physical therapy assessment of abdominal pain abdominal landmarks anatomy in the RUQ anatomy in the LUQ anatomy of the RLQ anatomy of the LLQ problem based history (OLDCART) abdominal pain nausea and vomiting indigestion abdominal distention change in bowel habits jaundice 4 quadrant method/9 regions 1. RUQ - right upper quadrant 2. LUQ - left upper quadrant 3. RLQ - right lower quadrant 4. LLQ - left lower quadrant ascending colon, duodenum, gallbladder, right kidney, liver, pancreas (head), transverse colon, ureter (right) descending colon, left kidney, pancreas (body and tail), spleen, stomach, transverse colon, ureter (left) appendix, ascending colon, bladder, cecum, rectum, ovary, uterus, fallopian tube (female), prostate and spermatic cord (male), small intestine, ureter (right) bladder, descending colon, ovary, uternus, fallopian tube (female), prostate and spermatic cord (male), small intestine, sigmoid colon, ureter (left) abdominal pain, nausea/vomiting, indigestion, abdominal distention, change in bowel habits, jaundice, urination onset, scale, location, timing, affected eating, what relieves, associated sx. onset, how often, what does vomitus look like, blood, LMPpregnancy, foods eaten, associated sx. onset, when does it happen, how does eating affect- worse or better, OTC antacids, associated sx- radiating pain, sweating, light headedness. onset, r/t eating, what relieves, weight loss,sob frequency, consistency, color, mucoid, fatty, watery. bloody onset, progression, pain, loss of appetite, risk factors- drugs, alcohol, www.flashcardbook.com Page 1
tattoos, raw shellfish, travel, well water, change in color of urine or stools urination types of abdominal pain visceral pain parietal pain referred pain GI symptoms the urinary tract changes in pattern, dysuria, frequency, urgency, associated sx (fever,chills,backpain), color change, weight gain or swelling of ankles/feet, SOB, decrease output visceral, parietal, and referred pain in organs. May be described as gnawing, burning, cramping, stabbing, or aching. May be severe and associated with sweating, pallor, N&V, and restlessness(pud, gallstone) inflammed parietal peritoneum. May be decribed as a steady, aching pain. Severe pain causes patients to lie very still.(appendicitis, cholecystitis); can be steady and achy pain originates in an abdominal structure but felt in a distant site. Example pancreatic back & biliary right shoulder; referred pain can come from the chest and free air in the pelvis can also refer pain to the right shoulder 1. Dysphagia? * diffuculity with swallowing 2. Odynophagia?* pain with swallowing 3. Recurrent vomiting? Hematemesis bright red or coffee ground? 4. Weight loss* 10 lbs or more in less than a month 5. Anemia 6. Change in bowel habits? 7.Diarrhea/Tenesmes/Steatorrhea? T - pain with defecation; s - fattiness to stool and cause BM's to float 8. Constipation/Obstipation? 9. Melena/Hematochezia* - hard/black stools/bleeding in GI 10. Jaundice? 11. Color of stools-acholic? Clay is grey; bile has not been added to stool and lacks brown/yellow color - greyish in color * indicates alarm symptom 1. Suprapubic pain? 2. Dysuria? Urgency Frequency? www.flashcardbook.com Page 2
3. Polyuria? Nocturia? 4. Urinary incontinence? 5. Hematuria? 6. Gross vs. microscopic 7. Kidney or flank pain? 8. Ureteral colic,does pain move? 9. back? does the pain travel? 10. kidney stones - pain moves 11. posterior view - may have abdominal pain or back pain as well abdominal pain RUQ pain epigastric pain from stomach middle of umbilicus hypogastric pain suprapubic/sacral pain pain referred to abdomen tips for enhancing the examination of the abdomen abdominal exam technique order if pain can refer to the chest, then the chest pain can also refer to the abdomen epigastric pain from the biliary tree and liver duodenum or pancreas can be right below the ziphoid process periumbilical pain from the small intestine, appendix, or proximal colon from the colon, bladder, or uterus; colonic pain may be more diffuse than illustrated from the rectum 1. pleurisy, pneumonia 2. pericardial friction rub 3. friction rub - refer to umbilical region or UQ regions 1. Tangential lighting: shine light from the side of the bed to see bowel waves 2. Empty bladder 3. Patient comfortable in supine position, pillow under head and perhaps knees, low back flat on table. 4. Patient's arms at side or folded across chest. 5. Warm your hands and stethoscope. 6. Watch patient's face for signs of discomfort. 1. inspection 2. auscultation www.flashcardbook.com Page 3
3. palpation 4. percussion <b>different order than a normal exam</b> ausculation of the abdomen what else are you listening for and how do you do it? ausculation for arteries light palpation 1. Auscultate before palpation or percussion, listen in all 4 quadrants, noise in any quadrant indicates bowel sounds present, normal is 6-34/min. Start in area shown. 2. Absence of bowel sounds can not be documented unless you have listened for 2-3 minutes or longer (5min) in the area shown 1. Pulsations, colorations, peristalsis (bowel waves visible on abdnomen) 2. Listen with the diaphragm - large part of the stethoscope; pick up higher pitched noises; bowel sounds have a specific meaning - high pitched could be some kind of obstruction due to moving through a narrow space 3. Start in RLQ and go clockwise Should hear bowel sounds Do not hear? Have to listen for 2-3 minutes or longer 4. 6-34 gurgles to be normal Immediate post op (maybe only 6 times in a minute - really have to listen) 7. Hyperactive - greater than 34 per min 8. Hypoactive - less than 6 per min 1. abdominal bruits - use the bell 2. friction rubs - remember the liver 3. Listen with the bell - can listen to these arteries 4. Takes practice 5. Over the RUQ - hear friction rub? Could have a swollen liver than is rubbing against abdominal parietal membrane 1. Perform first, start away from site of c/o pain- note tenderness, muscle tone, surface characteristics 2. Utilize relaxation techniques-breathe slowly through mouth 3. Use one finger if exquisite tenderness 4. If light palpation negative, check rebound tenderness www.flashcardbook.com Page 4
5. palpate light to deep and look at the patient's face, ask them to bend knees to for comfort deep palpation rebound tenderness pulsatile masses guarding palpation of the aorta bimanual palpation light vs deep palpation percussion more on percussion percussion technique 1. All four quadrants- used to delineate masses 2. Push down about 5 to 8 cm. 3. Correlate palpable findings with percussion. 4. Note pulsatile masses, fixed or mobile masses, and tenderness, to check rebound tenderness-push deeply, let go quickly push deeply and let go quickly (ask patient if they feel pain if they push or if you let go) appenditis - will hurt if you let go quickly aneurysm in an artery; do not press on these because you run the risk of causing a rupture of the artery and is not good trying to keep you from examining them (voluntary) ridget abdnominal area is involuntary not allowing you to push down 1. AAA high risk men >65y/o 2. Palpate gently, if concerned report 3. Ultrasound confirms, decreases mortality 1. palpation of the kidney 2. palpation of the spleen (best palpated on inhalation) 1. Assessment for peritoneal inflammation 2. Localize pain 3. Ask patient to cough 4. Palpate gently with one finger 5. Rebound tenderness? 6. Referred pain? 1. Percuss all four quadrants 2. Used to identify borders of solid and hollow organs. 3. Dull over solid organs- liver, spleen, stool. 4. Tympany is predominant sound. - over ribs on lungs 1. Tapping the borders of the organ to determine where it is located 2. Liver, spleen, stool 3. Percuss out a gastric bubble - stomach is empty - more tympanic 1. Tap and be on distal part of the fingers - other fingers are not on www.flashcardbook.com Page 5
the abdominal surface 2. too many fingers on the abdomen will trap the sound and will hear a dull sound checking for costovertebral angle tenderness percussion of the kidneys male reproductive system: sources of pain testicular torsion female reproductive system: possible sources of pelvic pain GERD hiatal hernia peptic ulcer disease direct or indirect percussion of the kidney 1. Costovertebral angle tenderness (CVAT)- 2. use direct or indirect over CVA to determine kidney pathology- pylonephritis, nephritis, or nephrolithiasis 3. differentiate between bladder infection and kidney infection 1. hernia 2. epididymitis 3. testicular torsion (surgical emergency) emergency; 6 hours from torsion time to time of death of testicles to intervene; athletes and young men/teenagers - early morning patient complains of right sided pain, male, woke up with pain, no fever, really bad right or left lower quadrant pain; often occurs from sleep 1. Pelvic Inflammatory Disease 2. Ovarian cyst 3. Endometriosis 4. Tubal Pregnancy- surgical emergency - women/young girls should know when their last period was caused by weakening of the LES, c.o heartburn, regurgitation, dysphagia (difficulty swallowing). Aggravated by lying down, relieved with sitting. Untreated/chronic can lead to Barrett's Esophagitis a precancerous condition. protrusion of the stomach through the hiatus of diaphragm usually due to muscle weakness. Same sx as GERD. ulcer that occurs in lower end of esophagus, stomach or duodenum. Helicobactor pylori is a risk factor for ulcer disease. C/O burning pain, in stomach occurs 2 hours after eating, in duodenum about 4 hours after eating & wakes in the night in pain and get relief with eating www.flashcardbook.com Page 6
crohn's disease ulcerative colitis diverticulitis appendicitis tests for appendicitis hepatitis cirrhosis cholecystitis pancreatitis inflammatory bowel disease, may occur mouth to anus but most common terminal end of the ileum and colon. Causes ulceration, bleeding, fissures, fistulas, & abcesses in mucosal lining. C/O severe pain, cramping, diarrhea, nausea, fever, chills, anorexia, and weight loss IBD of the rectum and large intestine. Mucosa becomes ulcerated and denuded and is risk for colon cancer. C/O severe pain, fever, chills, anemia, and weight loss with profuse bloody diarrhea, mucus and sometime pus. inflammation of diverticula (herniations away from the mucosal wall to form pockets). Become inflamed and abscess. C/O pain LLQ, nausea, vomiting, and altered bowel habits. inflammation with infection of appendix. Pain starts periumbilical then localizes usually in the RLQ accompanied by N&V, fever, and no stooling. rebound tenderness, McBurney's point(halfway between umbilicus & right ant. illiac crest. iliospsoas muscle test for acute appendicitis and suspect rupture or abscess, perform obturator muscle test. inflammation of liver due to several viruses. Causes vague abd pain, N&V, anorexia, malaise, fever, enlarged tender liver, jaundice, stools that are tan colored, amber urine. degenerative liver disease that impairs function & blood flow. Due to alcoholism, hepatitis & biliary obstruction. Exam is a palpable hard liver with ascites, spider angiomas, dark urine, tan stools & enlared spleen. Hardening of the liver inflammation of gallbladder, inflammation with stones is cholelithiasis. Causes RUQ pain, anorexia, indigestion and sometimes jaundice. Often occurs after eating a fatty meal. acute or chronic inflammation of pancreas as a result of autodigestion of the organ. Caused by alcoholism or obstruction of sphincter of Oddi by gallstones. C/O steady pain that is boring, dull, www.flashcardbook.com Page 7
or sharp & radiates to the back, steatorrhea, N&V, weight loss, & glucose intolerance. urinary tract infections (UTI) nephrolithiasis involves cystitis, urethritis, or pyelonephritis. Most bacteria originate from GI tract. C/O frequency, urgency, dysuria. Chills, fever in pyelonephritis. Pyuria on u/a, older adults may have delirium from fever or infection. kidney stones. c/o pain that often moves, hematuria, flank pain that may radiate to groin. www.flashcardbook.com Page 8