Chapter 22- Abdomen nur 319

Inspection: uniformly rounded; **umbilicus sunken (i**t 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.** 

obesity

Inspection: **single round curve** 

Auscultation: **depends of cause of gas (decreased or absent bowel sounds) hyperactive with early intestinal obstruction**. 

Percussion: tympany over large area 

Palpation: **May have muscle spasm of abdominal wall.** 

air/gas

• Inspection: Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin due to recent weight gain and 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 dullness.

• Palpation- Taut skin and increased intra-abdominal pressure limit palpation.

ascites

**Inspection:** __**Curve in lower half of abdomen**__**, toward midline. Everted umbilicus.** 

**Auscultation:** Normal bowel sounds over upper abdomen where intestines pushed superiorly. 

**Percussion:** **Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wave and shifting dullness.** 

**Palpation:** __**Transmits aortic pulsation, whereas ascites does not.**__ 

ovarian cyst (large)

**N&V or “morning sickness”, heartburn (pyrosis), GI motility decreases leading to constipation**

**diminished bowel sounds**

**fetal heart tones**

**tympany over intestines but dull over enlarging uterus**

**uterine fundus, fetal parts and fetal movement upon palpation**

pregnancy

localized distention

tympany predominates with scattered dullness over fecal mass

plastic like or ropelike mass with feces in the intestines

feces

localized distention

dull over mass if reaches up to the skin surface

has defined borders with palpation that is distinguished from enlarged organ or normally palpable structure

tumor

• Marked visible peristalsis, together with a distended abdomen

• Bowel sounds are hyperactive in early obstruction & hypoactive in late obstruction

• Symptoms include vomiting, fever, absence of stool or gas passage, & colicky pain from strong peristalsis above the obstruction

• Abdomen is distended & tender to palpation

intestinal obstruction

mild-to-moderate dull pain in the upper right quadrant (RUQ), epigastrium, anorexia, nausea, malaise, low-grade fever. Referred pain in the shoulder.

referred abdominal pain of the liver

burning pain in midepigastrium or behind lower sternum that radiates upward or “heart burn” 30-60 minutes after eating 

referred abdominal pain in the esophagus

sudden pain in the RUQ that may radiate to scapula and builds over time, lasts 2-4 hours after ingestion of fatty foods, alcohol, or caffeine. Associated with nausea and vomiting, a positive Murphy sign, or sudden stop in inspiration with RUQ palpation

referred abdominal pain in the gallbladder

Acute, boring midepigastric pain radiating to the back and sometimes to the left scapula or flank; severe nausea & vomiting. 

referred abdominal pain of the pancreas

Duodenal ulcer typically has dull, aching, gnawing pain; does not radiate; may be relieved by food; and may awaken the person from sleep. 

referred abdominal pain of the duodenum

dull, aching, gnawing epigastric pain (midline), 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

referred abdominal pain of the stomach

RLQ pain to palpation with maximal tenderness occurring over McBurney’s point. 

**Kidney**- Sharp pain occurs in RLQ and LLQ or paranephric area. 

referred abdominal pain of the appendix

Generalized abdominal pain in all 4 quadrants, with nausea and diarrhea.

referred abdominal pain of the small intestine

colicky pain gradually onsets in lower abdomen with bloating.

referred abdominal pain of the colon

Soft, skin covered mass. The protrusion of the omentum or intestine through a weakness or incomplete closure in the umbilical ring. It is worsened by increased intra-abdominal pressure like crying, coughing, or vomiting 

umbilical hernia

A bulge near an old operative scar. The hernia may not be seen when supine but is apparent when a person increases intra-abdominal pressure by sitting up or standing.  

incisional hernia

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. 

epigastric hernia

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. Usually it is not clinically significant. 

diastasis recti

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.

succussion splash

diminished or absent bowel sounds signal decreased motility

hypoactive bowel sounds

loud, gurgling bowel sounds (borborgmi) signal increased motility

hyperactive bowel sounds

A rough, grating sound, like two pieces of leather rubbed together, indicates peritoneal inflammation.  

peritoneal friction rub

Indicates turbulent blood flow, as found in constricted, abnormally dilated, or tortuous vessels. __**Listen with the bell.**__ Occurs with: aortic aneurysm, renal artery stenosis, and partial occlusion of femoral arteries. 

bruit

Heard in periumbilical region. Medium pitch, continuous sound, pressure on bell may obliterate it. Occurs with portal hypertension and cirrhotic liver. 

venous horn

Occurs with fatty infiltration, portal obstruction or cirrhosis, high obstruction of inferior vena cava, and lymphocytic leukemia. 

\-Liver feels __**enlarged and smooth but is tender to palpation**__ with early heart failure, acute hepatitis, or hepatic abscess.  

enlarged 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 easily palpable.  

enlarged nodular liver

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.**__ 

 

\-An __**enlarged, nontender**__ gallbladder also feels like a smooth, sausage-like mass. It occurs when the gallbladder is filled with __**stones**__, as with common bile duct obstruction. 

enlarged gallbladder

occurs with acute infections (mononucleosis), it is moderately enlarged and soft, with rounded edges. When the result of a chronic cause, the enlargement is firm or hard, with sharp edges. Usually not tender to palpation; it is tender only if the peritoneum is also inflamed

enlarged spleen

Enlarged with hydronephrosis, cyst, or neoplasm. Can be confused with Spleen enlargement. Extends forward and down. No sharp edge. Kidney has no palpable notch. Percussion over the kidney is tympanitic because of the overriding bowel. 

enlarged kidney

(>95%) are located below the renal arteries and extend to the umbilicus. A focal bulging >5 cm is palpable and feels like a pulsating mass. Bruit. Femoral pulses are present but decreased.  

aortic aneurysm