Liver

Gallbladder

Duodenum

Head of pancreas

Right kidney and adrenal

Hepatic flexure of colon

Part of ascending and transverse colon

`

Stomach

Spleen

Left lobe of liver

Body of pancreas

Left kidney and adrenal

Splenic flexure of colon

Part of transverse and descending colon

`

Cecum

Appendix

Right ovary and tube

Right ureter

Right spermatic cord

`

Aorta

Uterus (if enlarged)

Bladder (if distended)

`

1 Appetite.

_ Any change in appetite?

Is this a loss of appetite?

_ Any change in weight?

How much weight gained or lost?

Over what time period?

Is the weight loss due to diet?

`

Anorexia

is a loss of appetite from gastrointestinal (GI) disease,

as a side effect to some medications,

with pregnancy,

or with psychological disorders.

`

2 Dysphagia.

_ Any difficulty swallowing?

When did you first notice this?

`

Dysphagia

occurs with disorders of the throat or esophagus.

`

3 Food intolerance.

_ Are there any foods you cannot eat?

What happens if you do eat them:

allergic reaction, heartburn, belching, bloating, indigestion?

_

Do you use antacids? How often?

`

Food intolerance

(e.g., lactase deficiency resulting in bloating or excessive gas after taking milk products).

Pyrosis

(heartburn), a burning sensation in esophagus and stomach, from reflux of gastric acid.

Eructation (belching).

`

abdominal pain

_ Any abdominal pain? Please point to it.

_ Is the pain in one spot, or does it move around?

_ How did it start? How long have you had it?

_ Constant, or does it come and go?

 Occur before or after meals?

 Does it peak? When?

_ How would you describe the character: cramping (colic type), burning in pit of stomach, dull, stabbing, aching?

`

Abdominal pain may be visceral from an internal organ (dull, general, poorly localized);

parietal from inflammation of overlying peritoneum (sharp, precisely localized, aggravated by movement); or

referred

Table 21-2 on p. 559

Acute pain requiring urgent diagnosis occurs with appendicitis, cholecystitis, bowel obstruction, or a perforated organ.

`

_ Is the pain relieved by food, or worse after eating?

`

Chronic pain of gastric ulcers occurs usually on an empty stomach;

pain of duodenal ulcers occurs 2 to 3 hours after a meal and is relieved by more food.

`

_ Is the pain associated with menstrual period or irregularities, stress, dietary indiscretion, fatigue, nausea and vomiting, gas, fever, rectal bleeding, frequent urination, vaginal or penile discharge?

_ What makes the pain worse: food, position, stress, medication, activity?

_ What have you tried to relieve pain: rest, heating pad, change in position, medication?

`

5 Nausea/vomiting.

_ Any nausea or vomiting?

How often? How much comes up? What is the color? Is there an odor?

_ Is it bloody?

_ Is the nausea and vomiting associated with colicky pain, diarrhea, fever, chills?

_ What foods did you eat in the past 24 hours? Where?

At home, school, restaurant?

Is there anyone else in the family with same symptoms in past 24 hours?

Nausea/vomiting is common with GI disease, many medications, and with early pregnancy.

Hematemesis occurs with stomach or duodenal ulcers and esophageal varices.

Consider food poisoning.

bowel habits

_ How often do you have a bowel movement?

_ What is the color? Consistency?

_ Any diarrhea or constipation? How

long?

_ Any recent change in bowel habits?

_ Use laxatives? Which ones? How often do you use them?

`

Assess usual bowel habits.

Black stools may be tarry due to occult blood (melena) from GI bleeding or non-tarry from iron medications.

Gray stools occur with hepatitis.

Red blood in stools occurs with GI bleeding or localized bleeding around the anus.

`

7 Past abdominal history.

_ Any history of gastrointestinal problems: ulcer, gallbladder disease, hepatitis/jaundice, appendicitis, colitis, hernia?

_ Ever had any operations in the abdomen? Please describe.

_ Any problems after surgery?

_ Any abdominal x-ray studies?

How were the results?

medications

_ What medications are you currently taking?

_ How about alcohol—how much would you say you drink each day?

Each week?

When was your last alcoholic drink?

_ How about cigarettes—do you smoke?

How many packs per day? For how long?

`

Peptic ulcer disease

occurs with frequent use of nonsteroidal anti-inflammatory drugs (NSAIDs), alcohol, smoking, and Helicobacter pylori infection.

`

nutritional assessment

_ Now I would like to ask you about your diet.

Please tell me all the food you ate yesterday, starting with breakfast.

_ What fresh food markets are located in your neighborhood?

`

Nutritional assessment

Chapter 11

Many inner-city neighborhoods are fresh food “deserts,” lacking markets but full of fast-food restaurants.

aging adult

1 How do you acquire your groceries and prepare your meals?

Assess risk for nutritional deficit: limited access to grocery store,

income, or cooking facilities;

physical disability (impaired vision, decreased mobility, decreased strength, neurologic deficit).

`

aging adult

2 Do you eat alone or share meals with others?

`

Assess risk for nutritional deficit if living alone;

may not bother to prepare all meals;

social isolation;

depression.

`

aging adult

3 Please tell me all that you had to eat yesterday, starting with breakfast.

`

note:

Attempt week-long diary of intake.

 Food pattern may differ during the month if monthly income (e.g., Social Security check) runs out.

`

aging adult

_ Do you have any trouble swallowing these foods?

_ What do you do right after eating: walk, take a nap?

4 How often do your bowels move?

_ If the person reports constipation: What do you mean by constipation?

How much liquid is in your diet?

How much bulk or fiber?

_ Do you take anything for constipation, such as laxatives?

Which ones? How often?

`

aging adult

_ What medications do you take?

Consider GI side effects (e.g., nausea, upset stomach, anorexia, dry mouth).

INSPECT THE ABDOMEN

Contour

Stand on the person's right side and look down on the abdomen.

Then stoop or sit to gaze across the abdomen. Your head should be slightly higher than the abdomen.

Determine the profile from the rib margin to the pubic bone.

The contour describes the nutritional state and normally ranges from flat to rounded (Fig. 21-7).

`

Scaphoid abdomen caves in. Protuberant abdomen, abdominal distention (see Table 21-1, Abdominal Distention, pp. 557-558).

`

abdomen

symmetry

Shine a light across the abdomen toward you, or shine it lengthwise across the person.

The abdomen should be symmetric bilaterally (Fig. 21-8).

Note any localized bulging, visible mass, or asymmetric shape.

Even small bulges are highlighted by shadow.

Step to the foot of the examination table to recheck symmetry.

`

Bulges, masses.

Hernia—protrusion of abdominal viscera through abnormal opening in muscle wall (see Table 21-3, Abnormalities on Inspection, p. 560).

`

inspect abdomen

symmetry

Ask the person to take a deep breath to further highlight any change.

The abdomen should stay smooth and symmetric.

Or ask the person to perform a sit-up without pushing up with his or her hands.

`

Note any localized bulging.

Hernia, enlarged liver or spleen may show.

Umbilicus

Normally it is midline and inverted, with no sign of discoloration, inflammation, or hernia.

It becomes everted and pushed upward with pregnancy.

`

Everted with ascites or underlying mass (see Table 21-1).

`

The umbilicus is a common site for piercings in young women.

The site should not be red or crusted.

`

Deeply sunken with obesity.

Enlarged, everted with umbilical hernia.

Bluish periumbilical color occurs (though rarely) with intra-abdominal bleeding (Cullen sign).

`

Skin

The surface is smooth and even, with homogeneous color.

This is a good area to judge pigment because it is often protected from sun.

`

Redness with localized inflammation.

Jaundice (shows best in natural daylight).

Skin glistening and taut with ascites.

`

One common pigment change is striae (lineae albicantes)—silvery white, linear, jagged marks about 1 to 6 cm long (Fig. 21-9).

They occur when elastic fibers in the reticular layer of the skin are broken after rapid or prolonged stretching,

as in pregnancy or excessive weight gain.

Recent striae are pink or blue; then they turn silvery white.

`

Striae also occur with ascites.

Striae look purple-blue with Cushing syndrome

(excess adrenocortical hormone causes the skin to be fragile and easily broken from normal stretching).

`

skin inspection

Pigmented nevi (moles)

—circumscribed brown macular or papular areas—

are common on the abdomen.

`

Unusual color or change in shape of mole (see Chapter 12).

Petechiae.

skin inspection

Normally, no lesions are present, although you may note well-healed surgical scars.

If a scar is present, draw its location in the person's record, indicating the length in centimeters (Fig. 21-10).

(Note: Infrequently, a person may forget a past operation while providing the history.

If you note a scar now, ask about it.)

A surgical scar alerts you to the possible presence of underlying adhesions and excess fibrous tissue

`

Cutaneous angiomas (spider nevi) occur with portal hypertension or liver disease.

Lesions, rashes (see Chapter 12).

Underlying adhesions are inflammatory bands that connect opposite sides of serous surfaces after trauma or surgery

`

Veins usually are not seen, but a fine venous network may be visible in thin persons.

Prominent, dilated veins occur

with portal hypertension, cirrhosis, ascites, or vena caval obstruction.

Veins are more visible with malnutrition as a result of thinned adipose tissue.

`

Good skin turgor reflects healthy nutrition.

Gently pinch up a fold of skin;

then release to note the skin's immediate return to original position.

`

Poor turgor occurs with dehydration, which often accompanies GI disease.

`

Pulsation or Movement

Normally, you may see the pulsations from the aorta beneath the skin in the epigastric area,

particularly in thin persons with good muscle wall relaxation.

Respiratory movement also shows in the abdomen, particularly in males.

Finally, waves of peristalsis sometimes are visible in very thin persons.

They ripple slowly and obliquely across the abdomen.

`

Marked pulsation of aorta occurs with

widened pulse pressure (e.g., hypertension, aortic insufficiency, thyrotoxicosis) and with aortic aneurysm.

Marked visible peristalsis, together with a distended abdomen,

indicates intestinal obstruction.

`

Hair Distribution

The pattern of pubic hair growth normally has a diamond shape in adult males

and an inverted triangle shape in adult females (see Chapters 24 and 26).

Patterns alter with endocrine or hormone abnormalities, chronic liver disease.

`

Demeanor

A comfortable person is relaxed quietly on the examining table and has a benign facial expression and slow, even respirations.

`

Restlessness and constant turning to find comfort occur with the colicky pain of gastroenteritis or bowel obstruction.

Absolute stillness, resisting any movement, occurs with the pain of peritonitis.

Knees flexed up, facial grimacing, and rapid, uneven respirations also indicate pain.

`

AUSCULTATE BOWEL SOUNDS AND VASCULAR SOUNDS

Depart from the usual examination sequence and auscultate the abdomen next.

This is done because percussion and palpation can increase peristalsis, which would give a false interpretation of bowel sounds.

Use the diaphragm endpiece because bowel sounds are relatively high-pitched.

Hold the stethoscope lightly against the skin;

pushing too hard may stimulate more bowel sounds (Fig. 21-11).

Begin in the RLQ at the ileocecal valve area because bowel sounds are normally always present here.

`

Vascular Sounds

As you listen to the abdomen, note the presence of any vascular sounds or bruits.

Using firmer pressure, check over the aorta, renal arteries, iliac, and femoral arteries, especially in people with hypertension (Fig. 21-12).

Usually, no such sound is present.

However, a small number of healthy persons (usually younger than 40 years) may have a normal bruit originating from the celiac artery.³⁰

This is systolic, medium to low in pitch, and heard between the xiphoid process and the umbilicus.

`

Note location, pitch, and timing of a vascular sound.

A systolic bruit is a pulsatile blowing sound and occurs with stenosis or occlusion of an artery.

Venous hum and peritoneal friction rub are rare (see Table 21-5, Friction Rubs and Vascular Sounds, p. 562).

`

PERCUSS GENERAL TYMPANY, LIVER SPAN, AND SPLENIC DULLNESS

Percuss to assess the relative density of abdominal contents, to locate organs, and to screen for abnormal fluid or masses.

`

General Tympany

First, percuss lightly in all four quadrants to determine the prevailing amount of tympany and dullness (Fig. 21-13).

Move clockwise.

Tympany should predominate because air in the intestines rises to the surface when the person is supine.

`

Dullness occurs over a distended bladder, adipose tissue, fluid, or a mass.

Hyperresonance is present with gaseous distention.

`

percuss

Liver Span

Next, percuss to map out the boundaries of certain organs.

Measure the height of the liver in the right midclavicular line.

(For a consistent placement of the midclavicular line landmark, remember to palpate the acromioclavicular and the sternoclavicular joints and judge the line at a point midway between the two.)

Begin in the area of lung resonance, and percuss down the interspaces until the sound changes to a dull quality (Fig. 21-14).

Mark the spot, usually in the fifth intercostal space.

Then find abdominal tympany and percuss up in the midclavicular line.

Mark where the sound changes from tympany to a dull sound, normally at the right costal margin

Measure the distance between the two marks; the normal liver span in the adult ranges from 6 to 12 cm (Fig. 21-15).

The height of the liver span correlates with the height of the person; taller people have longer livers.

Also males have a larger liver span than females of the same height.

 Overall, the mean liver span is 10.5 cm for males and 7 cm for females.

`

An enlarged liver span indicates liver enlargement or hepatomegaly.

Accurate detection of liver borders is confused by dullness above the fifth intercostal space,

which occurs with lung disease (e.g., pleural effusion or consolidation).

Accurate detection at the lower border is confused when dullness is pushed up with ascites or pregnancy or with gas distention in the colon,

which obscures the lower border.

`

Splenic Dullness

Often the spleen is obscured by stomach contents,

but you may locate it by percussing for a dull note from the ninth to eleventh intercostal space just behind the left midaxillary line (Fig. 21-16).

The area of splenic dullness normally is not wider than 7 cm in the adult and should not encroach on the normal tympany over the gastric air bubble.

`

A dull note forward of the midaxillary line indicates enlargement of the spleen, as occurs with mononucleosis, trauma, and infection.

`

splenic dullness

Now percuss in the lowest interspace in the left anterior axillary line.

Tympany should result.

Ask the person to take a deep breath.

Normally, tympany remains through full inspiration.

`

In this site, the anterior axillary line,

a change in percussion from tympany to a dull sound with full inspiration is a positive spleen percussion sign,

indicating splenomegaly.

This method will detect mild to moderate splenomegaly before the spleen becomes palpable,

as in mononucleosis, malaria, or hepatic cirrhosis.

`

Costovertebral Angle Tenderness

Indirect fist percussion causes the tissues to vibrate instead of producing a sound.

To assess the kidney, place one hand over the twelfth rib at the costovertebral angle on the back (Fig. 21-17).

Thump that hand with the ulnar edge of your other fist.

The person normally feels a thud but no pain.

(Although this step is explained here with percussion techniques, its usual sequence in a complete examination is with thoracic assessment, when the person is sitting up and you are standing behind.)

`

Sharp pain occurs with inflammation of the kidney or paranephric area.

`

Special Procedures

At times, you may suspect that a person has ascites (free fluid in the peritoneal cavity) because of a distended abdomen, bulging flanks, and an umbilicus that is protruding and displaced downward.

You can differentiate ascites from gaseous distention by performing two percussion tests.

`

Ascites occurs with heart failure, portal hypertension, cirrhosis, hepatitis, pancreatitis, and cancer.

`

special procedures

Fluid Wave.First, test for a fluid wave by standing on the person's right side.

Place the ulnar edge of another examiner's hand or the patient's own hand firmly on the abdomen in the midline (Fig. 21-18).

(This will stop transmission across the skin of the upcoming tap.)

Place your left hand on the person's right flank.

With your right hand, reach across the abdomen and give the left flank a firm strike.

If ascites is present, the blow will generate a fluid wave through the abdomen and you will feel a distinct tap on your left hand.

If the abdomen is distended from gas or adipose tissue,

you will feel no change.

A positive fluid wave test occurs with large amounts of ascitic fluid.

`

Shifting Dullness.

shifting dullness.

In a supine person, ascitic fluid settles by gravity into the flanks, displacing the air-filled bowel upward.

You will hear a tympanitic note as you percuss over the top of the abdomen because gas-filled intestines float over the fluid (Fig. 21-19).

Then percuss down the side of the abdomen.

If fluid is present, the note will change from tympany to dull as you reach its level.

Mark this spot.

Now turn the person onto the right side (roll the person toward you) (Fig. 21-20).

The fluid will gravitate to the dependent (in this case, right) side, displacing the lighter bowel upward.

Begin percussing the upper side of the abdomen and move downward.

The sound changes from tympany to a dull sound as you reach the fluid level, but this time the level of dullness is higher, upward toward the umbilicus.

This shifting level of dullness indicates the presence of fluid.

`

Shifting dullness is positive with a large volume of ascitic fluid: it will not detect less than 500 mL of fluid.

Both tests, fluid wave and shifting dullness, are not completely reliable. Ultrasound study is the definitive tool.

`

PALPATE SURFACE AND DEEP AREAS

Perform palpation to judge the size, location, and consistency of certain organs and to screen for an abnormal mass or tenderness.

Review comfort measures on p. 536.

Because most people are naturally inclined to protect the abdomen,

you need to use additional measures to enhance complete muscle relaxation.

`

1 Bend the person's knees.

2 Keep your palpating hand low and parallel to the abdomen. Holding the hand high and pointing down would make anyone tense up.

3 Teach the person to breathe slowly (in through the nose, and out through the mouth).

4 Keep your own voice low and soothing. Conversation may relax the person.

5 Try “emotive imagery.” For example, you might say, “Now I want you to imagine you are dozing on the beach, with the sun warming your muscles and the sound of the waves lulling you to sleep.

Let yourself relax.”

6 With a very ticklish person, keep the person's hand under your own with your fingers curled over his or her fingers.

Move both hands around as you palpate; people are not ticklish to themselves.

7 Alternatively, perform palpation just after auscultation. Keep the stethoscope in place and curl your fingers around it, palpating as you pretend to auscultate.

People do not perceive a stethoscope as a ticklish object.

 You can slide the stethoscope out when the person is used to being touched.

`

Light and Deep Palpation

Begin with light palpation.

With the first four fingers close together, depress the skin about 1 cm (Fig. 21-21).

Make a gentle rotary motion, sliding the fingers and skin together.

Then lift the fingers (do not drag them) and move clockwise to the next location around the abdomen.

The objective here is not to search

 for organs but to form an overall impression of the skin surface and superficial musculature.

Save the examination of any identified tender areas until last.

This method avoids pain and the resulting muscle rigidity that would obscure deep palpation later in the examination.

`

Muscle guarding.

Rigidity.

Large masses.

Tenderness.

`

palpation

As you circle the abdomen, discriminate between voluntary muscle guarding and involuntary rigidity.

Voluntary guarding occurs when the person is cold, tense, or ticklish.

It is bilateral, and you will feel the muscles relax slightly during exhalation.

Use the relaxation measures to try to eliminate this type of guarding, or it will interfere with deep palpation.

If the rigidity persists, it is probably involuntary.

`

Involuntary rigidity is a constant, boardlike hardness of the muscles.

It is a protective mechanism accompanying acute inflammation of the peritoneum.

It may be unilateral, and the same area usually becomes painful when the person increases intra-abdominal pressure by attempting a sit-up.

Now perform deep palpation using the same technique described earlier, but push down about 5 to 8 cm (2 to 3 inches) (Fig. 21-22).

 Moving clockwise, explore the entire abdomen.

To overcome the resistance of a very large or obese abdomen, use a bimanual technique.

Place your two hands on top of each other (Fig. 21-23).

The top hand does the pushing; the bottom hand is relaxed and can concentrate on the sense of palpation.

With either technique, note the location, size, consistency, and mobility of any palpable organs and the presence of any abnormal enlargement, tenderness, or masses.

`

Making sense of what you are feeling is more difficult than it looks.

Inexperienced examiners complain that the abdomen “all feels the same,” as if they are pushing their hand into a soft sofa cushion.

It helps to memorize the anatomy and visualize what is under each quadrant as you palpate.

Also remember that some structures are normally palpable, as illustrated in Fig. 21-24.

`

deep palpation

Mild tenderness normally is present when palpating the sigmoid colon. Any other tenderness should be investigated.

Tenderness occurs with local inflammation, with inflammation of the peritoneum or underlying organ, and with an enlarged organ whose capsule is stretched.

`

If you identify a mass, first distinguish it from a normally palpable structure or an enlarged organ. Then note the following:

`

1 Location

2 Size

3 Shape

4 Consistency (soft, firm, hard)

5 Surface (smooth, nodular)

6 Mobility (including movement with respirations)

7 Pulsatility

8 Tenderness

`

palpation Liver

Next, palpate for specific organs, beginning with the liver in the RUQ (Fig. 21-25).

Place your left hand under the person's back parallel to the eleventh and twelfth ribs and lift up to support the abdominal contents.

Place your right hand on the RUQ, with fingers parallel to the midline.

Push deeply down and under the right costal margin.

Ask the person to breathe slowly.

With every exhalation, move your palpating hand up 1 or 2 cm.

It is normal to feel the edge of the liver bump your fingertips as the diaphragm pushes it down during inhalation.

It feels like a firm, regular ridge. Often, the liver is not palpable and you feel nothing firm.

`

Except with a depressed diaphragm, a liver palpated more than 1 to 2 cm below the right costal margin is enlarged.

Record the number of centimeters it descends and note its consistency (hard, nodular) and tenderness (see Table 21-6, Palpation of Enlarged Organs, on pp. 562-563).

`

Hooking Technique.

An alternative method of palpating the liver is to stand up at the person's shoulder and swivel your body to the right so that you face the person's feet (Fig. 21-26).

 Hook your fingers over the costal margin from above.

Ask the person to take a deep breath.

 Try to feel the liver edge bump your fingertips.

`

Spleen

Normally, the spleen is not palpable and must be enlarged three times its normal size to be felt.

To search for it, reach your left hand over the abdomen and behind the left side at the eleventh and twelfth ribs (Fig. 21-27, A).

Lift up for support. Place your right hand obliquely on the LUQ with the fingers pointing toward the left axilla and just inferior to the rib margin.

Push your hand deeply down and under the left costal margin and ask the person to take a deep breath.

You should feel nothing firm.

When enlarged, the spleen slides out and bumps your fingertips.

It can grow so large that it extends into the lower quadrants.

When this condition is suspected, start low so you will not miss it.

An alternative position is to roll the person onto his or her right side to displace the spleen more forward and downward (Fig. 21-27, B).

 Then palpate as described earlier.

`

The spleen enlarges with mononucleosis, trauma, leukemias, and lymphomas (see Table 21-6).

If you feel an enlarged spleen, refer the person but do not continue to palpate it.

An enlarged spleen is friable and can rupture easily with overpalpation.

Describe the number of centimeters it extends below the left costal margin.

`

Kidneys

Search for the right kidney by placing your hands together in a “duck-bill” position at the person's right flank (Fig. 21-28, A).

Press your two hands together firmly (you need deeper palpation than that used with the liver or spleen) and ask the person to take a deep breath.

In most people, you will feel no change.

Occasionally, you may feel the lower pole of the right kidney as a round, smooth mass slide between your fingers.

Either condition is normal.

`

Enlarged kidney.

Kidney mass.

`

The left kidney sits 1 cm higher than the right kidney and is not palpable normally.

Search for it by reaching your left hand across the abdomen and behind the left flank for support (Fig. 21-28, B).

Push your right hand deep into the abdomen and ask the person to breathe deeply.

You should feel no change with the inhalation.

`

Aorta

Using your opposing thumb and fingers, palpate the aortic pulsation in the upper abdomen slightly to the left of midline (Fig. 21-29).

 Normally, it is 2.5 to 4 cm wide in the adult and pulsates in an anterior direction.

`

Widened with aneurysm (see Tables 21-5 and 21-6).

Prominent lateral pulsation with aortic aneurysm pushes the examiner's two fingers apart.

`

the aging adult

On inspection, you may note increased deposits of subcutaneous fat on the abdomen and hips because it is redistributed away from the extremities.

The abdominal musculature is thinner and has less tone than that of the younger adult; thus, in the absence of obesity, you may note peristalsis.

Because of the thinner, softer abdominal wall, the organs may be easier to palpate (in the absence of obesity).

The liver is easier to palpate. Normally, you will feel the liver edge at or just below the costal margin.

 With distended lungs and a depressed diaphragm, the liver is palpated lower, descending 1 to 2 cm below the costal margin with inhalation.

The kidneys are easier to palpate.

`

Abdominal rigidity with acute abdominal conditions is less common in aging.

With an acute abdomen, the aging person often complains of less pain than a younger person would.

`

referred pain

Liver.

Hepatitis may have mild to moderate, dull pain in right upper quadrant or epigastrium, along with anorexia, nausea, malaise, low-grade fever.

`

referred pain

Esophagus. Gastroesophageal reflux disease (GERD) is a complex of symptoms of esophagitis,

including burning pain in midepigastrium or behind lower sternum that radiates upward, or “heartburn.”

Occurs 30 to 60 minutes after eating; aggravated by lying down or bending over.

`

referred pain

Gallbladder. Cholecystitis is biliary colic, sudden pain in right upper quadrant that may radiate to right or left scapula,

and which builds over time, lasting 2 to 4 hours, after ingestion of fatty foods, alcohol, or caffeine.

Associated with nausea and vomiting and with positive Murphy sign or sudden stop in inspiration with RUQ palpation.

`

referred pain

Pancreas. Pancreatitis has acute, boring midepigastric pain radiating to the back and

sometimes to the left scapula or flank, severe nausea, and vomiting.

`

Duodenum.

does not radiate, may be relieved by food, and may awaken the person from sleep.

`

referred pain

Stomach. Gastric ulcer pain is dull, aching, gnawing epigastric pain, usually brought on by food, radiates to back or substernal area.

Pain of perforated ulcer is burning epigastric pain

of sudden onset that refers to one or both shoulders.

`

Appendix.

persistent pain and tenderness localized in RLQ (McBurney point).

Pain is aggravated by movement, coughing, deep breathing; associated with anorexia, then nausea and vomiting, fever.

`

referred pain

Kidney. Kidney stones prompt a sudden onset of severe, colicky flank or lower abdominal pain.

Small intestine.

`

referred pain

Colon. Large bowel obstruction has moderate, colicky pain of gradual onset in lower abdomen, bloating.

 Irritable bowel syndrome (IBS) has sharp or burning, cramping pain over a wide area; does not radiate. Brought on by meals, relieved by bowel movement.

`