladder; pyloric; ileocecal
The __ is just below the diaphragm, between the liver and spleen. The __ rests under the posterior surface of the liver, just lateral to the right MCL. Small intestine is located in all four quadrants; It extends from the __ valve of the stomach to the __ valve in the right lower quadrant (RLQ), where it joins the colon.
is a soft mass of lymphatic tissue on the posterolateral wall of the abdominal cavity, immediately under the diaphragm;
- It lies obliquely with its long axis behind and parallel to the 10th rib, lateral to the midaxillary line. Its width extends from the 9th to the 11th rib, about 7 cm.
- just to the left of midline in the upper part of the abdomen
- 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.
a soft, lobulated gland located behind the stomach. It stretches obliquely across the posterior abdominal wall to the left upper quadrant.
- are retroperitoneal, or posterior to the abdominal contents
- well proetcted by
the posterior ribs and musculature.
- The 12th rib forms an angle with the vertebral column, the costovertebral angle.
- left is at 11th and 12th rib; right rets 1-2 cm lower than left
Right Upper Quadrant
- head of pancreas
- right kidney & adrenal
- hepatic flexure of colon
- part of ascending and transverse colon
left upper quadrant
- left lobe of liver
- body of pancrease
- left kidney & adrenal
- splenic flexure of colon
- part of transverse and ascending colon
right lower quadrant
- right ovary and tube
- right ureter
- right spermatic cord
left lower quadrant
- part of descending colon
- sigmoid colon
- left ovary and tube
- left ureter
- left spermatic cord
- uterus (if enlarged)
- bladder (if distended)
suprapubic; estrogen; sedentary lifestyle; abdomen hips
- some fat accumulates in the ___ area in females as a result of decreased ___ levels.
- Males also show some fat deposits in the abdominal area, which accentuates with a more __ __
- With further aging adipose tissue is redistributed away from the face and extremities and to the __ and __
salivation; esophageal emptying; aspiration; pernicious; iron deficiency; calcium; gallstones; females
- ___ decreases, causing a dry mouth and a decreased sense of taste
- __ __ is delayed. If an aging person is fed in the supine position, it increases risk for __.
- Gastric acid secretion decreases with aging. This may cause ___ anemia, __ __ anemia, and malabsorption of __.
- The incidence of __ increases with age, occurring in 10% to 20% of middle-age and older adults, being more common in ___.
size; drug metabolism; side effects
aging adult liver:
- __ decreases
- __ __ by the liver is impaired, in part because blood flow through the liver and liver size are decreased
- ^^ causes increased __ __
easier; fat; drier; esophageal emptying; gastric secretion; gall stones; size; constipaiton
- Weaker abdominal muscle; palpation is ___
- __ migrates to the abdomen & hips - both genders
- More fat; less water content = Older persons "___"
- Delayed __ __
- Decreased __ __
- Increased incidence of __ __
- Decreased liver __
Common complaint - __
constipation (aging adult)
- Constipation is not a physiologic consequence of aging.
- Common causes of constipation include decreased physical activity, inadequate intake of water, a low-fiber diet, side effects of medications, bowel obstruction, hypothyroidism
3. Food intolerance
4. Abdominal pain
6. Bowel habits
7. Past abdominal history 8. Medications
9. Nutritional assessment
poorly; ache-colicky; epigastric; periumbilical; suprpubic
Solid or hollow organs or structures
- Midline - __ localized
- Range- steady __ to vague to __ pain
- __: stomach, duodenum, biliary tract
- __: small bowel, appendix, cecum
- __: colon, sigmoid, GU tract
- Involves parietal peritoneum
Causes tenderness & guarding which progresses to rigidity
symptoms; embryology; aching; bilary; MI; gyn
- Produces ___ NOT signs
- Based on developmental __
- Localized in same cutaneous dermatone sharing same spinal cord levels as visceral inputs
- Pain - ___; close to surface
- __ - right infrascapular pain
- __ - epigastric, neck, jar or upper extremity
- __ - back or proximal lower extremity
is a loss of appetite from GI disease as a side effect to some medications, with pregnancy, or with mental health disorders.
occurs with disorders of the throat or esophagus.
(e.g., lactase deficiency resulting in bloating or excessive gas after taking milk products).
- ___: a form of indigestion felt as a burning sensation in the chest, caused by acid regurgitation into the esophagus.
- __: belching
occurs with stomach or duodenal ulcers and esophageal varices.
black; iron; hepatitis; red
___ stools may be tarry due to occult blood (melena) from GI bleeding or nontarry from ___ medications. Gray stools occur with ___.
- __ blood in stools occurs with GI bleeding or localized bleeding around the anus.
melena; hematemesis; sterrohea
Loose, gray-tan, clay-colored stool - absence of bile pigments
- ___: Black tarry stools 2ndary to upper GI bleed
- __: Red blood or coffee-ground emesis 2ndary to GI bleed
- ___: Yellow, pale stool with high fat content 2ndary to malabsorption
Although a toddler may attempt nonfoods at some time, he or she should recognize edibles by age 2 years.
emptied; warm; supine; arms; last; breathing; imagery; conversation; history
• The person should have ___ the bladder, saving a urine specimen if needed.
• Keep the room ___ to avoid chilling and tensing of muscles.
• Position the person ___, with the head on a pillow, the knees bent or on pillow, and the arms at the sides or across the chest. Don't place ___ over head
• 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 ___ to avoid any muscle guarding.
• Finally learn to use distraction: Enhance muscle relaxation through __ exercises; emotive __; your low, soothing voice; engaging in ___; or having the person relate his or her abdominal ___ while you palpate.
rib; pelvic; nutritional; flat; rounded; scaphoid; protuberant; distension
- Stand on the person's right side and look down on the abdomen. Then stoop or sit to gaze across the abdomen. Your head should be slightly higher than the abdomen. Determine the profile from the __ margin to the __ bone. The contour describes the __ state and normally ranges from __ to __.
- Abnormal: ___ abdomen caves in. __ abdomen, abdominal __
bulging; mass; asymmetric;
- Shine a light across the abdomen toward you or lengthwise across the person. The abdomen should be symmetric bilaterally. Note any localized __, visible __, or __ shape. Even small bulges are highlighted by shadow. Step to the foot of the examination table to recheck symmetry.
- Ask the person to take a deep breath to further highlight any change. The abdomen should stay smooth and symmetric. Or ask the person to perform a sit-up without pushing up with his or her hands.
bulges; hernia; sister mary joseph
- __, masses.
- ___—Protrusion of abdominal viscera through abnormal opening in muscle wall
- __ __ __ nodule is a hard nodule in umbilicus that occurs with metastatic cancer of stomach, large intestine, ovary. or pancreas.
- Note any localized bulging.
Hernia or enlarged liver or spleen may show.
pregnancy; ascites; obesity; hernia; intraperitoneal bleeding; Cullen
- Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia. It becomes everted and pushed upward with ___. The umbilicus is a common site for piercings in young women. The site should not be red or crusted.
- Abnormal: Everted with ___ or underlying mass; Deeply sunken with ___. Enlarged, everted with umbilical ___. Bluish periumbilical color occurs (though rarely) with __ __ (___ sign).
infalmmation; jaundice; taut; ascites
- The surface is smooth and even, with homogeneous color. This is a good area to judge pigment because it is often protected from sun.
- abnormal: Redness with localized __. ___ (shows best in natural daylight). Skin glistening and __ with __.
striate (linae 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 are pink or blue; then they turn silvery white.
Striae also occur with ascites.
Striae look purple-blue with ___ syndrome
nevi; color; shape
Pigmented ___ (moles)—circumscribed brown macular or papular areas—are common on the abdomen.
- abnormal: Unusual __ or change in __ of mole
Cutaneous angiomas; inflammaotry; trauma; surgery
normally no lesions are present, although you may note well-healed surgical scars. If a scar is present, draw its location in the person's record, indicating the length in centimeters. A surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue.
- Abnormal:__ __ (spider nevi) occur with portal hypertension or liver disease. Lesions, rashes; Underlying adhesions are ___ bands that connect opposite sides of serous surfaces after __ or __.
portal hypertension; cirrhosis; asicites; venal caval; malnutrition
- Veins usually are not seen, but a fine venous network may be visible in thin persons.
- Abnormal: Prominent, dilated veins occur with __ __, __, __, or __ __obstruction. Veins are more visible with ___ as a result of thinned adipose tissue.
- Good skin turgor reflects healthy nutrition. Gently pinch up a fold of skin; then release to note the immediate return of the skin to original position.
- Abnormal: Poor turgor occurs with ___, which often accompanies GI disease.
epigastric; males; piersalsis; pulse pressure; aortic aneurysm; intestinal obstruction
pulsation or movement:
- Normally you may see the pulsations from the aorta beneath the skin in the ___ area, particularly in thin people with good muscle wall relaxation. Respiratory movement also shows in the abdomen, particularly in __. Finally, waves of __ sometimes are visible in very thin people. They ripple slowly and obliquely across the abdomen.
- Abnormal: Marked pulsation of aorta occurs with widened __ __ (e.g., hypertension, aortic insufficiency, thyrotoxicosis) and __ __
- Marked visible peristalsis, together with a distended abdomen, indicates __ __
diamond; triangular; endocrine; liver
- The pattern of pubic hair growth normally has a ___ shape in adult males and an inverted __ shape in adult females
- Patterns alter with ___ or hormone abnormalities, chronic __ disease.
colicky; gastroenteritis; peritonitis;
- A comfortable person is relaxed quietly on the examining table and has a benign facial expression and slow, even respirations.
- Abnormal: Restlessness and constant turning to find comfort occur with the ___ pain of ___ or bowel obstruction.
- Absolute stillness,
resisting any movement, occurs with the pain of ___. Knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain.
high; lightly; RLQ
- Use the diaphragm endpiece because bowel sounds are relatively ___-pitched. Hold the stethoscope __ against the skin; pushing too hard may stimulate more bowel sounds. Begin in the ___ at the ileocecal valve area because bowel sounds normally are always present here.
air; fluid; 5-30; borborygmus;silent
- They originate from the movement of __ and __ through the stomach and large and small intestine
- are high-pitched, gurgling, cascading sounds, occurring irregularly anywhere from __-__ times per minute.
- One type of hyperactive bowel sounds is fairly common: hyperperistalsis, when you feel your "stomach growling," termed ___.
- A perfectly " __ abdomen" is uncommon; you must listen for 5 minutes by your watch before deciding if bowel sounds are completely absent.
are loud, high-
pitched, rushing, tinkling sounds that signal increased motility.
follow abdominal surgery or with inflammation of the peritoneum
aorta; renal; iliac; femoral; bruit; systolic bruit; venous hum; friction rub
- Using firmer pressure, check over the __, __ arteries, __, and __ arteries, especially in people with hypertension; Usually no such sound is present.
- __ - celiac artery; is systolic, medium to low in pitch, and heard between the xiphoid process and the umbilicus.
- Abnormal: __ __ is a pulsatile blowing sound and occurs with stenosis or occlusion of an artery.
- __ __ and peritoneal __ __ are rare
- Abnormal: The auscultation method can wrongly suggest that the feeding tube is correctly placed in the stomach; serious harm or even fatality can result from administering tube-feeding material into the lung.
tympany; dullness; clockwise; air; dullness; hyperresonance
- First percuss lightly in all four quadrants to determine the prevailing amount of __ and __. Move __. Tympany should predominate because __ in the intestines rises to the surface when the person is supine.
- Abnormal: __ occurs over a distended bladder, adipose tissue, fluid, or a mass.
- __ is present with gaseous distention
lung; dull; 5; MCL; costal margin; 6-12; longer; larger; longer; 10.5; 7
- Measure the height of the liver in the right MCL.
- begin in the area of __ resonance and percuss down the interspaces until the sound changes to a __ quality.
- Mark the spot, usually in the __th intercostal space. Then find abdominal tympany and percuss up in the ___.
- Mark where the sound changes from tympany to a dull sound, normally at the right __ __
- Measure the distance between the two marks; the normal liver span in the adult ranges from __-__ cm
- The height of the liver span correlates with the height of the person; taller people have ___ livers. Males also have a __ liver span than females of the same height. Overall the mean liver span is __ cm for males and __ cm for females.
hepatomegaly; lung; ascites; pregnancy; gas;
An enlarged liver span indicates liver enlargement or ___.
- Accurate detection of liver borders is confused by dullness above the 5th intercostal space, which occurs with ___ disease
- Accurate detection at the lower border is confused when dullness is pushed up with __ or __ or with __ distention in the colon, which obscures the lower border.
One variation occurs in people with chronic ___, in which the liver is displaced downward by the hyperinflated lungs. Although you hear a dull percussion note well below the right costal margin, the overall span is still within normal limits.
Clinical estimation of liver span screens for hepatomegaly and monitors changes in liver size. However, this measurement is a gross estimate; the liver span usually is ___ because clinicians place the upper border too low and/or the lower border too high
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.
stomach; 9-11; midaxillary; 7; tympany
- Often the spleen is obscured by ___ contents, but you may locate it by percussing for a dull note from the __-__ intercostal space just behind the left __ line. The area of splenic dullness normally is not wider than __ cm in the adult and should not encroach on the normal __ over the gastric air bubble.
mononucleosis; trauma; infection
A dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with __, __, and ___.
tympany; full; splenomegaly; mononucleosis; malaria; hepatic
- Now percuss in the lowest interspace in the left anterior axillary line. ___ should result. Ask the person to take a deep breath. Normally tympany remains through __ inspiration.
- Abnormal: In this site, the anterior axillary line, a change in percussion from tympany to a dull sound with full inspiration is a positive spleen percussion sign, indicating ___.
- This method detects mild-to-moderate splenomegaly before the spleen becomes palpable, as in __, __, or hepatic __.
fist; 12; ulnar; pain; kidney
- Indirect __ percussion causes the tissues to vibrate instead of producing a sound. To assess the kidney place one hand over the __ rib at the costovertebral angle on the back. Thump that hand with the __ edge of your other fist. The person normally feels a thud but no __. (Usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.)
- Sharp pain occurs with inflammation of the ___ or paranephric area.
- At times you may suspect that a person has ascites because of a distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward. You can differentiate ascites from gaseous distention by performing two percussion tests.
- Abnormal: Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.
- 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. (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.
- if ascites is present, the blow will generate a fluid wave through the abdomen, and you will feel a distinct tap on your left hand. If the abdomen is distended from gas or adipose tissue, you will feel no change.
- 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.
- 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.
shifting dullness cont:
- Now turn the person onto the right side (roll him or her toward you).
- The fluid will gravitate to the dependent side, displacing the lighter bowel upward.
- Begin percussing the upper side of the abdomen and move downward.
- The sound changes from tympany to a dull sound as you reach the fluid level; but this time the level of dullness is higher, upward toward the umbilicus.
- This test has less diagnostic value than the fluid wave test. Shifting dullness is positive with a large volume of ascitic fluid; it will not detect less than __-__ mL of
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.
- 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 and move clockwise to the next location around the abdomen.
- form an overall impression of the skin surface and superficial musculature.
- Abnormal: Muscle guarding. Rigidity. Large masses. Tenderness.
occurs when the person is cold, tense, or ticklish. It is bilateral, and you will feel the muscles relax slightly during exhalation. Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation. If the rigidity persists, it is probably involuntary.
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.
he technique described earlier but push down about 5 to 8 cm--Moving clockwise, explore the entire abdomen.
- 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.
11; 12; RUQ; midline; costal; slowly; exhalation; diaphragm; liver
Place your left hand under the person's back parallel to the __ & __ ribs and lift up to support the abdominal contents. Place your right hand on the __, with fingers parallel to the __. Push deeply down and under the right __ margin. Ask the person to breathe ___. With every ___, move your palpating hand up 1 or 2 cm. It is normal to feel the edge of the liver bump your fingertips as the ___ pushes it down during inhalation. It feels like a firm, regular ridge.
- Often the __ is not palpable and you feel nothing firm.
enlarged; consistency; tenderness
- Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is ___. Record the number of centimeters it descends and note its __ (hard, nodular) and __
- 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.
3; 11; 12; LUQ; costal; nothing
Normally the spleen is not palpable and must be enlarged __ times its normal size to be felt. To search for it, reach your left hand over the abdomen and behind the left side at the __ & __ ribs. Lift up for support. Place your right hand obliquely on the __ with the fingers pointing toward the left axilla and just inferior to the rib margin. Push your hand deeply down and under the left __ margin and ask the person to take a deep breath. You should feel __ firm.
lower; low; right
When enlarged, the spleen slides out and bumps your fingertips. It can grow so large that it extends into the ___ quadrants. When this condition is suspected, start __ so you will not miss it. An alternative position is to roll the person onto his or her __ side to displace the spleen more forward and downward. Then palpate as described earlier.
mononucleosis; leukemias; palpate; rupture
- The spleen enlarges with ___, trauma, __ and lymphomas, portal hypertension, and HIV infection
- If you feel an enlarged spleen, refer the person but do not continue to __ it. An enlarged spleen is friable and can __ easily with overpalpation.
Describe the number of centimeters that it extends below the left costal margin.
duck-bill; deeper; no; right
- Search for the right kidney by placing your hands together in a "__-__" position at the person's right flank. Press your two hands together firmly (you need __ palpation than that used with the liver or spleen) and ask the person to take a deep breath. In most people you will feel __ change. Occasionally you may feel the lower pole of the __ kidney as a round, smooth mass that slides between your fingers. Either condition is normal.
higher; palpable; push
The left kidney sits 1 cm ___ than the right kidney and is not __ normally. Search for it by reaching your left hand across the abdomen and behind the left flank for support. __ your right hand deep into the abdomen and ask the person to breathe deeply. You should feel no change with the inhalation.
thumb; fingers; 2.5-4; aneurysm; apart
Using your opposing __ and __, palpate the aortic pulsation in the upper abdomen slightly to the left of midline. Normally it is __-__ cm wide in the adult and pulsates in an anterior direction.
- Widened with ___; Prominent lateral pulsation with aortic aneurysm pushes the examiner's two fingers ___.
rebound tenderness (blumberg sign)
- assess when the person reports abdominal pain or when you elicit tenderness during palpation.
- Choose a site away from the painful area.
- Hold your hand 90 degrees, or perpendicular, to the abdomen.
Push down slowly and deeply then lift up quickly
- This makes structures that are indented by palpation rebound suddenly.
- A normal, or negative, response is no pain on release of pressure. Perform this test at the end of the examination because it can cause severe pain and muscle rigidity.
positive rebound tenderness with __ __: 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.
inspiratory arrest (murphy sign)
- Normally palpating the liver causes no pain.
- In a person with inflammation of the gallbladder (cholecystitis), pain occurs.
- Hold your fingers under the liver border. Ask the person to take a deep breath.
- A normal response is to complete the deep breath without pain.
- (Note: This sign is less accurate in patients older than 60 years; evidence shows that 25% of them do not have any
Iliopsoas muscle test
- Perform the test when the acute abdominal pain of appendicitis is suspected. With the person supine, lift the right leg straight up, flexing at the hip then push down over the lower part of the right thigh as the person tries to hold the leg up.
- When the test is negative, the person feels no change.
- When the muscle is inflamed (which occurs with an inflamed or perforated appendix), pain is felt in the RLQ.
- lift the person's right leg, flexing at the hip, and 90 degrees at the knee. Hold his or her ankle and rotate the leg internally and externally. There should be no pain. This test is less specific.
- An inflamed appendix irritates the obturator muscle, and this leg movement produces pain.
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
- A score of 7 increases the probability of appendicitis.
You may note an __ __ It appears at 2 to 3 weeks and is especially prominent when the infant cries. The hernia reaches maximum size at 1 month (up to 2.5 cm or 1 inch) and usually disappears by 1 year.
Another common variation is __ __, a separation of the rectus muscles with a visible bulge along the midline. The condition is more common with Black infants, and it usually disappears by early childhood.
fat; thinner; less; peristalsis;
- On inspection you may note increased deposits of subcutaneous ___ on the abdomen and hips because it is redistributed away from the extremities. The abdominal musculature is __ and has __ tone than that of the younger adult; thus in the absence of obesity, you may note __.
easier; costa margin; lower; rigidity; less
Because of the thinner, softer abdominal wall, the organs may be ___ to palpate (in the absence of obesity). The liver is easier to palpate. Normally you will feel the liver edge at or just below the __ __. With distended lungs and a depressed diaphragm, the liver is palpated ___, descending 1 to 2 cm below the costal margin with inhalation. The kidneys are easier to palpate.
- Abdominal ___ with acute abdominal conditions is less common in aging.
- With an acute abdomen the aging person often complains of __ pain than a younger person would.
- 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.
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.
- 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
- Palpation. Taut skin and increased intra-abdominal pressure limit palpation.
Ovarian Cyst (large)
- Inspection. Curve in lower half of abdomen, midline. Everted umbilicus.
- Auscultation. Normal bowel sounds over upper abdomen where intestines pushed
- Percussion. Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid
wave and shifting dullness.
- Palpation. Transmits aortic pulsation, whereas ascites does not.
- 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.
- 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.
- 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
may have mild-to-moderate dull pain in right upper quadrant (RUQ) or epigastrium, along with anorexia, nausea, malaise, low-grade fever.
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.
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.
has acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank, severe nausea, and vomiting.
typically has dull, aching, gnawing pain; does not radiate; may be relieved by food; and may awaken the person from sleep.
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.
- 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.
prompt a sudden onset of severe, colicky flank or lower abdominal pain.
has diffuse, generalized abdominal pain with nausea, diarrhea.
large bowel obstruction
has moderate, colicky pain of gradual onset in lower abdomen and bloating.
has sharp or burning cramping pain over a wide area; does not radiate. Brought on by meals; relieved by bowel movement.
- 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).
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.
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.
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.
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.
Marked peristalsis together with projectile vomiting in the newborn suggests __ __, an obstruction of the pyloric valve of the stomach. Pyloric stenosis is a congenital defect and appears in the 2nd or 3rd week.
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
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.
ndicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels. Listen with the bell
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.
- 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.
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 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.
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.
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
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.
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.
mcburneys; low; rebound tenderness; blumbergs; Rovsing's; psoas; obturator
- Pain begins in epigastric or periumbilical region and localizes to RUQ - ___ point
- Anorexia, nausea, vomiting,
- Usually __ grade fever -<100
- __ __ +
- __ sign
- Palpation LLQ causes RLQ pain - __ sing
- __ & - __ signs may be positive--NOT specific for appendicitis
older; asymptomatic; fatty; RUQ; RUQ; N/ V; Epigastric; tachycardia; Murphy's sign
gallstones & cholecystitis:
Most common cause for surgery - __ persons
- Presence of gallstones may be __
- May have belching, bloating, flatulence
S&S following __ meal
- Cramping ___ pain - may begin or radiate to R shoulder - lasts for several hours; occurs again with same meals
- __ & RUQ tenderness
- May have fever, __
- Respiratory arrest - + __ __
- Small outpouching of mucosa and submucosa in large bowel - predominates sigmoid colon.
- May be asymptomatic or symptomatic
- S&S - bloating, LLQ pain, constipation/diarrhea; others
Incidence increases with age; 50% at age 50
LLQ; fever; sounds; tenderness; hypoactive; mass; Guaiac + stools
Infection of herniated diverticulae
- Constant abdominal pain __ or diffuse
- __; altered bowel __
- Nausea; vomiting; malaise
- Mild/moderate abdominal tenderness - LLQ
- If perforated - severe __; fever, __ bowel sounds
- May palpate an abdominal __
- __ + __
back; boring; sitting; low; tachycardia; diaphoresis; hypotension; pleural effusion; left; Jaundice
- Abdominal pain - epigastrium & LUQ - radiates to the ___; pt restless
- Often described a __ pain
- Pain relieved somewhat by __ up and leaning forward
- Nausea and vomiting
- __ grade fever, __, tachypnea, __, __
- May have __ __ - __ lung
- __; distention may be present
pyrosis; regurgitation; hoarseness; cough
Gastroesophageal reflux disorder (GERD)
- ___ (heartburn)
- __, water brash
Sore throat; __
- __, Chest pain -non-radiating
cramping; obstipation; tenderness; absent; distention
Small & large bowel obstruction:
- __ abdominal pain
- Nausea; vomiting
- __ - severe & intractable constipation
- Abdominal __
- Bowel sounds - tinkling or __
- Bulge or protrusion of organ or part of organ through weakness in abdominal wall.
- Viscera moves into weakened area - causes bulge
- Most serious complication - strangulated hernia
inguinal; umbilical; femoral; incisional; hiatal
dysuria; frequency; hematuria; incontinence; bleeding; flu; jaundice; dark; clay
Abdomen -Relevant associated symptoms:
- Genitourinary - __, __, __, __
- Gyn - vaginal __; vaginal __
- Hepatitis - __ like syndrome; __, __ urine; __ colored stools
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