Advanced Abdominal Exam

Abdominal Assessment : Abdominal Assessment Dr. Michael Zychowicz Associate Professor Nurse Practitioner Mount Saint Mary College

Surface Anatomy to Consider : Surface Anatomy to Consider

More Anatomy : More Anatomy

More anatomy : More anatomy

Yes, more anatomy : Yes, more anatomy

Common Symptoms of Abdominal Disease : Common Symptoms of Abdominal Disease Pain Nausea / Vomiting Change in appetite Change in bowel habits Rectal bleeding Jaundice Abdominal distention Mass

Some pain questions to consider : Some pain questions to consider Onset and duration Sudden, gradual, persistent, or intermittent Character Dull, sharp, burning, stabbing, aching Location Radiation, superficial, deep, changing Associated symptoms N/V/D, change in abd girth, belching

More pain questions : More pain questions Relationship to internal and external stressors Relationship to time of day or bodily functions Recent stool characteristics Color, consistency, odor, frequency Urinary characteristics Frequency, color, odor, volume Medications Past, present, Rx or OTC

What makes the pain better? : What makes the pain better? Belching Stomach (?gastric distention) Eating Stomach or duodenum (?peptic ulcer) Vomiting Stomach or duodenum (?pyloric obstruction)

What makes the pain better? : What makes the pain better? Leaning forward Retroperitoneal structures (?pancreatic cancer, pancreatitis) Flexion of the knees Peritoneum (?peritonitis) Flexion of the right thigh Right psoas muscle (?appendicitis) Flexion of the left thigh Left psoas muscle (?diverticultitis)

When examining a person with complaint of nausea / vomiting : When examining a person with complaint of nausea / vomiting Possible causes: Severe irritation or distention of the stomach Obstruction of bile duct or intestines Toxins (drugs, parasites, viruses, etc.) CNS disorders (Medulla) MI Pregnancy

Investigate the nausea / vomiting further : Investigate the nausea / vomiting further Did you experience pain or nausea before vomiting How many times did you vomit Describe episode (forceful, retch, regurgitate) Was blood present Character of the vomiting What have you eaten in last 24 hours When was last BM Have you lost weight What meds are you currently taking

When examining a person with complaint of change in appetite : When examining a person with complaint of change in appetite Possible causes: Anorexia-loss of appetite for food Obesity Dysphagia-difficulty swallowing Hypothalamus lesions (Hunger & satiety center) Psychological Medication Financial

Investigate the change in appetite further : Investigate the change in appetite further Obtain ht. & wt., recent weight changes Muscle wasting evident Examine condition of teeth & mouth Assess skin turgor, mucous membranes Assess for depression 24 hour dietary recall

When examining a person with complaint of change in bowel habits : When examining a person with complaint of change in bowel habits Possible causes: Dehydration Obstruction Infection Toxins Inflammation Bleeding Colon cancer

Investigate the change in bowel habits further : Investigate the change in bowel habits further Ask color, shape, consistency, frequency & odor Describe what is different constipation acute diarrhea after a meal / infection or toxins alternating diarrhea and constipation / diverticulitis or colon cancer stool mixed with blood and mucous / ulcerative colitis

When examining a person with complaint of rectal bleeding : When examining a person with complaint of rectal bleeding Possible causes: Hemorrhoids Upper GI bleeding Lower GI bleeding Colorectal cancer Medication Injury / fall

Investigate the rectal bleeding further : Investigate the rectal bleeding further Pale, cool skin, tachycardia Describe color, odor, frequency Bright red blood on stool surface Bright red blood mixed with feces Melena-black tarry stool with distinct malodor / bleeding above duodenum with blood partially digested Black colored stool R/T medication Steatorrhea-pale yellow stool R/T increased fat /floats

When examining a person with complaint of Jaundice : When examining a person with complaint of Jaundice Possible causes: Liver disorder in which yellow bile pigments accumulate in the blood and are deposited in body tissue. Normally the liver cells secrete the bile pigments (bilirubin) as a component of bile. Hepatitis ETOH/ cirrhosis Obstructed bile passageway (GB stones, Ca) excess RBC destruction (hemolysis) excess bilirubin in the blood (Hyperbilirubinemia)

Investigate the jaundice further : Investigate the jaundice further Any RUQ pain radiating to right shoulder / scapula area Pain after ingestion of fatty meal Pain sudden / severe with N/V Dark tea-colored urine Clay-colored stool Pruritus

When examining a person with abdominal distention : When examining a person with abdominal distention Possible causes: intestinal obstruction paralytic ileus (absent BS) fecal impaction cirrhosis / ascites (Portal HTN) tumor / ovarian cancer pregnancy obesity aerophagia / gaseous / swallowing air

Investigate the abdominal distention further : Investigate the abdominal distention further When did you first notice increase in size of abdomen Are you having any difficulty breathing Do you have a feeling of fullness or pressure Obtain measurement of abdominal girth Any change in bowel / bladder habits / last BM Could you be pregnant Medications

When examining a person with complaint abdominal mass : When examining a person with complaint abdominal mass Possible causes: Tumor Obesity AAA Hernia

Investigate the abdominal mass further : Investigate the abdominal mass further With Obesity Uniformly rounded abdomen Umbilicus buried deeply in abdominal wall Excessive fat on other body areas If suspect Abdominal Hernia (raise head & shoulders) Protrusion of intestine through the abdominal wall may disappear momentarily when pushed back into the abdominal wall. If intestine becomes strangulated it may elicit pain, anorexia and vomiting

Social Hx considerations : Social Hx considerations Nutrition Alcohol intake Life stressors Exposure to infectious disease Use of illicit drugs or Rx abuse

Examination : Examination Inspect Auscultate Percussion Palpation

Quadrants : Quadrants

Inspection : Inspection

Inspection : Inspection General appearance Uncomfortable? Resp rate Shallow/ Increased in pts w/ abd pain Skin Jaundice hyperbilirubinemia Spider angiomas Alcoholic cirrhosis, pregnancy Facies Moonface – Cushing's

Inspect the abdomen : Inspect the abdomen Shape Striae Pink purple with Cushing's disease Silver normal with weight loss Grey turner’s sign Ecchymosis of flanks of the abdomen ?Hemorrhagic pancreatitis Cullen sign Bluish color of the peritoneum ?hemoperitoneum

Inspect the abdomen : Inspect the abdomen Any scars Hernias Superficial veins Vena cava obstruction Drain cephalad Portal hypertension Radiate from umbilicus

Auscultation : Auscultation Listen to bowel sounds for up to 2 mins

Auscultation : Auscultation Abdominal bruits Renal artery or abdominal aorta stenosis Peritoneal rubs Hepatic or spenic inflammation

Palpation : Palpation Light Diffuse rigidity – peritonitis Localized rigidity – appendix, gallbladder Hyperesthesia - peritonitis Deep Masses, pain, guarding

Palpation : Palpation Liver Ridge should be regular, firm, and smooth Hook or direct

Palpate the liver edge : Palpate the liver edge

Palpation : Palpation Spleen Reach over patient, elevate rib cage, palpate up and back Splenomegally – infection, tumor, vascular congestion

Palpation : Palpation Kidney Attempt to “capture” the kidney at the lower pole Use both hands at the flank under ribs

Palpation : Palpation Rebound tenderness Peritoneal irritation (appendicitis)

Percussion : Percussion General percussion Tympanic

Percussion : Percussion Liver 10 cm in width – normal

Percussion : Percussion Percuss over the liver for tenderness

Percussion : Percussion Spleen Percuss lowest interspace in L anterior axillary line Normally resonant or tympanic If dull then enlarged spleen

Percussion : Percussion CVA tenderness ?pyelonephritis

Percussion : Percussion Shifting dullness for ascites Fluid wave for ascites

Other tests : Other tests Iliopsoas test Lie on unaffected side Extend leg at hip with knee extended Increased pain – intra-abdominal inflammation Obturator test Flex knee then internally/externally rotate hip Increased pain – intra-abdominal inflammation