LCCW Ab Thorax: Midterm 1

What is the sequence of examination for the abdomen?

HIIPPRONEL

*normally HIPPIRONEL...but for abdomen the second "I" moves up before the "Ps"*

___________ & ___________ are the 2 light positions required for inspection.

Overhead & Tangenital (from the side)

Yellow coloured skin w/ yellow sclera is ___________ & indicates

Jaundice

Diffuse blue-grey skin that is darkened by the sun suggests ___________.

silver toxicity

Diffuse blue-grey skin w/ 2-10 mm dark macules suggests ___________.

arsenic toxicity

Genetic condition found in alkaptonuria in which homogentisic acid is deposited in the connective tissue creating darkeing in the pinna, nose, sclera, & other cartliage is called ___________.

ochronosis

___________ is a condition of excess iron storage that causes blue-grey, bronze or black skin discolourization that darkens in sun.

Hemochromatosis

A cicatrix is a ___________.

scar

Striae are ___________.

stretch marks

New stretch marks are ___________, and old stretch marks are ___________.

red/pink; white/silver

Violaceous/purple stretch marks suggest ___________.

Cushing's Syndrome (too much cortisol)

*large stripes on abdomen*

Ecchymosis is ___________.

bruising

Periumbilical ecchymosis is called ___________ sign.

Cullen's

Ecchymosis around the flank is called ___________ sign.

Gray Turner's

Cullen's & Gray Turner signs suggest what condition?

hemorrhagic pancreatitis

Varicose veins around the umbilicus are called _____________ & indicate _____________.

caput medusa; portal hypertension

A firm nodule near the umbilicus is called _____________ & indicates _____________.

Sister Mary Joseph; metastatic GI cancer

_____________ is a division of the linea alba (rectus abdominus).

Diastasis recti

*can only be seen when pt lifts head & shoulders off table*

Diastasis recti can be seen in _____________, _____________, or _____________.

infants; pregnancy; obesity

Name 4 common locations for hernias.

1. umbilicus

2. epgastric

3. inguinal

4. surgical sites

_____________ hernia's in infants usually close in 1-2 years.

Umbilicus

*DO NOT CLOSE IN ADULTS*

What are the 6 F's of Abdominal Distention?

Fat

Flatus (gas build up)

Fetus (pregnancy)

Fluid (ascites)

Fatal Growth (tumor)

Fibroids (females) & Feces (male & females)

...it's really 7 F's...

_____________ are common benign fatty tumors.

Lipomas

A bulging flank suggests _____________.

ascites

Yellow skin w/ white sclera indicates _____________.

Carotenemia

*too much beta-keratine*

When auscultating the abdomen, listen w/ the ______________ of the stethoscope.

diaphragm

Where do you auscultate for bowel sound?

START at right lower quadrant

______________ per minute is the normal rate of bowel sounds.

5-34 per minute

*must auscultate for 5 mins to determine if absent*

Absent bowel sounds are known as ______________.

paralytic ileus

Paralytic ileus suggests ______________ or ______________.

late obstruction or generalized peritonitis

*examples of late obstruction: chrons, hirsprungs, fecal compaction, intussception, volvulus*

Increased bowel sounds are known as ______________ and indicate ______________.

hyperperistalsis; diarrhea/early obstruction

High pitched, intermittent rushes of sound in bowel suggest ______________.

partial obstruction

There are ______________ locations to auscultate over abdominal arteries.

7

When listening over an artery, the normal sound is ______________.

NOTHING

A whooshing sound over the arteries is a ______________.

bruit

*obstruction ie. plaque/aneurysm*

The auscultation point for the ______________ is ______________ way between the xiphoid & umbilicus.

aorta; 1/2 to 2/3

Laterally to the aorta & below the ribs you can auscultate the ______________ bilaterally.

renal artery

*medial to lower ribs -- test for hypertension*

The auscultation point for the ______________ is half way b/w the ASIS & and the midline.

iliac artery

What are the 2 locations the femoral arteries can be auscultated?

above the mid point of inguinal ligament (abdomen)

&

below mid point of inguinal ligament (thigh)

What 2 organs do we listen for bruits & friction rubs over?

spleen (LUQ -- inf'r costal margin)

&

liver (RUQ -- sup'r costal margin)

What are the patient breathing instructions for listening for bruits?

sm inhale & hold breath

What are the breathing instructions for listening to friction rubs?

take deep breaths

*want to move organs around*

What causes friction rubs?

infection

trauma

infarction

tumor

Bruits indicate ___________.

stenosis/obstruction

Friction rubs indicate ___________.

inflammation of organ capsule (peritoneal surface)

The thigh has a ___________ tone.

flat

*patho = massive pleural effusion*

The liver has a ___________ tone.

dull

*patho = tumor/lobar pneumonia*

A normal lung has a ___________ tone.

resonant

*patho = simple chronic bronchitis*

T/F: There are NO normal hyper-resonant tones in the body.

TRUE

Hyper-resonant tones are found in ___________ pathologies.

emphysema

The abdomen has a ___________ tone.

tympany

*patho = pneumothorax*

How is the patient seated for abdomen percussion?

supine w/ knees bent

What is the dominant percussion tone in the 4 quadrants of the abdomen?

tympany

A dull percussion tone over the midline of the lower abdomen indicates: ___________, ___________, ___________, or ___________.

full bladder, pregnancy, tumor, or fluid

A dull percussion tone over gastric area might indicate a ___________.

tumor

What is the normal percussion tone over the liver?

dull

The liver is percussed over the ___________ & ___________ lines.

mid-clavicular & mid-sternal

Normal liver measurement is ___________ at the mid-clavicular line & ___________ at the mid-sternal line.

6-12 cm; 4-8 cm

What are the breathing instructions for percussion of the liver?

deeply inhale & hold breath

Percussion for the spleen over the ___________ at the ___________ line.

10th intercostal space; ant'r axillary line

What are the breathing instructions for percussing the spleen?

1) patient exhales -- examiner begins percussing

2) patient inhales deeply -- examiner continues percussing

A ___________ tone is a (+)/abnormal percussion finding for the spleen.

dull

*normal = tympany*

A dull spleen tone indicates a ___________.

splenomegaly

Name 3 reasons for a (+)/abnormal splenic percussion sign.

1. mononucleosis

2. inc. RBC destruction

3. malaria

Always percuss before palpating the spleen to avoid ___________.

rupturing enlarged spleen

When palpating the examiner always stands on the patient's ___________.

RIGHT

What is the one exception to standing on the right?

LEFT KIDNEY -- stand on the patient's left

For superficial palpate: gently/thoroughly palpate all 4 quadrants feeling for ___________, ___________, & ___________.

pain, nodules, & guarding

___________ guarding decreases on exhalation.

Voluntary

___________ guarding persists despite relaxation maneuvers.

Involuntary

Involuntary guarding suggests ___________.

peritonitis

Exquisite tenderness throughout abdomen & board like muscular rigidity suggest ___________.

generalized peritonitis

*localize pain by having pt cough -- palpation for rebound tenderness begins AWAY from tender area*

The ___________ sign is synonymous w/ rebound tenderness -- pain is inc. on rapid withdrawal of pressure (Bouncing on area of abdomen).

Blumberg

*area of tenderness = location of peritoneal inflammation*

The ___________ sign is when pRessing on the lower left quadrant increases tenderness in the lower right quadrant.

Rovsing

Rovsing sign suggests ___________.

peritonitis

___________ point is located just below the middle line connecting the umbilicus to the ASIS.

McBurney's

*textbook location of tenderness in appendicitis*

Name examples of localized peritonitis:

appendicitis

diverticulitis

pancreatitis

cholecystitis

duodenal ulcer

How must the knees be positioned for deep palpation?

bent -- softens the abdominal wall

T/F: Masses in the abdominal wall disappear when a patient raises their head & shoulders.

FALSE -- will remain palpable

*intra-abdominal masses are obscured by muscular contraction*

A ___________ is an example of a physiological mass.

pregnant uterus

___________ are examples of inflammatory masses.

inflamed diverticula or chron's dx

___________ are examples of vascular masses.

aortic aneurysm or angioma

A ___________ is an example of a neoplastic mass.

tumor

_____________ are examples of obstructive masses.

obstructed bladder & impacted feces (LLQ)

What are the 2 methods of liver palpation?

1) Direct Method

2) Hooking Method

For the direct method the doctor is positioned facing the patient's _____________.

head

*angled 45 degrees*

Direct Method: doctor's left hand is placed _____________.

under patients RIGHT rib cage

*helps to lift liver up towards palpating hand*

Direct Method: What are the breathing instructions?

have pt inhale deeply (while you push up towards pt ribs) & hold

*use small circular motion to explore entire lower liver margin*

For the hooking method of liver palpation the doctor is positioned facing the patient's _____________.

LEFT foot

The Hooking Method uses the _____________ maneuver.

Middleton

*patients first is placed under their rib cage*

Hooking Method: What are the breathing instructions?

deep inhale & hold

*take both hands -- hook fingers & pull up*

What is the normal liver margin like?

soft, regular, & smooth

*not tender to the touch*

Cirrhosis:

Tender (Y/N)?

Nodules (Y/N)?

Texture _____________.

Margin _____________.

Tender -- NO

Nodules -- YES

Texture -- firm/hard

Margin -- regular or irregular

Hepatitis:

Tender (Y/N)?

Nodules (Y/N)?

Texture _____________.

Margin _____________.

Tender -- YES

Nodules -- NO

Texture -- soft

Margin -- smooth

Cancer:

Tender (Y/N)?

Nodules (Y/N)?

Texture _____________.

Margin _____________.

Tender -- YES or NO

Nodules -- YES

Texture -- hard

Margin -- irregular

The gallbladder is located in the _______________.

RUQ

Who is at risk for gallbladder issues?

sedentary, middle aged, and overweight people

To palpate the liver, the examiner feeds their palpating hand under the ribcage on the patient's _______________.

exhale

*Dr. keeps pressure on the gallbladder as the patient INHALES*

Gallbladder palpation is (+) if a patient _______________ during palpation.

stops inhalation

The cessation of breath during gallbladder palpation is known as the _______________ sign.

Murphy's

*NOTE: this is different than Murphy's punch (tap) -- seen in the kidneys*