Winter Quarter 2010Winter Quarter 2010Adapted from previous years by Amanda Kocoloski, OMS IVAdapted from previous years by Amanda Kocoloski, OMS IV

Abdominal ExamAbdominal Exam

Agenda

HistoryAnatomyPhysicalPractice cases

2 gastrointestinal complaintsWork on incorporating GI into history and physical

exam skillsPractice documentation

History

Common Complaints:Abdominal painChange in appetiteDysphagia/Odynophagia

Difficult or painful swallowing

Nausea/VomitingJaundice

Change in bowel habitsMelena/Hematochezia

Dark tarry or red stools

HemorrhoidsAnal pruritis

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Anatomy

Regions (Anatomical) Quadrants (Clinical)

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Surface Anatomy

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Enhancing the Exam

Empty bladderPatient comfort (pillows and draping)Arms at side or crossed over chestAsk the patient to point to any painful areas;

examine lastWarm hands and stethoscopeTicklish or nervous patients: slow movements,

distraction, use their hands

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Exam Order

InspectionAuscultation

Percussion or palpation can alter bowel sound frequency

Bonus Question: What is the medical term for “stomach growling”?Borborygmus

PercussionPalpation

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Abdominal Physical ExamInspection

ContourFlatScaphoidDistendedSymmetry

MovementPeristalticRespirationsAortic pulsation

SkinScars – cicatrixStriaeDiscolorationVenous patternsEdema

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Abdominal Physical ExamAuscultation

4 quadrants15-20 secondsBowel sounds

FrequencyPitch

Vascular SoundsRenalIliacFemoral

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Abdominal Physical ExamPercussion

Notes ElicitedTympanic

Predominant due to gas in GI tractHyperresonantDull

Organs, fluid and fecesFlat

Distension of abdomenFluid vs. Air

Outline OrgansLiver, spleen, and gastric bubble

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Abdominal Physical ExamPalpation

Start farthest from pain and move towards it4 abdominal quadrants

Light palpationDeep palpation

Peritoneal inflammationPain with coughing, gentle palpationInvoluntary rigidityRebound tenderness

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Abdominal Physical ExamPalpation - Left Upper Quadrant

Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left kidney Left suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: superior

part

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Liver: left lobe Spleen Stomach Jejunum and proximal ileum Pancreas: body and tail Left Kidney Left Suprarenal gland Left colic (splenic) flexure Transverse colon: left half Descending colon: superior

part

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Abdominal Physical ExamPalpation - Left Upper Quadrant

Abdominal Physical Exam Palpation - Right Upper Quadrant

Liver: right lobe Gallbladder Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior

part Transverse colon: right half

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Abdominal Physical Exam Palpation - Right Upper Quadrant

Liver: right lobe Gallbladder – Murphy’s sign Stomach: pylorus Duodenum: parts 1-3 Pancreas: head Right suprarenal gland Right kidney Right colic (hepatic) flexure Ascending colon: superior

part Transverse colon: right half

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Abdominal Physical ExamPalpation - Right Lower Quadrant

Cecum Vermiform appendix

McBurney’s point Rovsing’s sign Psoas sign Obturator sign

Most of ileum Ascending colon: inferior

part Right ovary Right uterine tube Right spermatic cord Uterus (if enlarged) Urinary bladder (if full)

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Abdominal Physical ExamPalpation - Right Lower Quadrant

Cecum Vermiform appendix

McBurney’s Point Rovsing’s sign Psoas sign Obturator sign

Most of ileum Ascending colon: inferior

part Right ovary Right uterine tube Right spermatic cord Uterus (if enlarged) Urinary bladder (if full)

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18Walgreens.com

Abdominal Physical ExamPalpation - Left Lower Quadrant

Sigmoid colonDescending colon:

inferior partLeft ovaryLeft uterine tubeLeft ureter: abdominal

partLeft spermatic cord:

abdominal partUterus (if enlarged)Urinary bladder (if full)

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Abdominal Physical ExamPalpation - Left Lower Quadrant

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Sigmoid colonDescending colon:

inferior partLeft ovaryLeft uterine tubeLeft ureter: abdominal

partLeft spermatic cord:

abdominal partUterus (if enlarged)Urinary bladder (if full)

ExtrasAbdominal AortaInguinal Lymph NodesCostovertebral angle (CVA) tenderness

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Abdominal Physical ExamPractice- 20 Minutes

• Inspection– Contour– Skin– Movement

• Auscultation– Bowel sounds– Vascular sounds

• Percussion– Abdomen for masses or fluid– Liver span– Spleen– Gastric bubble

• Palpate– General palpation– Liver– Gallbladder– Spleen– R and L kidneys– Abdominal aorta– Inguinal lymph nodes

• Special:– Murphy’s sign– McBurney’s point– Rovsing’s sign– Psoas sign– Obturator sign– Rebound tenderness– CVA tenderness

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Practice Cases

• 45 minutes

Practice Documentation

• 15 minutes

Questions?

Have a great winter break!