coffee, onions, and peppermints suggesting gastroesophageal

Abdomen
Asst. Prof. Efrelyn A. Illelamo
reflux, assess faster and can be
correlated to myocardial
infarction
Excessive gas or flatus – the -find out if associated eating
January 31, 2019
passage of gas by rectum, specific foods
normally about 600mL per day - ingestion of milk/ milk products
Gassy food: broccoli, lentils,
asparagus, cabbage, beans
Anorexia- lack of appetite -intolerance to certain foods or
reluctance to eat due to
anticipated discomfort
Nausea- “feeling sick to my -ask about any vomitus or
stomach”, may progress to regurgitated material and inspect
retching or vomiting yourself
-color, smell, amount, presence
of blood
Retching- spasmodic movements
Right upper quadrant: liver, gallbladder, duodenum, lower pole of right of the chest and diaphragm that
kidney precede vomiting, the forceful
Left upper quadrant: spleen (behind the stomach), pancreas expulsion of gastric contents out
Left lower quadrant: colon, bladder, sacral promontory, s1 vertebra, through the mouth
uterus and ovaries Dysphagia- difficulty of -ask the patient to oint where
Right lower quadrant: bowel loops and appendix swallowing; sense food / liquid is dysphagia occurs and describe
sticking, hesitating, or won’t go what type of food
Common or Concerning Symptoms down right -w/ solid food in mechanical
 Abdominal Pain narrowing of esophagus both
 Indigestion- general term for distress associated with eating solids & liquids suggests a
that can have many meanings disorder of esophageal motility
 Nausea, Vomiting Odynophagia- pain on -sharp, burning pain suggests
 Hematemesis – vomiting of blood; brownish or blackish swallowing mucosal inflammation
vomitus with a “coffee grounds” appearance -squeezing, cramping pain
 Dysphagia- difficulty of swallowing suggests a muscular cause
 Odynophagia- pain in swallowing Constipation -be sure to clarify; decrease in
 Change in bowel function frequency of bowel movements;
Abdominal Pain
 Dysuria- difficulty of urination passage of hard and perhaps
Visceral Pain -Allow patient to
o Frequency- how many times do you urinate? painful stools; need to strain
- Hollow abdominal organs describe in own words
o Urgency- Always feel the urge but having difficulty to unusually hard; sense of
contract unusually forcefully or -Scale 1-10 pain and if it
release incomplete defecation of
when they are distended or interferes with patient’s
o Hesitancy- Sitting on the toilet even though no urine pressure in rectum
stretched usual actions (severity
is released Melena- black tarry spots How long and how often; amount
- Difficult to localize, stretched of pain)
 Prostatic pain- felt in the perineum and occasionally in the Hematochezia-red
- Varies in quality: in stools of red blood;
blood gnawing, is it pure blood
-Sudden/ gradually
rectum; burning sensation proximal to the glans penis mixed in with stool? Is there
burning, cramping, or aching when pain began
 Polyuria- excessive or an abnormally large production or blood on toilet paper?
Referred Pain -How long it lasts,
passage of urine Diarrhea - excessive frequency in -size, frequency, acute/chronic and volume;
- Felt in more distant sites, which
 Nocturia- waking up at night to urinate the passage of stools that are greasy/oily
-What factors aggravate
are innervated at approximately
 Urinary incontinence- involuntary control of urine usually unformed or watery -frothy,orfoul-smelling,
relieve the painfloating
w/ on
the same spinal nerves as the
surfacespecial
because of excessive
 Hematuria- blood in urine disordered structure reference to
Acute diarrhea- last to 2 weeks gas meals, antacids,
 Kidney or flank pain - May be felt superficially or
Chronic diarrhea- can last up to 4 -accompanied alcohol, by mucus, pus,
medication
 Ureteral Colic- urinary stones block urinary tract deeply but is usually localized
weeks or more blood -point to the pain
 Anorexia- loss of appetite - Often develops as initial pain
-intense urge with straining but
 Anorexia nervosa- diagnosed sickness; fear of gaining weight becomes more intense and thus
little or no result (tenesmus)
seems to radiate from the initial
Obstipation
site -there is no passage of either
feces or gas
Parietal Pain
Jaundice/
- Icterus- yellow
Inflammation of parietal -color of urine and stool: acholic
Gastrointestinal Problem Health history discoloration of skin and sclera (gray; without bile)
Heartburn – sense of burning or -special attention to discomfort peritoneum
from
- increased levels
Steady, aching of bilirubin -Skin itch
warmth that is retrosternal and and what relieves it -risk factor for hepatic disease
may radiate from the epigastrium -precipitated by exertion, and - Pain that is usually more severe
Intrahepatic
than visceral pain and more -meals of poor sanitation,
jaundice
to the neck occurring weekly or relieved by rest, suggesting - hepatocellular-
more often angina precisely damage
localizedtoover
the the ingestion of contaminated
hepatocytes
localized structure water/food stuffs (Hep. A)
-usually aggravated by food, -related to meals and made - cholestatic-
alcohol, chocolate, citrus fruits, worse during on or after eating, - Aggravated by movement/ -parenteral or mucous membrane
from impaired
excretion as a result of damages exposure to infectious body
coughing
- Irritation of parietal area
- Patients usually like to lie still
 hepatocytes or intrahepatic bile fluids(sexual contact, shared Note the ff:
ducts needle) (Hep. B) o Scars (describe or diagram location), striae (stretch
-Intravenous illicit drug use or mars normal), dilated veins, rashes
Extrahepatic jaundice- arises blood transfusion (Hep. C) o Umbilicus; contour, location, and any symptoms of
from obstruction of the -alcohol drinking inflammation
extrahepatic bile ducts (cystic -medication o Contour of abdomen: flat, rounded, protuberant, or
and common bile ducts) scaphoid
o Symmetry of abdomen
o Visible organ masses
o Any peristaltic waves
The Urinary Tract o Any pulsations (normal aortic pulsation is visible in
 General questions for urinary history include “do you have any the epigastric area
difficulty passing your urine?”” how often do you go?”
 Woman may report internal urethral discomfort, sometimes Auscultation
described as a pressure, or an external burning from the flow of Listen before percussion or palpation because these may alter bpwel
urine across inflamed or irritated labia sounds
 When typically feel a burning sensation proximal to glans penis 1. Bowel sounds (decreased or increased motility)
 Bladder disorders may cause suprapubic pain a. Normal: clicks and gurgles occurring at an estimated
frequency of 5 to 34 per minute
2. Bruits (Bruit of renal artery stenosis)
3. Friction rubs (liver tumor, splenic infarct)

Urgency -when it happens and how often Borborygmi – a rumbling or gurgling noise made by the movement of
Frequency -if patient has leaking small fluid and gas in the intestines; happens occasionally, “stomach growling”
amounts of urine with increased
Urge incontinence-involuntary intraabdominal pressure from Percussion
urination coughing, difficulty to hold urine - Amount and distribution of gas in abdomen and to identify
once with urge to void, loss of possible masses that are solid or fluid fueled, and the size of
large amounts of tissue, the liver and spleen
sensation of bladder fullness - Distribution of tympany and dullness
Polyuria -significant increase in 24 hour - Tympany usually predominates because the gastrointestinal
urine volume, > 3 liters tract is filled with gas
Nocturia Urinary frequency at night, - Dullness can be heard from scattered areas from fluid and
defined as wakening the patient feces
more than once
Hematuria -blood in urine, when visible to Palpation
naked eye it is called gross Before palpation, ask patient to point to any areas of pain.
hematuria 1. Keep hand and forearm on a horizontal plane, with fingers
together and flat on the abdominal wall, palpate the abdomen
Kidney Pain -may radiate anteriorly toward
with a light, gentle, dipping motion. Raise your hand gently as
umbilicus, typically dull, aching
you palpate around all the four quadrants.
and steady
a. Gentle Palpation: Lightly for guarding, rebound, and
Ureteral Pain -severe and colicky, originating at
abdominal tenderness, muscular resistance, and
the costovertebral angle and
some superficial organs and masses; also serves to
radiating around the trunk into
reassure and relax the patient
the lower quadrant of the
i. If resistance is present, try to distinguish it
abdomen, or into the upper thigh
from voluntary to involuntary muscle spasm
and testicle or labium
1. Let the patient relax.
2. Feel for relaxation of the muscles that usually accompanies
Techniques for Examination:
exhalation
1. Ensure good light
3. Ask the patient to mouth-breathe with the jaw dropped open
2. Make sure the patient is relaxed- supine position, with a pillow
b. Deep palpation: Deeply for masses or tenderness
under the head and another under the knees
i. Used to delineate abdominal masses
3. Full exposure of abdomen from above the xiphoid process to
ii. Identify the masses taking note of their
the pubic symphysis
shape, size, location, consistency,
a. Groin should be visible
tenderness, pulsations, and any mobility
b. Genitalia should remain draped
with respiration or pressure from the
c. Abdominal muscles should be released to enhance
examining hand.
all aspects of the examination, but especially
iii. Correlate your findings with the percussion
palpation
notes.
Inspection
 Ask the patient to cough and determine where the cough
1. Stand at the right side of the bed, inspect abdomen
produce a pain
2. Look at contour of abdomen, watch for peristalsis, helpful to sit
or bend down to see tangentially
Firm, boardlike abdominal wall— suggests peritoneal inflammation. - Palpation can confirm the enlargement but often misses large
spleens that do not descend below the costal margin.
Guarding is the involuntary contraction of the abdominal wall; if the - Percuss across the left lower anterior chest roughly from the
patient flinches, grimaces, or reports pain during palpation. border of cardiac dullness at the 6th rib to the anterior axillary
line and down to the costal margin, an area termed Traube’s
Rebound tenderness from peritoneal inflammation; it is considered space, noting change from tympany to dullness
positive if pain is greater when you withdraw your hand than when you - Patient must be: supine; lying on the right side with legs flexed
press down. Press slowly on a tender area, then quickly “let go.” Percuss at hips and knees it can bring the spleen forward and to the
gently to check for percussion tenderness. right palpable location

The Liver The Kidneys

Percussion 1. Retroperitoneal and not usually palpable
Measure its distance from the costal margin in the MCL, making sure that 2. Try to palpate each kidney (patient supine)
the vertical span is directly at the MCL to avoid inaccurate 3. Check for costovertebral angle (CVA) tenderness (patient
measurements. (60% accuracy percussion to 70% correlation to its sitting upright)
actual span) 4. Bladder: must be 400-600ml before dullness appears for
Use light to moderate percussion strike. percussion above the symphysis pubis.
1. Starting a level below from the umbilicus, strike upward until
tympany is replaced by dullness in the midclavicular line. The Aorta
2. Identify the upper border of liver dullness by starting at the 1. Palpate the aorta’s pulsations, In older people, estimate its
nipple line at the MCL. Lightly percuss from lung resonance width. (patient supine)
down toward liver dullness.
 If the liver is enlarged, its span of liver dullness also increases.

Palpation
 Place left hand behind patient, parallel to and supporting the
right 11th and 12th ribs and adjacent soft tissues.
 Remind the patient to relax.
 Push your left hand upward, the liver may be felt easier by your
other hand.
Hooking technique – helpful when the patient is obese.
1. Stand to the right of the patient’s chest and place two
hands, side by side, on the right abdomen on the border
of dullness.
2. Press in with the fingers and up toward the costal margin.
3. Let the patient take a deep breath.
4. The liver edge is now palpable with the fingerpads of both
hands.
If the liver is non-palpable:
 Place left hand flat on the lower right rib cage and gently strike
with the ulnar surface of the right hand.
 Ask patient to compare sensation to a similar strike produced
on the other side.
The Spleen
- Percussion suggests but does not confirm splenic enlargement.