Abnormal Findings (Chapter 21: Abdomen)

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1

Obesity

Inspection: Uniformly rounded. Umbilicus sunken (it adheres to peritoneum, laters of fat are superficial to it)

Auscultation: Normal bowel sounds

Percussion: Tympany. Scattered dullness over adipose tissue

Palpation: Normal. May be hard to feel though thick abdominal wall

2

Air or Gas

Inspection: Single round curve

Auscultation: Depends on cause of gas (e.g., decreased of absent bowel sounds with clues); hyperactive with early intestinal obstruction

Percussion: Tympany over large area

Palpation: May have muscle spasm of abdominal wall

3

Ascites

Inspection: Single curve. Everted umbilicus. Bulging flanks when supine. Taut, glistening skin; recent weight gain; increase in abdominal girth

Auscultation: Normal bowel sounds over intestines. Diminished over ascitic fluid

Percussion: Tympany at top where intestines float. Dull over fluid. Produces fluid wave and shifting dullness

Palpation: Taut skin and increased intra-abdmonal pressure limit palpation

4

Ovarian Cyst (Large)

Inspection: Cuver in lower half of abdomen, midline. Everted umbilicus

Auscultation: Normal bowel sounds over upper abdomen where intestines pushed superiorly

Percussion: Top dull over fluid. Intestines pushed superiorly. Large cyst produces fluid wee and shifting dullness

Palpation: Transmits aortic pulsation, whereas ascites do not

5

Pregnancy

Inspection: Single curve. Umbilicus protruding. Breast engorged

Auscultation: Fetal heart ones. Bowel sounds diminished

Percussion: Tympany over intestines. Dull over enlarging uterus

Palpation: Fetal parts. Fetal movements

6

Feces

Inspection: Localized distention

Auscultation: Normal bowel sounds

Percussion: Tympany predominates. Scattered dullness over fecal mass

Palpation: Plastic-like or ropelike mass with feces in intestines

7

Tumor

Inspection: Localized distention

Auscultation: Normal bowel sounds

Percussion: Dull over mass if reaches up to skin surface

Palpation: Define borders. Distinguish from enlarged organ or normally palpable structure

8

Umbilical Hernia

Soft, skin-covered mass, the protrusion of the momentum or intestine through a weakness or incomplete closure in the umbilical ring.

Accentuated by increased intra-abdominal pressure as with crying, coughing, vomiting, or straining; but the bowel rarely incarcerates or strangulates.

More common in premature infants. Most resolve spontaneously by 1 year.

In adult: occurs with pregnancy, chronic ascites, or chronic intrathoracic pressure (e.g., asthma, chronic bronchitis)

9

Epigastric Hernia

Protrusion of abdominal structures presents a small, fatty nodule at epigastrium at midline, through the linea alba. Usually one can feel it rather than observe it. May be palpable only when standing

10

Incisional Hernia

A bulge near an old preoperative scar that may not show when person is supine by is apparent when the person increases intra-abdominal pressure by a dit-up, by standing, or by the Valsalva maneuver

11

Diastasis Recti

Midline longitudinal ridge that is a separation of the abdominal rectus muscles. Ridge is revealed when intra-abdominal pressure is increased by raising head while supine. Occurs congenitally, and as a result of pregnancy or marked obesity in which prolonged distention or a decreased in muscle time has occurred. Is is not clinically significant

12

Succussion Splash

Unrelated to peristalsis, this is avery loud splash osculated over the upper abdomen when the infant is rocked side to side. Indicates increased air and fluid in the stomach, as seen with pyloric obstruction or large hiatus hernia,

Marked peristalsis together with projectile vomiting in the newborn suggests pyloric stenosis, an obstruction of the pyloric valve of the stomach. Pyloric stenosis is a congenital defect and appears in the 2nd and 3rd week.

After feeding, pronounced peristaltic waves cross from left to right, leading to projectile vomiting. Then one can palpate an olive-sized mass in the RUQ midway between the right costal margin and umbilicus. Refer promptly because risk for weight loss

13

Hypoactive Bowel Sounds

Diminished or absent bowel sounds signal decade motility as a result of inflammation as seen with peritonitis; from paralytic ileum as following abdominal surgery; or from late bowel obstruction. Occurs also with pneumonia

14

Hyperactive Bowel Sounds

Loud, gurgling sounds, "borborygmi" signal increased motility. They occur with early mechanical bowel obstruction (high-pitched), gastroenteritis, brisk diarrhea, laxative use, and subsiding paralytic ileus

15

Peritoneal Friction Rub

Rough, grating sound, like two pieces of leather rubbed together, indicates peritoneal inflammation. Occurs rarely.

Usually occurs over organs with large surface area in contact with the peritoneum.

Liver: friction rub over lower right rib cage from abscess or metastatic tumor

Spleen: friction rub over lower left rib cage in left anterior axially line from abscess, infection, or tumor

16

Vascular Sounds

Arterial: a bruit indicates turbulent blood flow, as found in constricted, abnormally dilate, or tortuous vessels. Listen with a bell.

Occurs with the following:

  • Aortic aneurysm: murmur is harsh, systolic or continuous and accentuated with systole. Note in person with HTN
  • Renal artery stenosis: murmur is midline or toward plant, soft, low-to-medium pitch
  • Partial occlusion of femoral arteries.

Venous hum: occurs rarely. Heard in periumbilical region. Originates from IVC. Medium pitch, continuous sound, pressure on bell may obliterate it. May have palpable thrill. Occurs with portal HTN and cirrhotic liver.


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