Describing the Abdomen split into quadrants to help

Describing the Abdomen The abdomen can also be split into 9 sections as well.

Right Upper Quadrant (RUQ) Liver & Gallbladder Head of Pancreas Duodenum Right adrenal gland Hepatic flexure of colon Portion of right kidney Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 7

Right Lower Quadrant (RLQ) Appendix Ascending colon Ovary Right ureter Bladder Uterus Mosby items

Left Upper Quadrant (LUQ) Spleen Stomach Pancreas Left lobe of liver Splenic flexure of colon Portions of transverse and descending colon Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 9

Left Lower Quadrant (LLQ) Lower left kidney Sigmoid colon Ovary Left ureter Descending colon Bladder Uterus Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 10

Assessing the Abdomen Chief complaint History of present illness Past medical history Family history Personal/Social history Physical Exam Differential Labs Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 11

Importance of History Present Illness GI versus cardiac causes Clues to Differential Abdominal “Review of Systems” Seven attributes of a symptom Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 12

Review of Systems for the Abdomen Abdominal pain Constipation Indigestion Jaundice Nausea Dysuria Vomiting Urinary frequency Diarrhea Hematuria Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 13

• Review of Related History Past Medical History Gastrointestinal disorders Urinary Tract Infections Surgeries Medications/Immunizations Trauma/Injury Blood transfusions Hepatitis Cancer Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 14

• Review of Related History Family History Familial Mediterranean Fever Inflammatory bowel disease Familial cancer syndromes Congenital malformations Cystic fibrosis, Celiac’s Kidney disease Gallbladder disease Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 15

• Review of Related History Personal and Social History Nutrition LMP (first day of last menstrual period) Stressful life events Travel /Exposure to infectious diseases Sexual history Use of alcohol and/or illicit drugs Tobacco use Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 16

• Review of Related History Pregnant Women Urinary symptoms Frequency, urgency, burning, suprapubic pain Ø Back pain Ø Abdominal pain Contractions Onset, frequency, duration, intensity Ø Leakage of fluid, blood Ø Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 17

• Review of Related History Older Adults Urinary Tract Infections Constipation Indigestion Dietary habits Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 18

Abdominal Exam Preparation Inspection Auscultation Percussion Palpation Mosby items and derived items © 2006,

Preparation for the Abdominal Exam Empty bladder Positioning Abdomen exposure Visualize anatomy Warm hands & stethoscope Approach from the right Remember chief complaint Watch face Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 20

Inspection (1) Skin characteristics: color, striae, rashes, lesions, scars, dilated veins Umbilicus: location, displacement, inflammation Contour: rounded, flat, scaphoid Symmetry: symmetric, bulges, distension Surface Motion: pulsations, peristalsis Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 21

Auscultation Bowel sounds: frequency, character Vascular sounds: bruits, venous hums Mosby items and derived

Percussion (1) Assess size & density of organs Detect presence of fluid, air, masses, tenderness Can be done independently or concurrently with palpation Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 23

Percussion (2) All quadrants: tympany vs dullness Liver span: at right MCL and at the MSL if enlarged Spleen percussion sign: lowest left ICS before & after deep breath Gastric bubble: left lower anterior rib cage, left epigastric area Kidneys: costovertebral angle Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 24

Percussion (3) If suspect ascites as result of percussion of abdominal wall may perform two additional tests: Shifting Dullness Test and the Fluid Wave Test Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 25

Palpation (1) Evaluation of organs for: size, shape, consistency, tenderness Evaluate umbilical ring Palpate for pulsation of abdominal aorta Detection of masses Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 26

Palpation (2) Light Palpation: all 4 quadrants; identify muscular resistance, tenderness, masses Deep palpation: all 4 quadrants; delineate organs and detect deeper masses Mass: location, size, shape, consistency, tenderness, pulsation, mobility, movement with respiration, superficial or intra-abdominal Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 27

Palpation (3) Liver: palpate lower border of right costal margin Aorta: for pulsation Bladder: distension Gallbladder, Spleen, Kidney not often done unless physician suspects abnormality Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 28

• Examination and Findings Additional Abdominal Tests Rebound tenderness Iliopsoas muscle test Obturator muscle test Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 29

Abdominal Signs/Associated Conditions Blumberg (rebound tenderness) Cullen: ecchymosis around umbilicus Grey Turner: ecchymosis of flanks Kehr: abdominal pain radiating to left shoulder Markel (heel jar test): up on toes, fall back on heels Mc. Burney: rebound tenderness, pain over appendix Murphy: abrupt cessation of respiration when gallbladder palpated Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 30

Differential by Anatomic Region-RUQ Duodenal ulcer Hepatomegaly Hepatitis Pneumonia Cholecystitis Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 31

Differential by Anatomic Region-LUQ Ruptured spleen Gastric ulcer Aortic aneurysm Perforated colon Pneumonia Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 32

Differential by Anatomic Region. Periumbilical Region Intestinal obstruction Acute pancreatitis Early appendicitis Mesenteric thrombosis Aortic aneurysm Diverticulitis Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 33

Differential by Anatomic Region-RLQ Appendicitis Ovarian cyst or mass/salpingitis Ruptured ectopic pregnancy Renal/ureteral stone Strangulated hernia Perforated cecum/regional ileitis Diverticulitis Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 34

Differential by Anatomic Region-LLQ Ovarian cyst or mass/salpingitis Ruptured ectopic pregnancy Diverticulitis Renal/ureteral stone Strangulated hernia Ulcerative colitis Perforated colon/regional ileitis Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 35

Acute Appendicitis Pain characteristic: periumbilical or epigastric; later localized to RLQ, +Mc. Burney Associated findings: anorexia, nausea, possible vomiting, low grade fever, guarding, +rebound tenderness, +iliopsas, +obturator, +Mc. Burney, +Markle Peritonitis possible if rupture occurs: guarding, shallow respirations, hypotension or shock, reduced or absent bowel sounds; can be life-threatening Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 36

Acute Cholecystitis Pain: severe pain in RUQ, epigastric or umbilical pain; lasting 2 -4 hours; after meals and especially after fatty meal; may be referred to right subscapular area Associated findings: RUQ tenderness & rigidity, +Murphy sign, palpable gallbladder, anorexia, vomiting, flatulence, fever; possible jaundice Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 37

Acute Pancreatitis Pain: dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain; may be present in one or both flanks with possible ecchymosis; pain may be referred to left shoulder Associated findings: epigastric tenderness, vomiting, fever, shock; +Grey Turner and Cullen signs which occur 2 -3 days after onset Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 38

Ectopic Pregnancy Pain: history of vague abdominal pain followed by sudden severe abdominal tenderness in LQ, especially on involved side Associated findings: hypogastric tenderness, symptoms of pregnancy, spotting, missed period, mass on bimanual pelvic exam; if ruptured: shock, rigid abdominal wall, distension, + Kehr, + Cullen Mittleschmertz: pain associated w/ovulation Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 39

Acute Hepatitis Pain: general abdominal discomfort; malaise Associated findings: jaundice, clay-colored stools and dark urine which may preceed jaundice by 1 to 5 days, enlarged liver Patients with cirrhosis: will also have ascites, prominent abdominal vasculature, cutaneous spider angiomas, generalized itching Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 40

Perforated Gastric or Duodenal Ulcer Pain: abrupt RUQ; may be referred to shoulders Associated findings: abdominal free air and distension with increased resonance over liver; tenderness in epigastrum or RUQ; rigid abdominal wall, rebound tenderness; hematemesis, melena, hypotension, increased pulse rate; “acute abdomen” is a life-threatening event Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 41

Abdominal Aortic Aneurysm Pain: painless but pain may indicate imminent rupture; steady throbbing midline pain over aneurysm which may radiate to back, flank Associated findings: nausea, vomiting, prominent aortic pulsation, bruit and or mass Life-threatening even if occurs in hospital setting Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 42

Pyelonephritis Pain: flank pain, back pain Associated findings: malaise, dysuria, nocturia, urinary frequency, possible fever, + costovertebral angle tenderness Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 43

Renal Calculi Pain: intense flank pain extending to groin & genital area; may be episodic Associated findings: fever, hematuria, + Kehr Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 44

Irritable Bowel Syndrome Pain: crampy, variable hypogastric pain; associated with abdominal bloating, distension; + bowel sounds Associated symptoms: flatus, constipation or diarrhea; may see mucous in stool; relief with passage of flatus or bowel movement Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 45

Diverticulitis Pain: epigastric, radiating down left side of abdomen especially after eating; may be referred to back Associated findings: tenderness on palpation, borborygmus, flatulence, diarrhea, possibly dysuria Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 46

Acute Diarrhea Pain: abrupt onset of crampy pain Associated findings: increased bowel sounds, diarrhea, nausea, vomiting, fever, and tenesmus; consider food poisoning if develops in 2 or more following ingestion of same food Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 47

Hernia Pain: localized pain that increases with lifting or exertion Associated findings: hernia on physical exam, history of abdominal trauma, surgery Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 48

References Mosby’s Guide to Physical Examination, 6 th Edition. Chapter 17 pp 521 -578. Bates’ Guide to Physical Examination and History Taking. Chapter 9 pp 317 -366. University of California, San Diego “A Practical Guide to Clinical Medicine” Accessed online 02/09/07 at medicine. ucsd. edu/clinicalmedicine/ Mosby items and derived items © 2006, 2003, 1999, 1995, 1991, 1987 by Mosby, Inc. an affiliate of Elsevier Inc. 49