Exam 2 Study Guide

Right Upper Quadrant (RUQ)

Liver, gallbladder, small bowel, pylorus, duodenum, head of pancreas, hepatic flexure of colon, portions of ascending and transverse colon, right adrenal gland, portion of right kidney

Left Upper Quadrant (LUQ)

Spleen, stomach, small bowel, left lobe of liver, body of pancreas, splenic flexure of colon, portions of transverse and descending colon, left adrenal gland, portion of left kidney

Right Lower Quadrant (RLQ)

Appendix, cecum, small bowel, portion of ascending colon, lower pole of right kidney, right ureter

Left Lower Quadrant (LLQ)

Sigmoid colon, small bowel, portion of descending colon, lower pole of left kidney, left ureter

Inspection of the abdomen

Assessment of skin color, surface characteristics, venous patterns, contour, symmetry, and surface movements

Color of the abdomen

May be paler than the rest of the body

Venous Patterns of the abdomen

Very faint, fine vascular network

Contour of the abdomen

Sunken or protruding slightly, smooth and symmetric

Symmetry of the abdomen

Even

Assessment process for an abdominal hernia

Ask patient to cough or take a deep breath with them elevating their head to indicate abdominal hernia

Seven Fs of abdominal distension

Fat, fetus, flatulence, feces, fibroid tumor, fatal tumor, or fluid

Landmark for measuring abdominal girth

Superior Iliac Crests

Part of stethoscope for auscultating bowel sounds

Diaphragm, press lightly

Significance of marked pulsations in the abdominal area

May indicate abdominal aneurysm

Normoactive bowel sounds

Heard every 5-15 seconds

Abdominal palpation process

Palpate all 4 quadrants using fingertips, depress abdomen 1-2 cm, palpate painful area last

Rigidity

Associated with peritoneal irritation, diffused or localized

Order of assessing areas of abdominal pain

Last

Difference between direct and indirect percussion

Direct: striking fingers directly on skin

Indirect: striking middle finger on surface with another finger

Anticipated tone heard on percussion of the abdomen

Tympany (due to presence of gas)

Dullness on percussion of the abdomen

May indicate organs like the liver or a full bladder

Enlarged liver

Hepatomegaly, 2-3 cm below the costal margin

Spleen enlargement

May indicate infection or trauma

Palpable gallbladder

If tender, may indicate cholecystitis

If NOT tender, may indicate common bile duct obstruction

Murphy's sign

Pain and abrupt stop of inhaling during deep palpation, indicates cholecystitis

Ascites

Caused by cirrhosis, associated with movement of dullness, fluid wave, distended abdomen, dilated upper abdominal veins, inverted umbilicus

McBurney's sign

Test for the appendix, located halfway between the umbilicus and the right anterior iliac crest, absence of pain is negative, presence of pain indicates appendicitis

Gastroesophageal reflux disease (GERD)

Flow of gastric secretions into the esophagus, causing heartburn, regurgitation, and dysphagia

Hiatal hernia

Protrusion of the stomach through the esophageal hiatus of the diaphragm, causing heartburn, regurgitation, and dysphagia

Peptic ulcer disease

Ulcer occurring in the lower end of the esophagus, stomach, or duodenum, causing burning pain after eating

Crohn's disease

Chronic inflammatory bowel disease that affects the terminal ileum and colon, causing severe abdominal pain, cramping, diarrhea, nausea, fever, chills, weakness, anorexia, and weight loss

Ulcerative colitis

Chronic inflammatory bowel disease that starts in the rectum and progresses through the large intestine, causing severe abdominal pain, fever, chills, anemia, weight loss, and profuse watery diarrhea

Diverticulitis

Inflammation of diverticula in the colon, causing cramping pain, nausea, vomiting, altered bowel habits, distended abdomen, decreased bowel sounds, and localized tenderness

Viral hepatitis

Inflammation of the liver caused by different viruses, with symptoms such as anorexia, abdominal pain, nausea, vomiting, malaise, fever, enlarged liver and spleen, jaundice, tan-colored stools, and dark urine

Cirrhosis

Chronic degenerative disease of the liver, causing palpable and hard liver, ascites, jaundice, spider angioplasty, dark urine, tan-colored stools, spleen enlargement, portal hypertension, esophageal varies, hepatic encephalopathy, and coma

Cholecystitis with cholelithiasis

Inflammation of the gallbladder, with gallstones present, causing right upper quadrant colicky pain, indigestion, and mild transient jaundice

Pancreatitis

Inflammation of the pancreas, causing steady, boring, dull, or sharp pain in the epigastrium, nausea, vomiting, weight loss, steatorrhea, and glucose intolerance

Urinary tract infections

Infections involving the urethra, urinary bladder, or renal pelvis, with symptoms such as frequency, urgency, dysuria, bacteriuria, flank pain, and confusion in older adults

Nephrolithiasis

Formation of stones in the kidney pelvis, causing fever, hematuria, and flank pain that may radiate to the groin and genitals

Temporal pulse

Lateral side of each eyebrow, assess perfusion and pain

Carotid pulse

Medial edge of the sternocleidomastoid muscle in the lower third of the neck, palpate one at a time to avoid reducing blood flow to the brain

Brachial pulse

Palpate groove between the biceps and triceps just medial to the bicep tendon at the antecubital fossa

Radial pulse

Thumb side of the forearm at the wrist, assess together to assess equality

Ulnar pulse

Located on the medial side of the forearm, used when radial pulse is difficult to assess or injured

Popliteal pulse

Artery behind the knee, assess perfusion by placing patient in a prone position with the leg slightly flexed

Posterior Tibial pulse

Inner aspect of the ankle below and slightly behind the medial malleolus

Dorsalis Pedis pulse

Dorsum of the foot between extension tendons of 1st and second toes

Auscultating bruits in the carotid artery

Listen with the bell of the stethoscope, low-pitched blowing sounds indicating turbulent blood flow from an occlusion of the vessel

Assessment of jugular vein pulsations

Elevate head of the bed until pulsations are seen above the clavicle, tilt head away from the side being examined, may indicate right-sided heart failure

Expected findings for rate, rhythm, amplitude, and contour of pulses

Rate: 60-100 beats/min

Rhythm: Regular

Amplitude: 2+ (normal)

Contour: Requires experience

Assessment for orthostatic hypotension

Decrease in SBP of at least 20mm Hg and/or DBP of at least 10mm Hg within 3 minutes of standing, associated with fluid volume deficit, antihypertensive medications, or prolonged bed rest

Assessment technique for skin turgor

Skin should immediately fall back into place, indicating elastic turgor

Assessment technique for extremity symmetry

Extremities should be symmetric in size, skin intact with elastic turgor, warm with appropriate color, pulses regular and smooth, capillary refill

Impaired peripheral pulses

May indicate arterial insufficiency

Assessment to evaluate competence of venous valves

Trendelenburg's test, failure of mechanisms that propel blood back to the heart

Documentation of a heart murmur

Timing, duration, pitch, quality, intensity, location

S3 heart sound

Rapid filling against the ventricle wall, associated with CHF, fluid volume overload, and abnormal ventricular valves

S4 heart sound

Rush of blood heard with atrial contraction against the ventricles, associated with noncompliant or stiff ventricle, hypertrophy, CAD, HTN, MI, aortic and pulmonic stenosis

Heart murmur

Turbulent blood flow, can be systolic or diastolic

Valvular heart disease

Acquired or congenital disorder of a heart valve, resulting in stenotic or incompetent valve

Angina pectoris

Chest pain caused by myocardial ischemia, occurs during activity, stress, or exposure to intense cold

Acute coronary syndrome

Spectrum of myocardial conditions from unstable angina to acute myocardial infarction

Unstable angina

New onset or worsening chest pain experienced at rest

Myocardial infarction

Death of myocardial cells due to sustained myocardial ischemia, commonly affects left ventricle

Left ventricular failure

Increased resistance to blood flow or weakening of left ventricular contraction, causing orthopnea, dyspnea, palpable thrill, S3 heart sound, systolic murmur, and crackles in lungs

Right ventricular failure

Hypertrophy or necrosis of right ventricle, causing peripheral edema, S3 heart sound, systolic murmur, and weight gain

Infective endocarditis

Inflammation of the endocardium caused by bacteria

Pericarditis

Inflammation of the pericardium, causing chest pain aggravated by deep breathing, lying flat, or coughing

Hypertension

High blood pressure, classified into different stages

Venous thrombosis and thrombophlebitis

Formation of a thrombus within a vein, causing dilated superficial veins, edema, redness, warmth, and tenderness

Aneurysm

Turbulent blood flow caused by narrowing of a blood vessel, bruits over the aorta suggest an aneurysm

Skin cancer prevention recommendations

Wear protective clothing, apply sunscreen, seek shade

ABCDEF mnemonic of melanoma

Asymmetry, Border, Color, Diameter, Evolving, Feeling

Hypopigmentation

Complete absence of pigmentation, e.g. albinism or vitiligo

Hyperpigmentation

Increased melanin deposition, e.g. melasma or hemosiderin staining

Expected variations of skin inspection

Pigmented nevi, freckles, patches, striae

Abnormal variations of skin inspection

Melanoma, vitiligo, moles

Clinical significance of cool skin

Associated with shock or hypothermia

Clinical significance of hot skin

Reflects hyperthermia or inflammation/infection

Assessment method for skin temperature

Evaluate using dorsal aspect of hands, should be warm

Clinical significance of diaphoresis

Excessive sweating, may indicate hyperthermia or anxiety

Assessing skin turgor

Pinch skin on forearm or under clavicle, should be elastic

Cause of 'tenting'

Poor skin turgor, may result from dehydration or weight loss

Chronic disease resulting in skin thickening

Diabetes mellitus, due to abnormal collagen from hyperglycemia

Excessively thin or shiny skin

Seen in hyperthyroidism, arterial insufficiency, or aging

Shapes, patterns, and lesions on skin

Round/oval, annular, iris, gyrate, singular/discrete, grouped/clustered, polycyclic, confluent, linear, zosteriform, generalized

Primary skin lesions: Macule

Flat, circumscribed area of color change, e.g. freckles or nevi

Primary skin lesions: Papule

Elevated, firm, circumscribed area, e.g. wart or mole

Primary skin lesions: Patch

Flat, nonpalpable, irregular-shaped macule, e.g. vitiligo or birthmarks

Primary skin lesions: Plaque

Elevated, firm, rough lesion with flat top surface, e.g. psoriasis or keratoses

Primary skin lesions: Wheal

Elevated irregular-shaped area of cutaneous edema, e.g. insect bites or urticaria

Primary skin lesions: Nodule

Elevated, firm, circumscribed lesion deeper in dermis than papule, e.g. dermatofibroma or melanoma

Primary skin lesions: Tumor

Elevated and solid lesion, may or may not be clearly demarcated, e.g. neoplasms or lipoma

Primary skin lesions: Vesicle

Elevated, circumscribed, superficial lesion filled with serous fluid, e.g. varicella or herpes zoster

Primary skin lesions: Bulla

Vesicle greater than 1 cm in diameter, e.g. blister

Primary skin lesions: Pustule

Elevated, superficial lesion filled with purulent fluid, e.g. impetigo or acne

Primary skin lesions: Cyst

Elevated, circumscribed, encapsulated lesion filled with liquid or semisolid material, e.g. cystic acne

Secondary skin lesions: Scale

Heaped-up keratinized cells, flaky skin, e.g. seborrheic dermatitis or pityriasis rosea

Secondary skin lesions: Lichenification

Rough, thickened epidermis due to rubbing or irritation, e.g. chronic dermatitis or psoriasis

Secondary skin lesions: Keloid

Irregular-shaped, enlarging scar that grows beyond wound boundaries, e.g. keloid formation