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Common signs & symptoms
Common What is causing it? Life-threatening?
Sudden onset of abdominal pain Indicates peritoneal irritation
Gastrointestinal System Renal or Urinary System Reproductive System
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The Abdomen (2 of 2)
Description of Abdominal Pain
Local General or diffuse Referred Colic
Erosion of the stomach or intestinal lining.
Epigastric or abdominal pain Hematemesis – blood in emesis
Bright red Coffe ground
Protrusion of tissue through body wall
pain red or blue skin discoloration incarcerated can be serious medical emergency
enlarged blood vessels in the esophagus
that can rupture
massive bright red bleeding (oral) Shock
Hx of liver disease or ETOH abuse
A blockage of the bowel lumen prohibiting
the passage of material
Hx of recent abdominal surgery constipation colicky abdominal pain abdominal distention Nausea/Vomiting
Inflammation of the
fever anorexia N/V RLQ pain Rebound tenderness
Inflammation of the
Gallstones? recent ingestion of fatty food? RUQ pain gradual onset not colicky pain
Calculi in the kidney
severe flank pain maybe colicky restlessness nausea & vomiting
Urinary Tract Infection (UTI)
Bacterial infection in the urinary tract
Lower abdominal pain Pain and/or burning with urination Hematuria Urgency and frequency
Inflammation of the kidney
Flank pain Pain and/or burning with urination Hematuria Fever
Pelvic Inflammatory Disease
The inflammation of the
Dull RLQ or LLQ pain abnormal vaginal discharge nausea & vomiting fever
Embryo gestation outside uterus (usually
RLQ or LLQ pain late LMP may have vaginal bleeding shock
Inflammation of the peritoneum Generalized abdominal pain Fever Rigid abdomen Nausea and/or vomiting Distention
Dissecting Abdominal Aortic Aneurysm
develops between arterial
shearing/tearing abdominal pain sudden onset shock unequal femoral pulses
all pain is not the same SAMPLE or HAM nausea, vomiting, diarrhea anorexia fever weakness or syncope
The physical exam
observe for distention palpate for TRPGR check all 4 quadrants start away from
Always consider a gynecological problem
with women having abdominal pain
Pregnant? LMP Normal? Prior gynecological problems
(NG tubes) gastrointestinal tube (GI tubes) colostomy / illeostomy
Pain “heartburn” Signs of shock And the following types of bleeding
Bright red rectal bleeding
indicates bleed close to anus.
obvious sign ( not subtle ) minor bleeds usually hemorrhoid
Dark, tar-like stools Lower GI bleed
Can be only indication of GI bleed
can represent significant blood loss
Coffee ground emesis
Partially digested blood
chronic stomach or duodenum
Bright red emesis
upper Gi bleed above stomach
Think Esophageal varices Can be severe
Enlarged blood vessels near the anus.
Rectal pain bleeding
Examination of Abdomen
Position of the patient: the patient should lie flat, with one pillow under the head in order to relax the muscles of abdominal wall. Exposure: abdomen should be exposed from xiphisternum to the pubis.
Shape of abdomen: • Normally full • Scaphoid: a sunken abdomen due to starvation or wasting disease • Protuberant: due to fat (gross obesity), fetus (pregnancy), flatus (gaseous distension due to intestinal obstruction), fluid (ascites). Symmetry: • Normally symmetrical • Asymmetry due to visible bulge due to hepatic, splenic and kidney enlargement or a tumour. Bulging may be central due to uterus, bladder or ovary enlargement.
Movements: •Normally moving equally with respiration •Respiratory movement of the abdomen usually cease in the presence of acute peritonitis. Umbilicus: •normally central and inverted •Placed upward due to pregnancy and huge ovarian cyst •Flat or everted due to ascites. Prominent veins: •Collateral veins visible due to IVC obstruction due to tumour or thrombosis, the direction of flow is upwards towards heart. •Collateral veins due to cirrhosis radiate from umbilicus forming Caput Medusa, the direction of flow is downwards towards the leg below the umbilicus. Skin: •Look for previous surgical scars, striae and pigmentations •Striae may be due to pregnancy, ascites, recent weight loss and Cushing’s syndrome.
Pulsations: •Usually transmitted from the abdominal aorta •Less frequently caused by right ventricle, the liver or an abdominal aneurysm. Peristalsis: •Prominent in small intestinal obstruction •May be visible as slow way of movement passing across the upper abdomen from left to right in pyloric stenosis •They may be present normally. Hernias: •Look for incisional, epigastric, umbilical, femoral and inguinal hernias. Inspection of abdomen at eye level: Squat down beside the bed so that the patient’s abdomen is at eye level, ask him to take slow and deep breaths through mouth and watch for any evidence of asymmetrical movement, indicating the presence of mass such as enlarged liver and spleen.
General principles: • Ensure that the examining hands are warm. • If patient is in a low bed, sit on, or kneel beside, the bed. • Ask the patient if any particular area is tender and examine this area last. • Encourage the patient to breath gently through the mouth. • If necessary, ask the patient to bend the knees to relax the abdominal muscles. Palpation can be divided into three phases: 5. Light 6. Deep and during 7. Inspiration Light palpation: Object: to note tenderness, guarding, rigidity and lump. Method: • Place the examining hand on the abdomen and thereafter maintain continuous contact with the patient’s abdominal wall. • Note the tenderness and lumps in each region.
Deep palpation: Object: to detect deeper masses and to define those already discovered. Method: • palpate the abdomen with the flat of the hand. If a mass is discovered describe its characteristics such as, • Site, size, tenderness. • Surface which may be regular or irregular. • Edges: regular/irregular • Consistency: hard/soft. • Mobility and movement with inspiration. • Pulsatile or not. • Whether one can get above the mass. Palpation during inspiration: The liver, spleen, kidney and gall bladder should be examined during inspiration. The key success in visceral palpation is to keep the examining hand still and wait for the organ’s edge to descend and strike during inspiration.
How to palpate liver?
• Place the hand flat on the abdomen with the fingers pointing upwards and position the sensing fingers (middle and index) lateral to the rectus muscle.
Press the hand firmly inward and upward and keep steady while the patient takes a breath through the mouth.
If the liver edge is palpable describe its character such as sharp or round, hard or soft, regular or irregular and non-tender or tender. Causes of tender hepatomegaly are hepatitis, liver abscess and congestion due to right heart failure.
Measuring Liver Span
Percuss from the fourth intercostal space downward and mark the upper border of liver identified when percussion note becomes dull from resonant, usually at the level of sixth rib. Now percuss from right iliac fossa upwards and mark the level where the lower border of liver is palpable. Measure this span that is usually less than 12.5cm. Span increases in hepatomegaly and decreases in cirrhosis. Liver may be palpable without hepatomegaly due to downward descent due to hyperinflation of lung in asthma and COPD.
How to measure spleen?
• • • Place the examining hand on the anterior abdominal wall with the fingertips well below the left costal margin, pressing inwards and upwards. Ask the patient to take deep breath, if spleen is enlarged it will hit the fingers during inspiration. If the spleen is not palpable, the patient must be rolled on the right side towards the examiner with left hip and knee flexed and palpation is repeated with the right hand while the left hand of examiner compressing left lower costal margin downwards. If spleen is still not palpable examine the patient from the left side, curling the fingers of the examining hand under the left costal margin as the patient breathes in deeply. Spleen can be palpated by hooking method while standing on the left side of the patient.
How to measure kidney?
• • • • • • Use a bimanual technique to palpate the kidneys. Place one hand posteriorly below the lower rib cage and the other over the upper quadrant anteriorly. Push both hands together firmly and feel the lower pole moving down between hands as the patient breathes in deeply. Push kidney back and forwards between the two hands- this is known as balloting. Assess the size, surface and consistency of palpable kidney. Examine the left kidney.
1. Percussion: Object: • To differentiate between abdominal distension due to ascites, gas, cystic or solid tumour. • To define the size and nature of organs and masses. General principles: • Percuss from resonant to dull area. • Percuss the upper border of liver, and then measure the liver span. Thrill: To detect the thrill, place a detecting hand on the patient’s flank; flick the skin of the abdominal wall over the other flank using the forefinger. Shifting dullness: • Percussion should be started in the midline (with the fingers pointing towards the feet) then continue percussion towards the flanks until a dull note is obtained. • Keep the finger in place as the patient rolls to the other side. • Pause for about 10seconds and percuss again. Ascites is suggested if the note becomes resonant and confirmed by obtaining a dull note while percussing back towards the umbilicus.
4. Auscultation: • Place the diaphragm of stethoscope just below the umbilicus and ascultate for peristalsis bowel sounds for at least 3 minutes before deciding that they are absent (i.e. paralytic ileus) Auscultate liver for bruit present in hepatoma. Auscultate for renal bruit on either side of midline above the umbilicus, it may be present in renal artery stenosis. Auscultate over the aorta for bruit.
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