Chapter 22: Abdominal Assessment

Chapter 22: Abdominal Assessment GI/GU Link · shared autonomic and somatic (S2-S4) innervation · bowels affect bladder · shared signs and symptoms: ↳ nausea & vomiting ↳ diarrhea ↳ abdominal discomfort/distention ↳ difficult to diagnose · Pain: ↳ Kidney: costovertebral angle ↳ bladder: suprapubic ↳ ureteral: costovertebral angle, flank, lower abdominal, testis or labia ↳ prostatic: perineum and rectum ↳ urethral: along penis to meatus or urethra to meatus Focused Health History · pain · nausea and vomiting · dysphagia · diet patterns · regurgitation, GERD, peptic ulcer disease... · change in bowel habits · hemorrhoids Physical Assessment · colonoscopy ① Inspection · jaundice, pruritus ② Auscultation · family history ③ Percussion · travel history ④ Palpation - - - - * ① Inspection · positioning: ↳ supine unless pregnant (then roll under right side) ↳ expose entire abdomen and drape accordingly & explain throughout assessment · skin (colour, veins, moisture, temperature, scars etc) · overall impression (size, shape/contour, symmetry, etc. ) · umbilicus · deep inhale → assess movement, symmetry, masses · also: ↳ urine (500mL per day! ) ↳ BM (Stool) ↳ emesis? Urine Output/Fluid Balance · We lose water through sweat, activity, exhaling, urine & feces · adequate intake depends on gender, age, air temperature, activity etc. · adults need a minimum of 1500mL/day · children have a weird fluid rule · red flag oliguria: ↳ < 1 mL/hr infants ↳ < 0.5 mL/hr children ↳ < 500mL/day adults Jaundice Ascites · > 500mL of extravascular peritoneal fluid · confirm with 'Shifting dullness' percussion · assessment with ultrasound Hernias · assess while patient is standing ② Auscultation · bowel sounds indicate bowel motility ↳ diaphragm of stethoscope ↳ RLQ and proceed clockwise in all quadrants ↳ listen for clicks, gurgles and occasional borborygmi (growling) · normal: ↳ Peristalsis sounds ↳ 5-30 sounds per minute ↳ RLQ most active b/c ileocecal valve · No sounds? Do 5 min auscultation in same place - · Bruits? ↳ indicates hypertension or narrowing of arteries from atherosclerosis ↳ aorta (midline) ↳ renal arteries (RUQ & LUQ) ↳ iliac arteries (RLQ & LLQ) ③ Percussion · Percussion is used to determine organ size and tenderness ↳ it also defects any fluid, air, or masses in the abdominal cavity · Liver: anterior percussion · spleen: anterior percussion · Kidneys: posterior percussion · Ascites presence → shifting dullness · tympany should be heard over most of the abdomen * Liver Percussion 1. Percuss from RMCL (right midclavicular line), 3rd ICS and move down ↳ note when dullness begins (liver is dull) 2. percuss from RMCL at umbilicus and move up ↳ note when dullness begins · Mean Liver size by percussion: ↳ 7cm women ↳ 10.5cm men · Normal finding: dullness (liver) between 5-7th ICS Splenic Percussion · supine position and elevate left arm · expected findings: 8-10 cm in left axillary 9-11th rib · Castell's method: ↳ find last intercostal space, left anterior axillary line ↳ first percuss on inspiration, then percuss on inhalation - expiration: resonant or tympany - inspiration: positive it dull, expected is resonance or tympany Kidney Percussion · at costovertebral angle posteriorly while patient is sitting · normal finding: no tenderness ④ Palpation · light palpation ↳ 1-2 cm depression ↳ use finger pads & dipping motion ↳ RLQ and proceed clockwise ↳ note any guarding, masses, or tenderness · deep palpation ↳ murphy's sign (RUQ): gallbladder disease RLQ ↳ rosving's sign (rebound tenderness): appendicitis A pain ↳ liver (RUQ) ↳ spleen should not be palpable Splenomegaly: do NOT palpate if you suspect enlarged spleen - - Palpation Tips # · if tensing muscles: ↳ bend knees ↳ palpate on expiration · ticklish: hand over yours · if you note a mass in the suprapubic region its likely a full bladder Palpation of Inguinal Nodes · gloves! · horizontal nodes · vertical nodes · expected findings: non-tender and slightly palpable, < 2 cm Horizontal nodes Vertical nodes Rectum & Stool · inspection: ↳ anus (fissures, fistulas, hemorrhoids, tumors, warts) ↳ Stool · palpation: ↳ sphincter tone, stenosis, blood, mucous, polyps, masses ↳ digital rectal exam (use lots of lube, feel for smooth walls, prostate, check finger after) Further Tests: · Blood Work · FIT (fecal immunochemical test) · ultrasound · Colonoscopy · CT scan · MRI - Expected Findings: · abdomen is flat (rounded) with active bowel sounds, soft, non-tender; no masses or hepatosplenomegaly. Liver span is 6 cm (6-12cm) in the MCL Red Flags · Rebound tenderness = more pain when palpation is withdrawn · Appendicitis ↳ pain at umbilicus toward RLQ (McBurney's Point) ↳ Rovsing sign: deep palpation in LLQ, quick withdraw of this stimuli elicits rebound tenderness in RLQ · Peritonitis ↳ abdominal surgery ↳ ectopic pregnancy ↳ perforation (trauma, ulcer, appendix, diverticulum)