Health

Assessment RLE
THE
GASTROINTESTI
NAL AND RENAL
SYSTEM
4 Quadrants of the abdomen
Quadrants of the abdomen
Common concerning symptoms: Gastrointestinal
o Abdominal pain - Abdominal pain is discomfort anywhere in your belly region — between
your ribs and your pelvis. We often think of abdominal pain as “stomach pain” or a
“stomachache,” but pain in your abdomen could be coming from other organs besides your
stomach, too. Location is an important clue to your abdominal pain, though it’s not the only
factor. It may indicate which organs are involved.
o Acute and chronic Indigestion – also called dyspepsia or an upset stomach is discomfort in
your upper abdomen. Indigestion describes certain symptoms, such as belly pain and a feeling
of fullness soon after you start eating, rather than a specific disease. Indigestion can also be a
symptom of other digestive disorders.
o Nausea - is an uncomfortable feeling in the back of your throat or an uneasiness in your
stomach. You may also feel dizzy, lightheaded or have difficulty swallowing. Nausea often goes
along with the urge to vomit but doesn’t always lead to vomiting.
o Vomiting - including blood (hematemesis),loss of appetite, early satiety (the inability to eat
a full meal or feeling full after only a small amount of food)
o Dysphagia - medical term for difficulty swallowing. dysphagia can be a sign of something
serious. It’s a common symptom following a stroke. Untreated dysphagia can pose risks like
food or liquid getting into your airway (aspiration). This can lead to a lung infection or
pneumonia.
Common concerning symptoms: :
Gastrointestinal
o Odynophagia - medical term for painful swallowing. Pain can be felt in your mouth,
throat, or esophagus. There’s no one single cause or treatment measure designated
for odynophagia. That’s because painful swallowing is related to numerous underlying
health conditions
o Diarrhea - loose, watery stool during a bowel movement. It’s common in both
children and adults and usually goes away on its own within a few days
o Constipation – a condition in which a person has uncomfortable or infrequent bowel
movements. Generally, a person is considered to be constipated when bowel
movements result in passage of small amounts of hard, dry stool, usually fewer than
three times a week
o Jaundice - condition in which the skin, sclera (whites of the eyes) and mucous
membranes turn yellow. This yellow color is caused by a high level of bilirubin, a
yellow-orange bile pigment. Bile is fluid secreted by the liver. Bilirubin is formed from
the breakdown of red blood cells.
 Common concerning symptoms: Urinary
and Renal
o Suprapubic pain – Suprapubic pain can have many causes, including urinary tract
infections, hernias, and inflammation of abdominal organs
o Dysuria - Dysuria is pain or discomfort when you urinate (pee). It burns! Dysuria isn’t
about how often you go (urinary frequency), though urinary frequency often happens
together with dysuria. Dysuria is not a diagnosis. It’s a sign or symptom of an underlying
health problem. Higher risk for pregnant, DM, bladder disease Dysuria is any discomfort
associated with urination. Abnormally frequent urination (e.g., once every hour or two) is
termed urinary frequency. Urgency is an abrupt, strong, often overwhelming, need to
urinate.
+ Hesitancy, decreased stream in males - having trouble starting to urinate or maintaining a
flow, ou have difficulty urinating. You may find it challenging to start a stream or keep it flowing. Your flow
may stop before your bladder is empty. more common in men. Cause: antidepressants, enlarged prostate,
stroke, MS
+ Polyuria and nocturia - when your body makes too much urine in a 24-hour period.
Nocturnal polyuria: when your body makes too much urine during the night. more
common as people age (usually older than 60), Cause: diuretic, increase fluid intake at
Common concerning symptoms: Urinary
and Renal
o Urinary incontinence - involuntary leakage of urine.
o Hematuria - Blood in the urine can look pink, red or cola-colored. Red urine isn't always
caused by red blood cells. Some medicines can cause urine to turn red,
o Flank pain and ureteral coli - A kidney stone causes excruciating pain when it enters a
ureter. The ureter contracts in response to the stone, causing severe, crampy pain (renal
or ureteral colic) in the flank or lower back that often extends to the groin or, in men, to a
testis. The pain typically comes in waves. A wave may last 20 to 60 minutes and then
stop. Cause: abdominal aortic aneurysm, problems with the spine or spinal nerves,
musculoskeletal injuries, and tumors that involve the back of the abdomen
(retroperitoneum
Patterns and Mechanisms of Abdominal Pain

Three broad CATEGORIES OF ABDOMINAL

PAIN
1. Visceral pain - pain we feel when our internal
organs are inflamed, diseased, damaged or injured,
- can be result of
underlying condition like IBD, IBS, cancer,
pancreatitis, intestitial cystitis
Patterns and Mechanisms of Abdominal Pain

Three broad CATEGORIES OF ABDOMINAL

PAIN
2. Parietal pain - It results from irritation of parietal
peritoneum caused by inflammation, infection or chemical
reaction.. The parietal peritoneum covers the
abdominal and pelvic walls as well as the
diaphragm.
Patterns and Mechanisms of Abdominal Pain
Patterns and Mechanisms of Abdominal Pain

Three broad CATEGORIES OF ABDOMINAL

PAIN
3. Referred pain – felt at distance from the
disease organ.
 THE GASTROINTESTINAL TRACT - Upper Abdominal Pain, Discomfort, and
Heartburn

Onset: First determine the timing of the pain. Is it acute or chronic? Acute abdominal pain has
many patterns. Did the pain start suddenly or gradually? When did it begin? 
Location: Then ask the patient to point to the pain. Patients are not always clear when they try
to describe in words where pain is most intense. The quadrant where the pain is located can be
helpful. Often underlying organs are involved. If clothes interfere, repeat the question during the
physical examination.
Duration: How long does it last? What is its pattern over a 24-hour period? Over weeks or
months? Are you dealing with an acute illness or a chronic and recurring one?
Characteristic Symptoms: Ask patients to describe the pain in their own words. Pursue
important details: “Where does the pain start?” “Does it radiate or travel anywhere?” “What
is the pain like?”  If the patient has trouble describing the pain, try offering several choices:  “Is
it aching, burning, gnawing . . . ?”  Ask the patient to rank the severity of the pain on a scale of
1 to 10. Note that severity does not always help you to identify the cause. Sensitivity to
abdominal pain varies widely and tends to diminish in older patients, masking acute abdominal
conditions. Pain threshold and how patients accommodate to pain during daily activities also
affect ratings of severity.
 CHRONIC Upper Abdominal Pain or Discomfort

CHRONIC - something that continues over an extended period of time. A chronic condition is
usually long-lasting and does not easily or quickly go away.
 Dyspepsia - as chronic or recurrent discomfort or pain centered in the upper abdomen which
is characterized by postprandial fullness, early satiety, and epigastric pain or burning.
 Discomfort - a subjective negative feeling that is nonpainful. It can include various
symptoms such as bloating, nausea, upper abdominal fullness, and heartburn.
- Note that bloating, nausea, or belching can occur alone or be associated
with other disorders. When they occur alone they do not meet the criteria for dyspepsia.
- Many patients with upper abdominal discomfort or pain will have functional,
or nonulcer, dyspepsia, defined as a 3-month history of nonspecific upper abdominal discomfort
or nausea not attributable to structural abnormalities or peptic ulcer disease. Symptoms are
usually recurring and typically present for more than 6 months.
 CHRONIC Upper Abdominal Pain or Discomfort

CHRONIC - something that continues over an extended period of time. A chronic condition
is usually long-lasting and does not easily or quickly go away. usually lasts longer than six
months. This type of pain can continue even after the injury or illness that caused it has
healed or gone away
 ● Many patients with chronic upper abdominal discomfort or pain complain primarily of
heartburn, acid reflux, or regurgitation. If patients report these symptoms more than
once a week, they are likely to have GERD (90%).
 Heartburn - is a rising retrosternal burning pain or discomfort occurring weekly or
more often. It is typically aggravated by food such as alcohol, chocolate, citrus fruits,
coffee, onions, and peppermint; or positions like bending over, exercising, lifting, or
lying supine.
- Some patients with GERD have atypical respiratory symptoms such as
cough, wheezing, and aspiration pneumonia.
- Others complain of pharyngeal symptoms, such as hoarseness and
chronic sore throat. ● Some patients may have “alarm symptoms,” such as difficulty
swallowing (dysphagia), pain with swallowing (odynophagia), recurrent vomiting, and
ACUTE and CHRONIC LOWER Abdominal Pain or
Discomfort
Acute : means sudden. Acute symptoms appear, change, or worsen rapidly. Acute pain
means pain that will lessen or stop as healing occurs.
Acute pain usually comes on suddenly and is caused by something specific. It is sharp in quality. Acute
pain usually doesn’t last longer than six months. It goes away when there is no longer an underlying
cause for the pain.
1. Acute Lower Abdominal Pain - Patients may complain of acute pain localized to the
right lower quadrant. Find out if it is sharp and continuous or intermittent and
cramping, causing them to double over.

2. Chronic Lower Abdominal Pain - If there is chronic pain in the quadrants of the
lower abdomen, ask about change in bowel habits and alternating diarrhea and
constipation.
Abdominal pain associated with gastrointestinal symptoms and other related symptoms

1. Nausea - is an uncomfortable feeling in the back of your throat or an uneasiness in your

stomach. You may also feel dizzy, lightheaded or have difficulty swallowing. Nausea often goes
along with the urge to vomit but doesn’t always lead to vomiting.
2. Hematemesis - vomiting blood. You may vomit blood along with your stomach contents, or
blood alone. It may be fresh and bright red, or older, darker and coagulated, like coffee
grounds. Hematemesis is a sign of internal bleeding from the upper portion of your digestive
tract — the esophagus, stomach and first portion of your small intestine called the duodenum.
Ex: bleeding ulcer, ruptured blood vessels, chronic pancreatitis
3. Anorexia - is an eating disorder characterized by an abnormally low body weight, an intense
fear of gaining weight and a distorted perception of weight. usually severely restrict the
amount of food they eat. They may control calorie intake by vomiting after eating or by
misusing laxatives, diet aids, diuretics or enemas. They may also try to lose weight by
exercising excessively.
4. Food fear - Cibophobia is defined as the fear of food. People with cibophobia often avoid food
and drinks because they’re afraid of the food itself. The fear may be specific to one type of
food, such as perishable foods, or it may include many foods. It can cause a number of
symptoms, including panic, shortness of breath, and dry mouth. Ex: perishable food, lefetover
foods, expirations foods
Abdominal pain associated with gastrointestinal symptoms and other related symptoms

5. Dysphagia
6. Odynophagia
7. Change in bowel function
8. Diarrhea and constipation
9. Jaundice
THE RENAL SYSTEM

1. Suprapubic Pain - Disorders in the urinary tract may cause pain in either the
abdomen or the back. Bladder disorders may cause suprapubic pain. In bladder
infection, pain in the lower abdomen is typically dull and pressure-like.  In
sudden overdistention of the bladder, pain is often agonizing; in contrast, chronic
bladder distention is usually painless.  Pain of sudden overdistention
accompanies acute urinary retention.
2. Dysuria − Burning sensation / pain during urination. − Difficulty of voiding.
- Women may report internal urethral discomfort, sometimes
described as a pressure or an external burning from the flow of urine across irritated
or inflamed labia. Men typically feel a burning sensation proximal to the glans penis.
In contrast, prostatic pain is felt in the perineum and occasionally in the rectum.
- Painful urination accompanies cystitis or urethritis.
- If dysuria, consider bladder stones, foreign bodies, tumors; also
acute prostatitis. In women, internal burning occurs in urethritis, and external
burning in vulvovaginitis.
Urgency − Is an unusually intense and immediate desire to void, sometimes
leading to involuntary voiding or urge incontinence.
Frequency − Abnormally frequent voiding. Urgency suggests bladder infection
or irritation. In men, painful urination without frequency or urgency suggests
urethritis.
THE RENAL SYSTEM

3. Polyuria − Refers to a significant increase in 24-hour urine volume, roughly

defined as exceeding 3 liters.
Nocturia − Refers to urinary frequency at night, sometimes defined as
awakening the patient more than once; urine volumes may be large or small

4. Urinary Incontinence - An involuntary loss of urine that may become socially

embarrassing or cause problems with hygiene.
If the patient reports incontinence, ask:  When does it happen? How often?  Do
you leak small amounts of urine with increased intra-abdominal  pressure from
coughing, sneezing, laughing, or lifting?  Is it difficult to hold the urine once there
is an urge to void?  Is a large amount of urine lost?  Is there a sensation of
bladder fullness? Frequent leakage?  Do you void small amounts of urine but have
difficulty emptying the bladder?
a. Stress incontinence with increased intra-abdominal pressure suggests
decreased contractility of urethral sphincter or poor support of bladder neck; urge
incontinence, if unable to hold the urine, suggests detrusor overactivity; overflow
incontinence, when the bladder cannot be emptied until bladder pressure exceeds
urethral pressure, indicates anatomic obstruction by prostatic hypertrophy or
stricture, or neurogenic abnormalities. b. Functional incontinence may
arise from impaired cognition, musculoskeletal problems, or immobility.
THE RENAL SYSTEM

c. Overflow urinary incontinence - when the bladder cannot be emptied until bladder
pressure exceeds urethral pressure, indicates anatomic obstruction by prostatic
hypertrophy or stricture, or neurogenic abnormalities.

5. Hematuria - Gross hematuria − Blood in the urine is visible to the naked eye. −
May appear frankly bloody
Microscopic hematuria − Blood may be detected only during
microscopic urinalysis.
- In women, be sure to distinguish menstrual blood from hematuria.
If the urine is reddish, ask about ingestion of beets or medications that might
discolor the urine. Test the urine with a dipstick and microscopic examination before
you settle on the term hematuria.

6. Kidney or Flank Pain and Ureteral Colic

Kidney pain − Often reported as flank pain. − Is a visceral pain usually
produced by distention of the renal capsule and typically dull, aching, and steady.
Ureteral pain − It is usually severe and colicky, originating at the costovertebral
angle and radiating around the trunk into the lower quadrant of the abdomen, or
possibly into the upper thigh and testicle or labium
PHYSICAL EXAMINATION

For a skilled abdominal examination, you need

good light and a relaxed and well-draped patient,
with exposure of the abdomen from just above the
xiphoid process to the symphysis pubis.
The groin should be visible. The genitalia should
remain draped.
The abdominal muscles should be relaxedto
enhance all aspects of the examination, but
especially palpation.
Important Areas of Examination - ABDOMEN
1. INSPECTION - The skin assessment
+ Scars – describe or diagram the location
+ Striae – old silver striae or stretch marks are normal
+ Dilated veins – a few small veins maybe visible normally
+ Rashes and lesions
+ Ecchymosis - the medical term for bruises. These form when blood pools under your skin. They're
caused by a blood vessel break. Bleeding under
● The umbilicus
+ The contour of the abdomen – is it flat, rounded, scaphoid (an inward concavity of the anterior
abdominal wall.). Is the abdomen symmetric? Are there any local bulges? Any visible organ
masses? Look for any enlarge liver or spleen can be seen below the rib cage
+ Increased peristaltic wave – wait for additional minutes if suspected for intestinal obstruction.
visible in very thin people.
+ Increased pulsations – the normal aortic pulsation is frequently visible in the epigastrium.
Important Areas of Examination - ABDOMEN
2. AUSCULTATION - Auscultation provides important information about bowel motility. Listen to the
abdomen before performing percussion or palpation because these maneuvers may alter the
frequency of bowel sounds.
Important Areas of Examination - ABDOMEN
2. AUSCULTATION
+ Abdominal bruit – vascular sound resembling murmurs,
sometimes described as blowing sound. Most frequent
cause is occlusive arterial disease. It is typically heard
over the aorta, renal arteries, iliac arteries and femoral
arteries. The bell of the scope is best used.
+ Friction Rub - produced by friction between roughened
peritoneal surfaces, for example from inflammation or
tumour. It is heard as a creaking or grating noise during
respiration. Over the liver, a friction rub may be caused
by: malignancy:
Important Areas of Examination - ABDOMEN

3. PERCUSSION - Percussion helps you to assess the

amount and distribution of gas in the abdomen and to
identify possible masses that are solid or fluid-filled.
Percuss the abdomen lightly in all four quadrants to assess
the distribution of tympany and dullness.
Important Areas of Examination - ABDOMEN

4. PALPATION
● Light palpation - Feeling the abdomen gently is
especially helpful for identifying abdominal tenderness,
muscular resistance, and some superficial organs and
masses.
● Deep palpation - This is usually required to delineate
abdominal masses. Again using the palmar surfaces of
your fingers, push down about 5 to 8 cm (2 to 3 inches)
and feel in all four quadrants.
Important Areas of Examination - LIVER
1. PERCUSSION - Measure the vertical span of liver dullness in the right midclavicular line.
1. Locate the midclavicular line carefully to avoid inaccurate measurement from use of a
“wandering landmark.”
2. Identify the upper border of liver dullness in the midclavicular line. Starting at the nipple line,
lightly percuss from lung resonance down toward liver dullness.
3. Now measure in centimeters the distance between the two points—the vertical span of liver
dullness
Liver span in the mid-clavicular line is 6-12 cm.
• 2. PALPATION - Place your right hand on the patient's abdomen in the right lower quadrant.
Gently move up to the right upper quadrant lateral to the rectus muscle. Gently pressing in and
up, ask the patient to take a deep breath. If the liver is enlarged, it will come downward to meet
your fingertips and will be recognizable.
+ Normal: the edge of the liver may be palpable just below the costal margin. It is soft and
smooth and may be slightly tender.
+ Caution:
• You should try to palpate liver by superficial palpation and not deep palpation. Liver edge is just
hugging anterior abdominal wall. With superficial palpation, let the liver edge come and touch
your fingers with deep breathing rather than you going after liver.
Important Areas of Examination - KIDNEYS
SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing possible ascites - Ascites is the accumulation of fluid in the peritoneal
cavity.
SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing possible ascites - Ascites is the accumulation of fluid in the peritoneal
cavity.
SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing possible appendicitis - inflammation of the appendix, a small pouch
attached to the large intestine in the right lower quadrant of the abdomen. If the
appendix becomes blocked it will become inflamed and swollen leading to pain,
nausea, vomiting, diarrhea, and fever. If not treated promptly, the appendix can burst
which is a medical emergency requiring an appendectomy.
1. Ask the patient about their general symptoms.
2. 2. Investigate the abdominal pain further. Abdominal pain with appendicitis
begins as generalized or periumbilical (around the belly button) pain. Pain can also
come from the lower right quadrant of the abdomen where the appendix is located.
The patient may also complain of pain during deep breathing, movement, coughing,
or sneezing. If the appendix ruptures, pain may be felt throughout the abdomen
 SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing possible appendicitis –
3. Follow the IAPP sequence.
Inspection, auscultation, light palpation (starting at a spot away from the pain), and abdominal percussion
should be performed in that order during the abdominal examination. It has been demonstrated that
percussion of the abdomen is a more reliable method for detecting the rebound tenderness linked to
peritoneal irritation than quick-release palpation.
4. . Check for signs of peritoneal inflammation.
Test for the following signs:
• Localized tenderness to percussion
• Right lower quadrant guarding
• Cutaneous hyperesthesia, a sensation derived from the T10 to L1 nerve roots, is often an early
although inconsistent sign of appendicitis. Lightly touching the patient with the stethoscope creates
this uncomfortable sensation.
• McBurney’s sign (rebound tenderness over McBurney’s point – the center of the right lower
quadrant)
• Rovsing’s sign (right lower quadrant pain upon palpation of the left lower quadrant)
• Dunphy’s sign (increased sharp abdominal pain with coughing)
SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing possible appendicitis –
5. Test for other appendicitis signs.
The psoas sign (pain when lifting the right leg against resistance) and the obturator sign
(pain on internal rotation of the flexed right hip) are related findings.
SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing possible acute cholecystitis - acute or chronic inflammation of the
gallbladder.
 progressing right upper abdominal pain with bloating, food intolerances (especially
greasy and spicy foods), increased gas, nausea, and vomiting.
 Pain in the midback or shoulder may also occur. This pain could be present for
years until diagnosis.
 Murphy's sign, is usually classic for this disease. - Murphy's sign is elicited in
patients with acute cholecystitis by asking the patient to take in and hold a deep
breath while palpating the right subcostal area. If pain occurs when the inflamed
gallbladder comes into contact with the examiner's hand, Murphy's sign is positive
SPECIAL TECHNIQUES
Please refer to page 505 – 508)
 Assessing ventral hernia - A ventral (abdominal) hernia refers to any protrusion of
intestine or other tissue through a weakness or gap in the abdominal wall. Umbilical
and incisional hernias are specific types of ventral hernias.