Physical Assessment Arnoldi

Different Parts of the Large Intestine

Cecum

  • Ileal contents empty into cecum via ileocecal valve and appendix extends from base of cecum

Ascending Colon

  • Rises from the cecum along the right posterior abdominal wall to the undersurface of the liver, where it turns toward midline (hepatic flexure)

Transverse Colon

  • Crosses abdomen toward spleen, turning downward at splenic flexure

Descending Colon

  • Continues along the left abdominal wall to rim of pelvis, where it turns medially and inferiorly to form sigmoid colon

Rectum

  • Extends from sigmoid colon to the pelvic floor to the anal canal, terminating at the anus

Anus

  • Where poopy leaves

Where is the pancreas located?
Behind and beneath the stomach
Where is the spleen located?
Lcoated in left upper quadrant above the left kidney and below the diaphragm
Where are the kidneys located?
Located bilaterally in retroperitoneum of upper abdomen
What and Where is the rectus abdominus located?

  • Your 6 pack, or 4 pack, or 2 pack
  • Anteriorly

Where are the internal and external obliques located?
Laterally
What and where is the Linea alba located?
Tendinous band midline between the rectus abdominus muscles

 

Where are the inguinal ligaments located?

 

From anterior superior spine of the ilium on each side of the pubus
Important Organ Changes in Infants

  • GI tract continues to develop after birth until 2-3 yrs of age
  • Liver is very large at birth
  • Spleen is active in blood formation during first year of birth
  • Kidney growth increases incrementally after birth

Important Organ Changes in Pregnant Women

  • Abdominal wall muscles stretch and lose tone
  • Organs are displaced and affect functions
  • Heartburn
  • Gallstones
  • Urinary stasis or urgency
  • Constipation or flatus
  • Hemorrhoids

 

Important Organ Changes in Geriatrics

  • GI tract motility slows, secretion and absorption slows, and digestion overall decreases
  • Food tolerance diminishes
  • Diminished ability of liver to metabolize certain drugs
  • Delayed gastric emptying
  • Gallstones caused by increase in biliary lipids

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Regions of the Abdomen:  Name position 1

Epigastric

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Regions of the Abdomen:  Name position 2

Umbilical

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Regions of the Abdomen:  Name position 3

Hypogastric or Pubic

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Regions of the Abdomen:  Name position 4

Right Hypochondriac

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Regions of the Abdomen:  Name position 5

Left Hypochondriac

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Regions of the Abdomen:  Name position 6

Right Lumbar

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Regions of the Abdomen:  Name position 7

Left Lumbar

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Regions of the Abdomen:  Name position 8

Right Inguinal

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Regions of the Abdomen:  Name position 9

Left Inguinal
Abdominal Distension below the umbilicus could be a sign of:

  • Ovarian tumor
  • Uterine fibroids
  • Pregnancy
  • Distended bladder

Abdominal Distension above the umbilicus could be a sign of:

  • Carcinoma
  • Pancreatic cyst
  • Gastric dilation

Asymmetric Abdominal Distension could be a sign of:

  • Hernia
  • Tumor
  • Cysts
  • Bowel obstruction

What are bruits and where can they be heard?

  • Sounds of turbulent flow rushing past an obstruction
  • Can be heard in aortic, renal, iliac, and femoral arteries

What are friction rubs and where can they be heard?

  • High pitched sounds in association with respiration
  • Indication of inflammation of peritoneal surface from tumor, infection, infarct
  • May be heard over spleen and liver

What is a venous hum and where can it be heard?

  • Soft, low-pitched, continuous sounds
  • Can be heard over epigastric region and around umbilicus

Appendicitis: Usual Pain Characteristics and Location of pain

  • Initial: Preumbilical or Epigastric
  • May become localized to RLQ

Appendicitis: Possible Findings

  • Guarding
  • Tenderness
  • Anorexia
  • Nausea or vomiting after pain onset
  • Low-grade fever

Renal calculi: Usual Pain Characteristics and Location of pain

  • Intense
  • Flank, extending to groin and genitals
  • May be episodic

Renal calculi: Possible Findings

  • Fever
  • Hematuria

Cholecystitis: Usual Pain Characteristics and Location of pain

  • Severe
  • Unrelenting RUQ or epigastric pain
  • May be referred to right subscapular area

Cholecystitis: Possible Findings

  • RUQ tenderness and rigidity
  • Palpable gallbladder
  • Anorexia
  • Vomiting
  • Fever

Pancreatitis: Usual Pain Characteristics and Location of pain

  • Dramatic, sudden, excruciating LUQ, epigastric, or umbilical pain
  • Present in one or both flanks
  • May be referred to left shoulder

Pancreatitis: Possible Findings

  • Epigastric tenderness
  • Vomiting
  • Fever
  • Shock

Diverticulitis: Usual Pain Characteristics and Location of pain

  • Epigastric
  • Radiating down left side of abdomen especially after eating
  • May be referred to back

Diverticulitis: Possible Findings

  • Flatulence
  • Borborygmi
  • Diarrhea
  • Dysuria
  • Tenderness on palpation

Ectopic Pregnancy: Possible Findings

  • Hypogastric tenderness
  • Symptoms of pregnancy
  • Spotting
  • Irregular menses
  • Soft abdominal wall
  • Mass on bimanual pelvic exam
  • Rupture: shock, rigid abdominal wall, distention

Ectopic Pregnancy: Usual Pain Characteristics and Location of pain

  • Lower quadrant
  • Referred to shoulder
  • With rupture is agonizing

Splenic Rupture: Usual Pain Characteristics and Location of pain

  • Intense
  • LUQ, radiating to left shoulder
  • May worsen with foot of bed elevated

Splenic Rupture: Possible Findings

  • Shock
  • Pallor
  • Lower temperature

Irritable Bowel Syndrome: Usual Pain Characteristics and Location of pain

  • Hypogastric
  • Crampy, variable, infrequent, associated with bowel function

Irritable Bowel Syndrome: Possible Findings

  • Negative physical exam
  • Pain with gas, bloating, distension
  • Relief with passage of flatus or feces

Lactose Intolerance: Usual Pain Characteristics and Location of pain

  • Crampy pain after ingesting dairy products

Lactose Intolerance: Possible Findings

  • Associated diarrhea
  • Negative physical exam

Diverticular Disease: Usual Pain Characteristics and Location of pain
Localized pain
Diverticular Disease: Possible Findings

  • Abdominal tenderness
  • Fever

Constipation: Usual Pain Characteristics and Location of pain

  • Colicky or dull and steady pain that does not progress or worsen

Constipation: Possible Findings

  • Fecal mass palpable
  • Stool in rectum

Uterine Fibroids: Usual Pain Characteristics and Location of pain

  • Pain related to menses, intercourse

Uterine Fibroids: Possible Findings
Palpable myoma(s)
Hernia: Usual Pain Characteristics and Location of pain

  • Localized pain that increases with exertion or lifting

Hernia: Possible Findings
Hernia on physical exam
GERD: Usual Pain Characteristics and Location of pain

  • Burning, gnawing pain in mid-epigastrum
  • Worsens with recumbency

GERD: Possible Findings
Negative Physical Exam
Peptic Ulcer: Usual Pain Characteristics and Location of pain
Burning or gnawing pain
Peptic Ulcer: Possible Findings
May have epigastric tenderness on palpation
Gastritis: Usual Pain Characteristics and Location of pain
Constant burning pain in epigastrum
Gastritis: Possible Findings

  • + Nausea, vomiting, diarrhea
  • Fever
  • Physical exam negative

Auscultate with stethoscope diaphragm to listen for:

  • Bowel sounds
  • Friction rubs over liver and spleen

Auscultate with bell of stethoscope to listen for:

  • Venous hums in epigastric area and around umbilicus
  • Bruits over aorta, renal, and femoral arteries

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