Exam V: Abdominal Flow

Kidney is band like effect of pain

Ureter innervation causes the pain to feel like it can range from the back to the labium majora

Where 12th rib meets vertebral column = kidney location

1. Introduce yourself; be clear you are a medical student

2. Tell them Dr. _____ will be in afterwards

3. Wash hands

4. Ask permission to do exam

5. Ask patient if they have anymore questions

6. Thank the patient

Usually have a sheet over hips and legs area EVEN WHEN WEARING PANTS/SHORTS
Simple way to show respect
Stand on right side of supine patient!!!! *** = for consistency purposes!
Liver is close and spleen is farther away
Make sure pants are pulled down to ASIS

Flat
Scaphoid- little body fat and muscles make shovel appearance
Distended/Protuberant

Peritoneum – primarily soft and smooth providing lubrication and protection
Fascia holds bodily organs inside, or hernia occurs

1. Semilunar= spagalia

2. Incisional hernia from weakness of tissues in that location

3. Femoral canal: where vessels and nerves that exit and go into the leg; can herniate

4. Epigastric hernia

5. Umbilical hernia

Have them flex head at waist (semi sit up) with shoulders lifted and that will cause intra-abdominal pressure to visualize hernias if present

Anterior abdominal can become weak especially during weight gain = hernias

Ridge – see the bulge/rectus diathesis = not a hernia; needs weight loss and exercise

Clicks and gurgles

Borborygmus: Rumbling of the large bowel

Should not be used for counting, only used for distinguishing sounds in sick patients

Hypoactive: ileus, peritonitis (must auscultate for 2 minutes)
Normoactive: 5 to 34 per minute
Hyperactive: diarrhea, early obstruction

Borborygmi: absence with ileus (paralyzed bowel), and increases with obstruction

High-pitched tinkling: intestinal air and fluid under high pressure in a dilated bowel
Bowel separates solid, liquid, and gases, so if mixed = abnormal

Rushes of high-pitched sounds concurrently with cramping: obstruction

Rare
Systolic and diastolic
Indicates increased collateral circulation between portal and systemic venous systems
Hepatic cirrhosis

Rare
Grating which occurs with respirations
Indicate inflammation of peritoneal surfaces
Tumors, infection, abscess, splenic infarct

Assess resonance
Dullness: increased with mass, organomegaly
Tympanic: predominates, gastric bubble
Hyperresonant: obstruction

Can use percussion to find where the liver is located; intestines (less solid), kidneys, etc. are underneath

Bladder height CANNOT be percussed because in pelvis, unless patient has had gradual enlargement of bladder or full with incontinence
Therefore if you can palpate the bladder, this is ABNORMAL

Use distraction
Watch facial expression for grimace
Flex hips and knees if abdomen is tense

Light palpation (think skin and sub Q tissues) = 0ne hand using finger pads for tenderness, masses
Deep palpation (think abdominal organs) = two hands, one on top the other

Tenderness
Masses
Hepatomegaly/masses: begin in the RLQ and work cephalad to the right costal margin and use rolling hand technique

Kidney- won’t feel kidneys unless issue

Uterine height: not palpable, unless pregnant or fibroids; gestational age can be determined by height of uterus

Bladder distension

Size of the aorta- Feel aorta pulsation to approximate size; enlarged = far more palpable than normal aorta

Begin at the umbilicus and work diagonally to the left costal margin

May use posterior lift

Spleen is behind the stomach and above the left kidney

The fingers must press more firmly

Left hand under patients ribs and push up to right hand =get better impression of spleen

Enlarged spleen is only time is it palpable

Guarding

Rigidity

Rebound

Ask patient which hurts more:

1. Pushing in: push in slowly but deeply OR

2. Letting go: suddenly lift hand from depressed position

Should be a significant difference

Fluid Wave

Patient is supine

Place lateral hands down the abdomen centrally (inhibits transmission through adipose)

Tap one side and feel for transmission in opposite hand

Special tests for those with liver failure

By reducing the proteins made by liver, then fluid leaks into the intra-abdominal wall

Someone holds skin while someone else palpates the right and left sides

If fluid accumulation then easily movable from side to side = severe liver failure, but not much movement probably just ate too much

Murphy’s sign = cholecystitis related

After determining tenderness in right upper quadrant, could be pancreas, 2nd portion of duodenum, stomach, etc., but only one thing moves when you breathe and that is the liver

Hand on abdomen and find most tender spot (locate patient’s problem) and patient will tell you point of max pain, then do not move hand while patient takes deep breath

If more pain = gallbladder is issue because moves with liver when not supposed to

Lloyd’s punch is associated kidney issues

Kidney stones, extra water, or infection/purulent exudate

Patient faced away from you

If tender in that place = identified problem

Hit your own hand pretty hard = shouldn’t hurt patient unless kidney is inflamed = Lloyd’s punch

Abdominal exam is not complete unless Lloyd’s punch!!!!

If patient cannot sit upright have them roll onto their side = no excuse for not doing this test