PHAS 7050 Exam 2

liver, gallbladder, pylorus, duodenum, head of pancreas, hepatic flexure, R kidney, ascending and transverse colon

RUQ contents

L lobe of liver, spleen, stomach, body and tail of pancreas, splenic flexure, L kidney, transverse and descending colon

LUQ contents

cecum, appendix, ascending colon, R ovary and fallopian tube, R ureter

RLQ contents

sigmoid colon, descending colon, L ovary and fallopian tube, L ureter

LLQ contents

costovertebral angle

angle formed by the 12th rib and the vertebral column on the posterior thorax, overlying the kidney; allows for assessment of kidney pathology

inferior to renal arteries

most aneurysms of the abdominal aorta occur?

iliac arteries

are sometimes palpable in the lower abdomen

femoral arteries

palpable in the groin/inguinal area, palpation dependent on habitus

xiphoid to symphysis pubis

full exposure of the abdomen requires exposure of

supine, knees flexed, feet flat on table, draped appropriately; good lighting

proper approach and positioning for abdominal exam

inspection, auscultation, percussion, palpation, abdominal vasculature

proper sequence of abdominal exam

scars, striae, dilated veins, rashes, lesions, color; pulsations, contour, umbilicus

noted with inspection of abdomen

Cushing's disease

pink-purple striae

portal hypertension (cirrhosis, IVC obstruction)

dilated veins

visible aortic pulsation

can indicate abdominal aortic aneurysm or small size

scaphoid abdomen

flat abdomen

rounded abdomen

protuberant abdomen

ascites

may be indicated by bulging flanks due to free fluid

umbilical hernia

ventral hernia

auscultation

performed first during abdominal exam as bowel sounds may be altered if listening after percussion and palpation; use diaphragm

borborygmi

loud, gurgling bowel sounds signaling increased motility or hyperperistalsis; occurs with early bowel obstruction, gastroenteritis, diarrhea

absent bowel sounds

may be secondary to bowel obstruction, abdominal surgery, paralytic ileus, or peritonitis; listen for minimum 1-2 min/quadrant

bruits

abnormal "swishing" sounds; may indicate vascular stenosis or AAA

flat

heard on percussion over bone or heavy muscle

dull

heard over normal liver or heart, over a lung or abdominal mass, or over a lung area with accumulated fluid

resonant

normal lung sound

hyperresonant

heard when there is air trapping in lung; COPD or pneumothorax

tympanitic

heard on percussion over gastric air bubble

percussion

used to assess amount and distribution of gas, identify masses that are solid/fluid filled, estimate liver size

right mid clavicular line

followed along chest and abdomen when percussing for liver size

tympany to dullness

percussed with lower liver border

resonance to dullness

percussed with upper liver border

light palpation

used to note tenderness, muscular resistance, guarding, and superficial organs and masses

deep palpation

used to delineate masses (location, size, shape, consistency, tenderness, pulsations)

pregnant uterus

may be palpated above the level of the symphysis pubis in the midline; physiologic mass

diverticulitis, AAA, colon cancer, distended bladder, dilated loop of bowel

pathologic/concerning masses found on deep palpation

left hand under the abdomen, right hand over into RUQ

bimanual technique for palpating liver edge

hooking technique

helpful for liver assessment with obese patients

two handed technique

use both hands to palpate edge of liver

right lateral decubitus

used for assessment of spleen

CVA tednerness

indicator for pyelonephritis

size of abdominal aorta

McBurney's Point

RLQ point (1/3 of the way from the ASIS to the umbilicus) tenderness indicative of appendicitis

guarding

contraction of abdominal wall

voluntary guarding

may diminish if patient is distracted

involuntary guarding

will persist, suggests peritonitis

rigidity

involuntary contraction of the abdominal wall from peritoneal inflammation, usually firm, stiff

rebound tenderness

peritoneal inflammation causes increased pain when the examiner takes away his/her hand abruptly

Rovsing's sign

pain in RLQ with palpation of LLQ indicative of appendicitis

referred rebound sign

complaint of pain in RLQ after palpating LLQ and taking hand away abruptly

psoas sign

pain in RLQ with contraction or stretch of psoas muscle

obturator sign

RLQ pain with stretch of obturator (hip flexion and internal rotation)

rectal exam, pelvic exam

always performed on patients with abdominal pain

PID, adnexal inflammation/mass/cysts/abscess

should be considered in F patients

shifting dullness

percuss from area of tympany to area of dullness, turn to R side and percuss again, dullness should shift (dullness indicates fluid presence)

Murphy's Sign

used to test for acute cholecystitis; deeply palpate the RUQ and ask patient to take a deep breath; catching breath or stopping due to pain is positive finding

C7

vertebra prominens, easily palpable at back of neck

ribs 7,8

at level of inferior angle of scapula

just above the clavicle

location of apex of lungs

6th rib, midclavicular line; 8th rib, midaxillary line

location of inferior border of lungs anteriorly

T10

inferior border of lungs posteriorly

T3 spinous process

level of spine of scapula, medial border of oblique fissures

6th rib, midclavicular line

lateral border of oblique fissures

4th rib anteriorly, 5th rib (midaxillary line) posteriorly

horizontal fissure of R lung

Sternal Angle (Angle of Louis)

anterior thoracic landmark where the body of the sternum meets the manubrium; site of tracheal bifurcation into L and R bronchus

T4 spinous process

location of bifurcation of trachea posteriorly

pleurae

serous membranes lubricated with pleural fluid; allow lungs to move easily within ribcage during breathing

visceral pleura

covers outer surface of lung

parietal pleura

line the inner ribcage and upper surface of diaphragm

pleural space

space between visceral and parietal pleura

diaphragm

primary muscle of respiration

scalenes, sternocleidomastoids, pectoralis minor, intercostals

accessory muscles of respiration; indicate respiratory distress

inspection, palpation, percussion, auscultation

order of examination of the thorax and lungs

skin colors, nails (clubbing), tracheal position, shape of chest, thoracic deformities

noted on inspection of thorax

less than

A:P diameter should be (more than/less than) the width of the transverse diameter

barrel chest

increased A:P diameter, indicator of COPD

pectus excavatum

a chest that is hollowed out/funnel chest; congenital

pectus carinatum

forward protrusion of the sternum; pigeon chest; congenital

kyphosis

excessive outward curvature of the spine, causing hunching of the back.

kyphoscoliosis

combination of kyphosis and scoliosis, which may produce a severe restrictive lung defect as a result of poor lung expansion

rate, rhythm, chest wall movement, effort

noted on inspection of breathing

retractions

inward movement of the chest wall (intercostals) with inspiration; usually a sign of respiratory distress

tachypnea

rapid breathing; more than 20 cycles/minute

hyperpnea/hyperventilation

rapid deep breathing

bradypnea

slow breathing; less than 12 breaths/minute

apnea

absence of breathing

Cheyne-Stokes Breathing

hyperpnea alternating with apnea; may be normal in infants

tactile fremitus

palpable vibrations transmitted through bronchopulmonary tree to chest wall; use the ulnar surface of hands/bony palmar surface at base of fingers

increased

fremitus with pneumonia (fluid in lungs)

decreased/absent

fremitus with air trapping (COPD/pneumothorax)

pneumothorax

air in the pleural cavity; may cause unilateral changes when assessing chest expansion

resonant

percussion of healthy lung

flat

percussion of pleural effusion

dull

oercussion of lobar pneumonia

hyperresonant

percussion of COPD, pneumothorax

tympanitic

percussion of large pneumothorax

diaphragmatic excursion

distance that the diaphragm moves with inhalation; percuss on deep breath and exhalation