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Front Back
Structures by quadrant, also:

epigastric, umbilical, suprapubic
LLQ: sigmoid colon

RLQ: Cecum, ascending, descending and transverse colon

LUQ: spleen, left kidney

RUQ: liver, lower pole of rt. kidney

Epigastric:

Umbilical: stomach

Suprapubic: bladder
Spleen's location, enlargement and radiation
Lies against the diaphragm at the level of the 9th, 10th and 11th ribs, mostly posterior ot the left midaxillary line. lateral to and behind the stomach, just above left kidney. Tip is normally palpable below the let costal margin in some adults.

With enlargement it expands anteriorly, downward and medially (can replace tympany of stomach with dullness).

Radiation to left abdomen and left shoulder.
Visceral
Visceral occurs when hollow abdominal organs contract or distend. Typically located near midline:

RUQ or epigastric from biliary tree and liver
Epigastric from stomach, duodenum or pancreas
Periumbilical from small intesting, appendix or proximal colon
Hypogastric from colon, bladder or uterus
Suprapubic or sacral from rectum.
Parietal
originates in parietal peritoneum and caused by inflammation. Steady, aching pain usually more severe than visceral and localized directly over involved structure. Pts want to lie still.
Referred pain
felt in distant sites which are innervated at approximately the same spinal levels as the disordered structure.

E.g. pain of duodenal or pancreatic origin referred to back.

from biliary tree to right shoulder or right posterior chest

from pleurisy or acute AMI to upper abdomen
Light vs. deep palpation
Light identifies abdominal tenderness, muscular resistance and some superficial organs and masses. Keep hand on horizontal plane.

Deep is used to delineate abdominal masses. Use two hands.
Rebound tenderness
Pain that is worse when you withdraw quickly (due to inflammed peritoneum). Location of pain is where the real problem might be.
Shifting dullness
With ascites, dullness shifts to the more dependent side, whereas tympany shifts to the top
Rovsing's sign

Psoas sign

Obturator sign

Cutaneous hyperesthesia

Voluntary vs. involuntary guarding

Murphy's sign
Rovsing's sign: referred rebound tenderness while pressing in LLQ. (+) is pain in RLQ with pressure or quick withdrawl.

Psoas sign: (+) when abdominal pain worsens from flexion of right leg at hip.

Obturator sign: (+) rt. hypogastric pain when you rotate the leg internally at the hip when both hip and knee are flexed (it stretches the internal obturator muscle).

Cutaneous hyperesthesia: Picking up a fold of patient's skin and not pinching it. Localized pain in all or part of RLQ may accompany apendicitis.

Voluntary vs. involuntary guarding: Voluntary guarding suggests the patient in uncomfortable or in pain. Involuntary guarding is present in peritoneal inflammation. To help assess, try to relax the patient, feel for relaxation of abdominal muscles that accompanies exhalation, ask the patient to mouth breathe with the jaw open. Voluntary guarding usually decreases with these maneuvers.

Murphy's sign: (+) pain with inspiration when you hook left thumb or fingers of right hand under costal margin at the point where the lateral border of the rectus muscle intersects with the costal margin. Shows acute cholecystitis.
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