Physical Assessment Exam 1

4 abdominal quadrants

• RUQ

  • liver

  • gallbladder

  • duodenum

  • head of pancreas

  • right kidney & adrenal gland

  • Hepatic flexure of colon

  • part of ascending colon

• LUQ

  • stomach

  • spleen

  • left lobe of liver

  • body of pancreas

  • left kidney & adrenal gland

  • splenic flexure of colon

  • part of descending colon

• RLQ

  • cecum

  • appendix

  • right ovary & tube

  • right ureter

  • right spermatic cord

• LLQ

  • part of descending colon

  • sigmoid colon

  • left ovary & tube

  • Left ureter

  • left spermatic cord

Solid vs Hollow Viscera

• Solid (shape stays): liver, pancreas, spleen, adrenal glands, kidneys, ovary & uterus

• Hollow organs (depends on whats inside, shape changes): stomach, gallbladder, small intestine, colon, bladder

Peritoneum

• lining & covering

• Parietal Peritoneum: lines the abdominal wall

• Visceral Peritoneum: covers the organs

CVA

Costovertebral angle

• used to asses kidneys

• normal = pt feels a thud but no pain

• abnormal = CVA tenderness = kidney inflammation

Developmental differences: Infants

• Abdomen is protuberant

• abdominal muscles are immature

• liver is relativley larger

• bladder is located higher

• organs are easier to palpate

• umbilical cord = 2 arters + 1 vein

• umbilical hernia: common in infants, more obvious when cry usually disappears by 1 year

Developmental differences: pregnancy

• decrease GI mobility

• longer gastric emptying (results in constipation

• morning sickness, heartburn, Hemorrhoids, enlarged uterus displaces organs, linea nigra, striae

Developmental differences: Aging adult

• relaxed abdominal muscles

• less salivation = bad breath

• delayed esophageal emptying

• delayed gastric secretion

• increased gallstones

• liver gets small

• impaired drug metabolism

Lactase intolerance

• lactase = enzyme needed to digest lactose (milk sugar)

• not enough lactase = gas, bloating & abdominal pain

Abdominal contour

• normal = flat to rounded

• Symmetrical = inspect contour, symmetry, umbilical, skin, pulsation, hair

• Abdmominal distention: gas, ascities, pregnancy, feces, tumor, ovarian cyst

Abdominal assessment order

• inspection

• Auscultation

• Percussion

• Palpation

• listen before percussion/palpation bceuase that can stimulate persistalisis & bowel sounds

Bowel sounds

• Normal = high pitched, gurgling/cascading, irregular, 5-30 times/min

• Hypoactive: low, can occur with abdominal surgery/inflammation

• Hyperactive: high, sounds are loud & high pitched, listen for 5 mins before saying BS are absent

• Tymphany: hallow/drum sound. common over stomach & intestines

• Dullness: sold or fluid. percussion is used to evaluate density & screen for fluid and masses

Abdominal tests

• Mcburneys test: press on mcburneys point in RLQ b/ween top of right hip an umbilicus, when pain is present it suggests appendicitis

• Illiopsoas: pt flex right hip against resistance. Pain suggest appendix inflammation when lifting leg muscle rubs against appendix

• Obturator: flex patients hip & knee to 90 degrees, suggest appendix inflamation puts pressure & rubs against appendix

• Murphy: place fingers under right costal margin & push, pt breathes out and push down, pain suggests gallbladder inflammation (cholecystitis)

• Liver Hook test: hook finger and feel tip of liver

• Spleen test: LUQ should not feel liver

Referred pain

• Liver = RUQ

• Gallbladder = RUQ

• Appendix = RLQ

• Pancreas = midepigastric (radiates)

• Kidney = flank lower abdomen

• esophagus = behind lower sternum

• Ulcer = shoulder

• small intestine = diffuse/generlized

• Colon = colicky + bloating

Intestinal obstruction

• very high yeild

• No gas + no stool + distention

• hx: previous abdominal surgery

• early obstruction = hyperactive BS

• late obstruction = hypoactive/silent bs

Aortic Aneuysm

• usually 2.5 to 4 cm wide

• widened & enlarged aorta

Hepatitis B & C

• screening ages include 18-79

• risk factors: perinatal, enviornmental, sexual activity, drug use

Abnormal findings: Inspection

• Umbilical hernia: bulge at or around the belly button, caused by abdominal tissue pushing through a weak spot in the abdominal wall

• Epigastric hernia: bulge in middle abdomen

• Incisional hernia: bulge that develops through previous surgical incision because the abdominal wall is weakened there

• Diastasis recti: seperation/weakining of abdomnial muscles along midline

• Succussion splash: splashing or gurgling sound heard when the abdomen is gently moved or shaken

• Pyloric stenosis signs: newborn/infant. forecful projectile vomiting accompanied by marked visible peristalsis

Abnormal findings- Ausculation

• Peritoneal friction rub: grating/rubbing sound produced when inflamed abdominal surfaces rub against eachother

• Arterial bruit: whooshing sound over an artery caused by turbulent blood flow

• Venous hum: continous humming sounds caused by blood flowing through a vein

Abnormal findings - Palpation

• enlarged liver: hepatomegaly, liver is enlarged more than normal, may extend below right costal margin

• Nodular liver: enlarged liver with irregular or lumpy/nodular surface instead of smooth surface

• Enlarged gallbladder: large enough to be felt

• enlarged spleen (red flag, easy rupture)

• enlarged kidney

• Aortic aneurysm: widened/enlared of abdominal aorta

  • AAA = abdominal aortic aneurysm if ruptures can cause massive internal bleeding

ischemic vs venostatic ulcer

• Ischemic ulcer: caused by not enough blood flow to the tissue, tissues do not receive oxygen & nutrients to heal. BLOOD CANNOT GET IN

• Venosatic Ulcer: caused by poor venous blood return, causing blood to pool in leg, blood cannot get out

location of pulses

• temoral: temple

• carotid: side of neck

• Brachial: inside of upper arm/antecubital area

• radial wrist, thumb side

• femoral (1st in assessing in legs): just below inguinal ligament

• popiteal (2): behind the knee

• posterior tibial (3): behind the medial malleolus (inside ankle)

• Dorsalis pedis (4): top of foot, lateral to the big toe extensor tendon

pulses

0 - absent

1+ weak

2+ normal

3+ increased/full/bounding

Veins

• carries deoxygenated blood &

• carries waste products away from tissues

• return blood to the heart

• generally run parallel to arteries

• closer to skin surfaces than arteries

• important veins: deep (femoral & popiteal), superficial (great & small saphenous), perforators ( connect the superficial & deep venous system)

How does venous blood move

• low pressure system

• blood is pumped back toward the heart by

  • skeletal muscle contraction

  • pressure changes from breathing

  • intraluminal valves (valves inside veins that help keep blood moving in correct direction towards the heart)

Capacitance

• veins that are called Capacitance vessels because they stretch & hold a large amount of blood

Incompetent valves

• valves that dont work properly & allow blood to flow backward/pool

• dialated tortuous varicose veins are connected with incompetent valves increasing venous pressure & causes further vein dialation

lymph node in the arm

Epitrochlear node (elbow)

axillary nodes (armpit)

spleen

• LUQ, detroys old RBCs, produces antibodies, stores RBCs, filters mircoorganisms from blood

Tonsils

• palatine, lingial, adenoid

• loaced near enterance of respiratory & GI tracts

• repsonds to local inflammation

Thymus

• flat pink gray gland located in the superior mediastinum, behind the sternum & in front aorta

Lymphatic system

• returns excess fluid from tissues to blood stream

• returns plasma proteins to the bloodstream

• helps defend the body against disease/infection

• absorbs lipids from intestinal tract

right lymphatic duct vs thoracic duct

Peripheral Artery Disease

• ongoing

• risk factors: smoking, diabetes, hypertension, high cholesterol, obesity, CKD

• PAD is infleunced by genetic & enviormental/life style factors

Arteriosclerosis

• peripheral blood vessels beocme ridgid & hardened

• aging increasing vascular rigidity

Intermittent claudification

• leg pain or cramping associated with PAD (with activity)

• exercise —> muscles need more oxygen —> inadequate arterial blood supply —> pain/cramping

• Arterial disease: symp r/t oxygen deficit

• Venous disease: symp r/t metabolic waste buildup

edema grading

• to check pitting edema, press firmly over the tibia or medial malleolus for 5 seconds than release

• 1+ mild pitting, slight indentation disappears rapidly

• 2+ moderate pitting, indentation disappears rapidly

• 3+ deep pitting, indentation remains, legs look swollen

• 4+ very deep pitting indentation lasts a long time, leg is grossly swollen/distorted

bilateral vs unilateral edema

• bilateral = swelling in both legs

  • pregnancy can cause diffuse bilateral pitting edema

• unilateral edema

  • swelling affecting one leg

  • can be asscoiated with a venou problem like DVT

Modified Allen Test

• provides information about the adequacy of collateral circulation of the hand

• test of collateral circulation

• checks wether hand has adequate alternate blood flow

Deep Vein Thrombosis

• DVT

• blood clot in deep vein, commonly involving veins of the lebs

• risks: prolonged bed rest, immobilization, HF

• DVT can lead to PE (travels to lungs & blocks circulation)

• watch for: leg cramping, swelling, skin changes & temp/color

Ankle brachial index

• ABI is a non-invasive test to evaluate the extent of PAD

• compares BP in the ankle with the BP in the arm

• it is noninvasive, highly specific, readily availible, used to determine extent of PAD

  • 1.0-1.4 is normal

Well scores & DVT

• used to estimate probability of DVT

• considers findings such as:

  • cancer/malignancy

  • limited mobility

  • leg swelling

  • previous DVT

  • non-varicose vein swelling

  • wether another diagnosis is at least as likely as DVT

• 0 or less = low probability

• 1-2 = moderate

• 3 or higher = high

Arterial vs Venous stasis ulcer

• Arterial (ischemic) ulcer: caused by inadequte arterial flow/oxygen supply

  • PAD abnormality

• Venous (Stasis) ulcer: associate with venous insufficiency

  • difficulty of blood return to heart, venous pressure increases

Abnormalities of arms

Raynaud phenomenom: (vascular)small blood vessels usually in fingers and toes undergo episodes of vasospasms, causing chnages in blood flow and skin color

Lymphedema: swelling caused by accumilation of lymphatic fluid in the tissues when lymph drain isnt working well

Abnormalities of legs

Neupathic ulcers: ulcers associated with nerve damage (decreases sensation in feet)

Superficial varicose veins: enlarged, twisted, visible veins close to the surface of the skin. Venous valves become more incompetent, allowing blood to move backward & increase pressure in veins

Aneurysms: abnormal dialation/weaking of blood vessel

Occlusion: blockage of blood vessel that interferes with blood flow. In an artery occlusion can reduce blood flow to tissues beyond the blockage = ischemia

Heart

• has 4 chambers:

  • right atrium: receives deoxygenated blood returning from the body

  • right ventricle: pumps deoxygenated blood to the lungs

  • Left atrium: recieves oxygenated blood from the lungs

  • left ventricle: pumps oxygenated blood to the body

  • right = receives blood from body and sends it to lungs

  • left = receives blood and sends it to the body

Structure of the heart

• pericardium: protective sac that surrounds the heart

• myocardium: muscular layer of the heart that contracts & pumps blood

• endocardium: inner lining of the heart chambers

Heart valves

• Tricuspid (AV valve): b/ween RA and RV

• Pulmonary (semilunar valve): b/ween RV and pulmonary artery

• Mitral/Bicuspid (AV valve): b/ween LA & LV

• Aortic (semilunar valve): b/ween LV and aorta

• AV valve opens during diastole= allow blood to move from atria to ventricle

• Semilunar valve opens during systole to allow blood to leave ventricles

S1 & S2 sounds

• S1

  • tricuspid & mitral valve close

  • beginning of systole

• S2

  • Aortic & pulmonary valve close

  • beginning of diastole

Electric pathway

SA → AV → Bundle of His/AV bundle → Right & Left bundle branches → Perkinjie Fibers

• Pathway a RBC takes from LV back to heart & RA 

• Blood flow through the heart

Pathway a RBC takes from LV back to heart & RA 

1. LV

2. Aorta

3. Arteries

4. Arterioles

5. Body tissues/capillaries

6. Venules

7. Veins

8. Vena cava

9. RA

Blood flow through the heart

• Deoxygenated blood (blue) 

• Oxygenated blood (red) 

1. Inferior Vena Cava 

2. Superficial Vena Cava 

3. Right atrium 

4. Tricuspid valve

5. Right ventricle 

6. Pulmonary valve 

7. Pulmonary artery (then goes to the left/right lung, and travels back into the the heart to the pulmonary veins) 

8. Left atrium 

9. Mitral valve 

10. Left ventricle 

11. Aortic valve 

12. Aorta 

JVD

• Jugular venous distention

• jugualar veins in neck appear unusually distented/visible

• when sitting up cannot see it laying down (semi fowler)

Small bowel obstruction vs ileus (post surgical)

• SBO: blockage, no gas or stool passing, hyperactive sounds earlier 

• Ileus: sounds are silent, distention, decreased motility 

Is Pernicious anemia due to decreased gastric acid secretion?

• No, it is due to an decrease of intrinsic factor, leading to malabsorption of B12  

sternal angle/angle of louis

• sternal angle (angle of louis) is where manubrium meets the boy o the sternum