Professional guide to signs symptoms, 6th edition

Associated findings include vague abdominal pain, fever, anorexia, nausea, vomit-ing, constipation or diarrhea, bleeding tenden-cies, severe pruritus, palmar erythema, spider angiomas, l

P ROFESSIONAL G UIDE TO

P ROFESSIONAL G UIDE TO

of our knowledge, these procedures reflect currently cepted practice Nevertheless, they can’t be consideredabsolute and universal recommendations For individualapplications, all recommendations must be considered

ac-in light of the patient’s clac-inical condition and, before ministration of new or infrequently used drugs, in light

ad-of the latest package-insert information The authorsand publisher disclaim any responsibility for any ad-verse effects resulting from the suggested procedures,from any undetected errors, or from the reader’s misun-derstanding of the text

© 2011 by Lippincott Williams & Wilkins All rights served This book is protected by copyright No part of itmay be reproduced, stored in a retrieval system, ortransmitted, in any form or by any means—electronic,mechanical, photocopy, recording, or otherwise—with-out prior written permission of the publisher, except forbrief quotations embodied in critical articles and re-views and testing and evaluation materials provided bypublisher to instructors whose schools have adopted itsaccompanying textbook For information, write Lippin-cott Williams & Wilkins, 323 Norristown Road, Suite

re-200, Ambler, PA 19002-2756

Printed in ChinaPGSS6E—010310

Library of Congress Cataloging-in-Publication Data

Professional guide to signs & symptoms — 6th ed

WY 49 P964 2011]

RC69.P77 2011616⬘.047—dc22

Selected signs & symptoms 724

Potential agents of bioterrorism 744

Adverse effects associated with herbs 746

Guide to laboratory test results 752

CONTENTS

Assistant Professor and Academic Coordinator

Department of Physician Assistant Studies

University of South Alabama

Fort Smith, Arkansas

Laura M Criddle, RN, PhD, CNS-BC, ONC,

Coastline Writing Consultants

Assistant Professor (Retired)

University of North Carolina—Wilmington

School of Nursing

Wilmington, North Carolina

Julia Anne Isen, RN, MS, FNP-C

Assistant Clinical Professor

Anna Lee Jarrett, PhD, ACNP/ACNS, BC

APN/Program Manager, Rapid Response TeamCentral Arkansas Veterans Healthcare SystemLittle Rock, Arkansas

Cynthia Miculan, RN, MSN, ONC, CE-BC

Clinical ManagerThe University HospitalCincinnati, Ohio

Steven Noakes, MPAS, PA-C

Division Officer, Acute Care ClinicMarine Corps Recruit DepotSan Diego, California

Allen Phelps, MPAS, PA-C

Physician AssistantNaval Medical CenterSan Diego, California

Rexann G Pickering, RN, BSN, MS, MSN, PhD, CIM, CIP

Administrator, Human Protection–ResearchMethodist Healthcare

Richard R Roach, MD, FACP

Assistant Professor of Internal Medicine

Michigan State University

Kalamazoo Center for Medical Studies

Kalamazoo, Michigan

Ora V Robinson, RN, PhD

Assistant Professor

California State University

San Bernardino, California

Phillip Todd Smith, MHS, PA-C

Assistant Professor

Department of Physician Assistant Studies

University of South Alabama

Mobile, Alabama

Allison J Terry, RN, MSN, PhD

Director, Center for Nursing

Alabama Board of Nursing

Gail A Viergutz, MS, ANP-C

Nurse Practitioner, Emergency Department and

With continuing advances in medical

technolo-gy, laboratory studies, and diagnostic testing,

clinical diagnosis and physical examination

skills are in danger of becoming a lost art I

have seen too many students and novice

practi-tioners become overly dependent on frequently

imperfect, unreliable, and expensive tests to

di-agnose the cause of their patients’ illnesses The

sixth edition of Professional Guide to Signs &

Symptoms will help ensure that this doesn’t

hap-pen This fully reviewed and updated edition

provides a comprehensive yet

easy-to-understand compilation of many important

signs and symptoms seen in clinical practice,

and can help guide initial interventions and the

appropriate use of laboratory and diagnostic

studies

The scope and organization of this sixth

edi-tion make it a valuable reference for students,

nurses, and practitioners at all levels of training

and expertise More than 500 clinical signs and

symptoms are arranged alphabetically and

dis-cussed in the body of the text The new full-color

format is appealing and enables quick and easy

retrieval of relevant information Easy-to-read

tables, charts, and illustrations make

difficult-to-grasp physiologic and clinical concepts

un-derstandable Potentially obscure pathologic

signs are clearly explained and should become

more readily apparent to the astute clinical

ob-server New sections examining troublesome

in-fectious diseases (methicillin-resistant

Staphylo-coccus aureus, vancomycin-resistant

enterococci, and vancomycin-resistant S.

aureus) and popcorn lung disease (diacetyl

ex-posure) are included

Each sign and symptom is reviewed in a cise and standard format Every entry beginswith a brief review of the sign or symptom and

con-is followed, where applicable, by a focused dcon-is-cussion of possible emergency interventions.Relevant history and physical findings are thenreviewed and possible medical causes are dis-cussed Special considerations for caregiversprovide practical advice, and pointers for pedi-atric and elderly populations should be particu-larly helpful for those who care for patients ateither end of the age spectrum Detailed differ-ential diagnosis matrixes and flowcharts inter-spersed throughout the text aid patient assess-ment and diagnosis, while patient counselingsections provide helpful recommendations forpatients and families once the diagnosis is es-tablished

dis-An additional 250 less frequently tered selected signs and symptoms are brieflyreviewed in the first appendix Updated sections

encoun-on the signs and symptoms of bioterrorismagents and the adverse effects of herbal reme-dies are particularly timely The guide to obtain-ing a patient history provides helpful tips forconducting a medical interview, collecting pri-mary clinical data, and performing a thoroughreview of systems The index is cross-referenced and thorough, and the inside-the-cover listing of common signs and symptoms inboth English and Spanish make this sixth edi-tion a valuable reference for students, nurses,and practitioners living or traveling abroad

I believe anyone who provides clinical care topatients and who is interested in the focusedand appropriate use of medical technology,

diagnostic testing, and initial interventions will

find this comprehensive text extremely valuable

The standardized format with its easy-to-read

tables, charts, and illustrations make this sixth

edition an indispensable tool for the inquisitive

student, nurse, or clinical practitioner

Charles W Mackett III, MD, FAAFP

Associate Professor and Executive

Vice Chairman

Department of Family Medicine

University of Pittsburgh (Pa.) Medical Center

F O R E W O R D ix

Abdominal distention

Abdominal distention refers to increased

ab-dominal girth—the result of increased

intra-abdominal pressure forcing the intra-abdominal wall

outward Distention may be mild or severe,

de-pending on the amount of pressure It may be

localized or diffuse and may occur gradually or

suddenly Acute abdominal distention may

sig-nal life-threatening peritonitis or acute bowel

obstruction

Abdominal distention may result from fat,

fla-tus, a fetus (pregnancy or intra-abdominal mass

[ectopic pregnancy]), or fluid Fluid and gas are

normally present in the GI tract but not in the

peritoneal cavity However, if fluid and gas are

unable to pass freely through the GI tract,

ab-dominal distention occurs In the peritoneal

cavity, distention may reflect acute bleeding,

ac-cumulation of ascitic fluid, or air from

perfora-tion of an abdominal organ

Abdominal distention doesn’t always signal

pathology For example, in anxious patients or

those with digestive distress, localized

disten-tion in the left upper quadrant can result from

aerophagia—the unconscious swallowing of air

Generalized distention can result from ingestion

of fruits or vegetables with large quantities of

unabsorbable carbohydrates, such as legumes,

or from abnormal food fermentation by

mi-crobes Don’t forget to rule out pregnancy in all

females with abdominal distention

EMERGENCY INTERVENTIONS If the

pa-tient displays abdominal distention, quickly

check for signs of hypovolemia, such as pallor,

diaphoresis, hypotension, rapid and thready pulse, rapid and shallow breathing, decreased urine out- put, poor capillary refill, and altered mentation Ask the patient if he’s experiencing severe abdomi- nal pain or difficulty breathing Find out about any recent accidents, and observe the patient for signs

of trauma and peritoneal bleeding, such as Cullen’s sign or Turner’s sign Then auscultate all abdominal quadrants, noting rapid and high- pitched, diminished, or absent bowel sounds (If you don’t hear bowel sounds immediately, listen for at least 5 minutes.) Gently palpate the ab- domen for rigidity Remember that deep or exten- sive palpation may increase pain.

If you detect abdominal distention and rigidity along with abnormal bowel sounds, and the pa- tient complains of pain, begin emergency inter- ventions Place the patient in the supine posi- tion, administer oxygen, and insert an I.V catheter for fluid replacement Prepare to insert

a nasogastric tube to relieve acute intraluminal distention Reassure the patient and prepare him for surgery

H ISTORY AND PHYSICAL EXAMINATION

If the patient’s abdominal distention isn’t acute,ask about its onset and duration and associatedsigns A patient with localized distention mayreport a sensation of pressure, fullness, or ten-derness in the affected area A patient with gen-eralized distention may report a bloated feeling,

a pounding heartbeat, and difficulty breathingdeeply or breathing when lying flat The patientmay also feel unable to bend at his waist Be

A

sure to ask about abdominal pain, fever,

nausea, vomiting, anorexia, altered bowel

habits, and weight gain or loss

Obtain a medical history, noting GI or biliary

disorders that may cause peritonitis or ascites,

such as cirrhosis, hepatitis, or inflammatory

bowel disease (See Detecting ascites.) Also note

chronic constipation Has the patient recently

had abdominal surgery, which can lead to

ab-dominal distention? Ask about recent

acci-dents, even minor ones, like falling off a

step-ladder

Perform a complete physical examination

Don’t restrict the examination to the abdomen

because you could miss important clues to the

cause of abdominal distention Next, stand at

the foot of the bed and observe the recumbent

patient for abdominal asymmetry to determine

if distention is localized or generalized Then

assess abdominal contour by stooping at his

side Inspect for tense, glistening skin and

bulging flanks, which may indicate ascites

Ob-serve the umbilicus An everted umbilicus may

indicate ascites or an umbilical hernia An

in-verted umbilicus may indicate distention from

gas; it’s also common in obese individuals

In-spect the abdomen for signs of an inguinal or

femoral hernia and for incisions that may point

to adhesions; both may lead to intestinal

ob-struction Then auscultate for bowel sounds,

abdominal friction rubs (indicating peritoneal

inflammation), and bruits (indicating an

aneurysm) Listen for a succussion splash—a

splashing sound normally heard in the stomach

when the patient moves or when palpation

dis-turbs the viscera An abnormally loud splash

indicates fluid accumulation, suggesting gastric

dilation or obstruction

Next, percuss and palpate the abdomen to

determine if distention results from air, fluid, or

both A tympanic note in the left lower quadrant

suggests an air-filled descending or sigmoid

colon A tympanic note throughout a generally

distended abdomen suggests an air-filled

peri-toneal cavity A dull percussion note throughout

a generally distended abdomen suggests a

fluid-filled peritoneal cavity Shifting of dullness

later-ally when the patient is in the decubitus

posi-tion also indicates a fluid-filled abdominal

cavity A pelvic or intra-abdominal mass causes

local dullness upon percussion and should be

palpable Obesity causes a large abdomen with

generalized rather then localized dullness and

without shifting dullness, prominent tympany,

or palpable bowel or other masses

Palpate the abdomen for tenderness, notingwhether it’s localized or generalized Watch forperitoneal signs and symptoms, such asrebound tenderness, guarding, rigidity, McBurney’s point, obturator sign, and psoassign Female patients should undergo a pelvicexamination; males, a genital examination Allpatients who report abdominal pain should un-dergo a digital rectal examination with fecaloccult blood testing Finally, measure abdomi-nal girth for a baseline value Mark the flankswith a felt-tipped pen as a reference point for

subsequent measurements (See Abdominal tention: Causes and associated findings, pages 4

dis-and 5.)

M EDICAL CAUSES

◆Abdominal cancer Generalized abdominal

distention may occur when the cancer—mostcommonly ovarian, hepatic, or pancreaticcancer—produces ascites (usually in a patientwith a known tumor) It’s an indication of ad-vanced disease Shifting dullness and a fluidwave accompany distention Associated signsand symptoms may include severe abdominalpain, an abdominal mass, anorexia, jaundice, GIhemorrhage (hematemesis or melena), dyspep-sia, and weight loss that progresses to muscleweakness and atrophy

◆Abdominal trauma When brisk internal

bleeding accompanies trauma, abdominal tention may be acute and dramatic Associatedsigns and symptoms of this life-threatening dis-order include abdominal rigidity with guarding,decreased or absent bowel sounds, vomiting,tenderness, and abdominal bruising The pa-tient may feel pain over the trauma site, or overthe scapula if abdominal bleeding irritates thephrenic nerve Signs of hypovolemic shock(such as hypotension and rapid, thready pulse)appear with significant blood loss

dis-◆Bladder distention Various disorders cause

bladder distention, which in turn causes lowerabdominal distention Slight dullness on percus-sion above the symphysis indicates mild bladderdistention A palpable, smooth, rounded, fluctu-ant suprapubic mass suggests severe distention;

a fluctuant mass extending to the umbilicus dicates extremely severe distention Urinarydribbling, frequency, or urgency may occur withurinary obstruction Suprapubic discomfort isalso common

in-◆Cirrhosis In cirrhosis, ascites causes

gener-alized distention and is confirmed by a fluidwave, shifting dullness, and a puddle sign

2 A B D O M I N A L D I S T E N T I O N

Umbilical eversion and caput medusae (dilated

veins around the umbilicus) are common The

patient may report a feeling of fullness or

weight gain Associated findings include vague

abdominal pain, fever, anorexia, nausea,

vomit-ing, constipation or diarrhea, bleeding

tenden-cies, severe pruritus, palmar erythema, spider

angiomas, leg edema, and possibly splenomegaly

Hematemesis, encephalopathy, gynecomastia,

or testicular atrophy may also occur Jaundice

is usually a late sign Hepatomegaly occurs

ini-tially, but the liver may not be palpable in

ad-vanced disease

◆Gastric dilation (acute)

Left-upper-quadrant distention is characteristic in acutegastric dilation, but the presentation varies Thepatient usually complains of epigastric fullness

or pain and nausea with or without vomiting.Physical examination reveals tympany, gastrictenderness, and a succussion splash Initially,peristalsis may be visible Later, hypoactive orabsent bowel sounds confirm ileus The patientmay be pale and diaphoretic and may exhibittachycardia or bradycardia

◆Heart failure Generalized abdominal

dis-tention due to ascites typically accompanies

Step 1 With the patient in a supine

posi-tion, percuss from the umbilicus outward

to the flank, as shown Draw a line on

the patient’s skin to mark the change

from tympany to dullness

Step 2 Turn the patient onto his side.

(Note that this position causes ascitic

flu-id to shift.) Percuss again and mark the

change from tympany to dullness Any

difference between these lines can

indi-cate ascites

Fluid wave

Have another person press deeply into

the patient’s midline to prevent vibration

from traveling along the abdominal wall

Place one of your palms on one of the

patient’s flanks, as shown Strike the

op-posite flank with your other hand If you

feel the blow in the opposite palm,

as-citic fluid is present

(Text continues on page 6.)

4 A B D O M I N A L D I S T E N T I O N

SIGNS & SYMPTOMS

Abdominal distention: Causes and associated findings

Abdominal mass Abdominal pain Abdominal rigidity Anorexia Bowel sounds, absent Bowel sounds, hyperactive Bowel sounds, hypoactive Constipation Diarrhea Edema

6 A B D O M I N A L D I S T E N T I O N

ized abdominal distention with a fluid wave andshifting dullness It may also produce elevatedblood pressure, hematuria or oliguria, fatigue,anorexia, depression, pallor, periorbital edema,scrotal swelling, and skin striae

◆Ovarian cysts Typically, large ovarian cysts

produce lower abdominal distention nied by umbilical eversion Because they’re thinwalled and fluid filled, these cysts produce a flu-

accompa-id wave and shifting dullness—signs that mimicascites Lower abdominal pain and a palpablemass may be present

◆Paralytic ileus Paralytic ileus, which

pro-duces generalized distention with a tympanicpercussion note, is accompanied by absent orhypoactive bowel sounds and, occasionally,mild abdominal pain and vomiting The patientmay be severely constipated or may pass flatusand small, liquid stools

◆Peritonitis In peritonitis—a life-threatening

disorder—abdominal distention may be ized or generalized, depending on the extent ofperitonitis Fluid accumulates first within theperitoneal cavity and then within the bowel lu-men, causing a fluid wave and shifting dullness.Typically, distention is accompanied by reboundtenderness, abdominal rigidity, and sudden andsevere abdominal pain that worsens with move-ment

local-The skin over the patient’s abdomen may pear taut Associated signs and symptoms usu-ally include hypoactive or absent bowel sounds,fever, chills, hyperalgesia, nausea, and vomit-ing Signs of shock, such as tachycardia and hy-potension, appear with significant fluid loss intothe abdomen

ap-◆Small-bowel obstruction Abdominal

dis-tention, which is characteristic in small-bowelobstruction—a life-threatening disorder—ismost pronounced during late obstruction, espe-cially in the distal small bowel Auscultation re-veals hypoactive or hyperactive bowel sounds,whereas percussion produces a tympanic note.Accompanying signs and symptoms includecolicky periumbilical pain, constipation, nau-sea, and vomiting; the higher the obstruction,the earlier and more severe the vomiting Re-bound tenderness reflects intestinal strangula-tion with ischemia Associated signs and symp-toms include drowsiness, malaise, and signs ofdehydration Signs of hypovolemic shock ap-pear with progressive dehydration and plasmaloss

◆Toxic megacolon (acute) Toxic megacolon

is a life-threatening complication of infectious

severe cardiovascular impairment and is

con-firmed by shifting dullness and a fluid wave

Signs and symptoms of heart failure are

numer-ous and depend on the disease stage and

de-gree of cardiovascular impairment Hallmarks

include peripheral edema, jugular vein

disten-tion, dyspnea, and tachycardia Common

associated signs and symptoms include

hepato-megaly (which may cause right-upper-quadrant

pain), nausea, vomiting, productive cough,

crackles, cool extremities, cyanotic nail beds,

nocturia, exercise intolerance, nocturnal

wheezing, diastolic hypertension, and

car-diomegaly

◆Irritable bowel syndrome (IBS) IBS may

produce intermittent, localized distention—the

result of periodic intestinal spasms Lower

ab-dominal pain or cramping typically

accompa-nies these spasms The pain is usually relieved

by defecation or by passage of intestinal gas

and is aggravated by stress Other possible

signs and symptoms include diarrhea that may

alternate with constipation or normal bowel

function; nausea; dyspepsia; straining and

ur-gency at defecation; feeling of incomplete

evac-uation; and small, mucus-streaked stools

◆Large-bowel obstruction Dramatic

abdom-inal distention is characteristic in large-bowel

obstruction, a life-threatening disorder; in fact,

loops of the large bowel may become visible on

the abdomen Constipation precedes distention

and may be the only symptom for days

Associ-ated findings include tympany, high-pitched

bowel sounds, and sudden onset of colicky

low-er abdominal pain that becomes plow-ersistent

Fe-cal vomiting and diminished peristaltic waves

and bowel sounds are late signs

◆Mesenteric artery occlusion (acute) In

mesenteric artery occlusion—a life-threatening

disorder—abdominal distention usually occurs

several hours after the sudden onset of severe,

colicky periumbilical pain accompanied by rapid

(even forceful) bowel evacuation The pain later

becomes constant and diffuse Related signs

and symptoms include severe abdominal

ten-derness with guarding and rigidity, absent

bow-el sounds and, occasionally, a bruit in the right

iliac fossa The patient may also experience

vomiting, anorexia, diarrhea, or constipation

Late signs include fever, tachycardia,

tachyp-nea, hypotension, and cool, clammy skin

Ab-dominal distention or GI bleeding may be the

only clue if pain is absent

◆Nephrotic syndrome Nephrotic syndrome

may produce massive edema, causing

general-A B D O M I N general-A L M general-A S S 7

or ulcerative colitis that produces dramatic

ab-dominal distention The distention usually

de-velops gradually and is accompanied by a

tym-panic percussion note, diminished or absent

bowel sounds, and mild rebound tenderness

The patient also experiences abdominal pain

and tenderness, fever, tachycardia, and

dehy-dration

S PECIAL CONSIDERATIONS

Position the patient comfortably, using pillows

for support Place him on his left side to help

fla-tus escape or, if he has ascites, elevate the head

of the bed to ease his breathing Administer

drugs to relieve pain, and offer emotional

sup-port

Prepare the patient for diagnostic tests, such

as abdominal X-rays, endoscopy, laparoscopy,

ultrasonography, computed tomography scan,

or possibly paracentesis

P EDIATRIC POINTERS

Because a young child’s abdomen is normally

rounded, distention may be difficult to

ob-serve However, a child’s abdominal wall is

less well developed than an adult’s, so

palpa-tion is easier When percussing the abdomen,

remember that children normally swallow air

when eating and crying, resulting in

louder-than-normal tympany Minimal tympany with

abdominal distention may result from fluid

ac-cumulation or solid masses To check for

ab-dominal fluid, test for shifting dullness instead

of for a fluid wave (In a child, air swallowing

and incomplete abdominal muscle

develop-ment make the fluid wave difficult to

interpret.)

Some children won’t cooperate with a

physi-cal examination Try to gain the child’s

confi-dence, and consider allowing him to remain in

the parent’s or caregiver’s lap You can gather

clues by observing the child while he’s

cough-ing, walkcough-ing, or even climbing on office

furni-ture Remove all the child’s clothing to avoid

missing any diagnostic clues Also, perform a

gentle rectal examination

In neonates, ascites usually results from GI or

urinary perforation; in older children, from heart

failure, cirrhosis, or nephrosis Besides ascites,

congenital malformations of the GI tract (such

as intussusception and volvulus) may cause

ab-dominal distention A hernia may cause

disten-tion if it produces an intestinal obstrucdisten-tion In

addition, overeating and constipation can cause

distention

G ERIATRIC POINTERS

As people age, fat tends to accumulate in thelower abdomen and near the hips, even whenbody weight is stable This accumulation,together with weakening abdominal muscles,commonly produces a potbelly, which someelderly patients interpret as fluid collection orevidence of disease

P ATIENT COUNSELING

If the patient’s anxiety triggers air swallowing ordeep breathing that causes discomfort, advisehim to take slow breaths If the patient has anobstruction or ascites, explain food and fluid re-strictions Stress good oral hygiene to preventdry mouth

Abdominal mass

Commonly detected on routine physical ination, an abdominal mass is a localizedswelling in one abdominal quadrant Typically,this sign develops insidiously and mayrepresent an enlarged organ, a neoplasm,

exam-an abscess, a vascular defect, or a fecal mass

Distinguishing an abdominal mass from anormal structure requires skillful palpation Attimes, palpation must be repeated with the pa-tient in a different position or performed by asecond examiner to verify initial findings A pal-pable abdominal mass is an important clinicalsign and usually represents a serious—and per-haps life-threatening—disorder

EMERGENCY INTERVENTIONS If the patient has a pulsating midabdominal mass and severe abdominal or back pain, sus- pect an aortic aneurysm Quickly take his vital signs Because the patient may require emer- gency surgery, withhold food or fluids until the patient is examined Prepare to administer oxy- gen and to start an I.V infusion for fluid and blood replacement Obtain routine preoperative tests, and prepare the patient for angiography Frequently monitor blood pressure, pulse rate, respirations, and urine output.

Be alert for signs of shock, such as tachycardia, hypotension, and cool, clammy skin, which may indicate significant blood loss.

H ISTORY AND PHYSICAL EXAMINATION

If the patient’s abdominal mass doesn’t suggest

an aortic aneurysm, take a detailed history Ask

the patient if the mass is painful If so, ask if the

pain is constant or if it occurs only on palpation

Is it localized or generalized? Determine if the

patient was already aware of the mass If he

was, find out if he noticed any change in its size

or location

Next, review the patient’s medical history,

paying special attention to GI disorders Ask the

patient about GI symptoms, such as

constipa-tion, diarrhea, rectal bleeding, abnormally

colored stools, and vomiting Has the patient

noticed a change in appetite? If the patient is

fe-male, ask whether her menstrual cycles are

reg-ular and when the 1st day of her last menstrual

period was

Perform a complete physical examination

Next, auscultate for bowel sounds in each

quad-rant Listen for bruits or friction rubs, and check

for enlarged veins Lightly palpate and then

deeply palpate the abdomen, assessing any

painful or suspicious areas last Note the

pa-tient’s position when you locate the mass Some

masses can be detected only with the patient in

a supine position; others require a side-lying

position

Estimate the size of the mass in centimeters

Determine its shape Is it round or sausage

shaped? Describe its contour as smooth, rough,

sharply defined, nodular, or irregular Determine

the consistency of the mass Is it doughy, soft,

solid, or hard? Also, percuss the mass A dull

sound indicates a fluid-filled mass; a tympanic

sound, an air-filled mass

Next, determine if the mass moves with your

hand or in response to respiration Is the mass

free-floating or attached to intra-abdominal

structures? To determine whether the mass is

located in the abdominal wall or the abdominal

cavity, ask the patient to lift his head and

shoulders off the examination table, thereby

contracting his abdominal muscles While these

muscles are contracted, try to palpate the mass

If you can, the mass is in the abdominal wall; if

you can’t, the mass is within the abdominal

cavity (See Abdominal masses: Locations and

causes.)

After the abdominal examination is complete,

perform pelvic, genital, and rectal

examina-tions

M EDICAL CAUSES

◆Abdominal aortic aneurysm An abdominal

aortic aneurysm may persist for years,

produc-ing only a pulsatproduc-ing periumbilical mass with a

systolic bruit over the aorta However, it may

become life-threatening if the aneurysm pands and its walls weaken In such cases, thepatient initially reports constant upper abdomi-nal pain or, less often, low back or dull abdomi-nal pain If the aneurysm ruptures, he’ll reportsevere abdominal and back pain And after rup-ture, the aneurysm no longer pulsates

ex-Associated signs and symptoms of ruptureinclude mottled skin below the waist, absentfemoral and pedal pulses, lower blood pressure

in the legs than in the arms, mild to moderatetenderness with guarding, and abdominalrigidity Signs of shock—such as tachycardiaand cool, clammy skin—appear with significantblood loss

◆Bladder distention A smooth, rounded,

fluctuant suprapubic mass is characteristic Inextreme distention, the mass may extend to theumbilicus Severe suprapubic pain and urinaryfrequency and urgency may also occur

◆Cholecystitis Deep palpation below the

liver border may reveal a smooth, firm,sausage-shaped mass However, in acute in-flammation, the gallbladder is usually too ten-der to be palpated Cholecystitis can cause se-vere right-upper-quadrant pain that mayradiate to the right shoulder, chest, or back;abdominal rigidity and tenderness; fever; pal-lor; diaphoresis; anorexia; nausea; and vomit-ing Recurrent attacks usually occur 1 to 6hours after meals Murphy’s sign (inspiratoryarrest elicited when the examiner palpates theright upper quadrant as the patient takes adeep breath) is common

◆Cholelithiasis A stone-filled gallbladder

usually produces a painless quadrant mass that’s smooth and sausage-shaped However, passage of a stone throughthe bile or cystic duct may cause severe right-upper-quadrant pain that radiates to the epigas-trium, back, or shoulder blades Accompanyingsigns and symptoms include anorexia, nausea,vomiting, chills, diaphoresis, restlessness, andlow-grade fever Jaundice may occur with ob-struction of the common bile duct The patientmay also experience intolerance of fatty foodsand frequent indigestion

right-upper-◆Colon cancer A right-lower-quadrant mass

may occur in cancer of the right colon, whichmay also cause occult bleeding with anemiaand abdominal aching, pressure, or dull cramps.Associated findings include weakness, fatigue,exertional dyspnea, vertigo, and signs andsymptoms of intestinal obstruction, such as ob-stipation and vomiting

8 A B D O M I N A L M A S S

A B D O M I N A L M A S S 9

Abdominal masses: Locations and causes

The location of an abdominal mass provides an important clue to the causative disorder Belowyou’ll find the disorders responsible for abdominal masses in each of the four abdominal quad-rants

Right upper quadrant

◆Aortic aneurysm (epigastric area)

◆Cholecystitis or cholelithiasis

◆Gallbladder, gastric, or hepatic carcinoma

◆Hepatomegaly

◆Hydronephrosis

◆Pancreatic abscess or pseudocysts

◆Renal cell carcinoma

Right lower quadrant

◆Bladder distention (suprapubic area)

◆Colon cancer

◆Crohn’s disease

◆Ovarian cyst (suprapubic area)

◆Uterine leiomyomas (suprapubic area)

Left upper quadrant

◆Aortic aneurysm (epigastric area)

◆Gastric carcinoma (epigastric area)

◆Hydronephrosis

◆Pancreatic abscess (epigastric area)

◆Pancreatic pseudocysts (epigastric area)

◆Renal cell carcinoma

◆Splenomegaly

Left lower quadrant

◆Bladder distention (suprapubic area)

◆Colon cancer

◆Diverticulitis

◆Ovarian cyst (suprapubic area)

◆Uterine leiomyomas (suprapubic area)

◆Volvulus

Occasionally, cancer of the left colon also

causes a palpable mass Usually though, it

pro-duces rectal bleeding, intermittent abdominal

fullness or cramping, and rectal pressure The

patient may also report fremitus and pelvic

dis-comfort Later, he develops obstipation,

diar-rhea, or pencil-shaped, grossly bloody, or

mucus-streaked stools Typically, defecation

relieves pain

◆Crohn’s disease In Crohn’s disease, tender,

sausage-shaped masses are usually palpable in

the right lower quadrant and, at times, in the

left lower quadrant Attacks of colicky

right-lower-quadrant pain and diarrhea are common

Associated signs and symptoms include fever,

anorexia, weight loss, hyperactive bowel

sounds, nausea, abdominal tenderness with

guarding, and perirectal, skin, or vaginal

fistulas

◆Diverticulitis Most common in the

sig-moid colon, diverticulitis may produce a

left-lower-quadrant mass that’s usually tender,

firm, and fixed It also produces intermittent

abdominal pain that’s relieved by defecation

or passage of flatus Other findings may

in-clude alternating constipation and diarrhea,

nausea, low-grade fever, and a distended and

tympanic abdomen

◆Gallbladder cancer Gallbladder cancer

may produce a moderately tender, irregular

mass in the right upper quadrant

Accompany-ing it is chronic, progressively severe epigastric

or right-upper-quadrant pain that may radiate

to the right shoulder Associated signs and

symptoms include nausea, vomiting, anorexia,

weight loss, jaundice, and possibly

hepatosplenomegaly

◆Gastric cancer Advanced gastric cancer

may produce an epigastric mass Early findings

include chronic dyspepsia and epigastric

dis-comfort, whereas late findings include weight

loss, a feeling of fullness after eating, fatigue,

and occasionally coffee-ground vomitus or

me-lena

◆Hepatic cancer Hepatic cancer produces a

tender, nodular mass in the right upper

quad-rant or right epigastric area accompanied by

se-vere pain that’s aggravated by jolting Other

effects include weight loss, weakness, anorexia,

nausea, fever, dependent edema, and

occasion-ally jaundice and ascites A large tumor can also

cause a bruit or hum

◆Hepatomegaly Hepatomegaly produces a

firm, blunt, irregular mass in the epigastric

re-gion or below the right costal margin

Associated signs and symptoms vary with thecausative disorder but commonly include as-cites, right-upper-quadrant pain and tender-ness, anorexia, nausea, vomiting, leg edema,jaundice, palmar erythema, spider angiomas,gynecomastia, testicular atrophy, and possiblysplenomegaly

◆Hydronephrosis By enlarging one or both

kidneys, hydronephrosis produces a smooth,boggy mass in one or both flanks Other findingsvary with the degree of hydronephrosis The pa-tient may have severe colicky renal pain or dullflank pain that radiates to the groin, vulva, ortestes Hematuria, pyuria, dysuria, alternatingoliguria and polyuria, nocturia, accelerated hy-pertension, nausea, and vomiting may alsooccur

◆Ovarian cyst A large ovarian cyst may

pro-duce a smooth, rounded, fluctuant mass, bling a distended bladder, in the suprapubic re-gion Large or multiple cysts may also causemild pelvic discomfort, low back pain, menstru-

resem-al irregularities, and hirsutism A twisted or tured cyst may cause abdominal tenderness,distention, and rigidity

rup-◆Pancreatic abscess Occasionally, pancreatic

abscess may produce a palpable epigastric massaccompanied by epigastric pain and tenderness.The patient’s temperature usually rises abruptlybut may climb steadily Nausea, vomiting, diar-rhea, tachycardia, and hypotension may alsooccur

◆Pancreatic pseudocysts After pancreatitis,

pseudocysts may form on the pancreas, causing

a palpable nodular mass in the epigastric area.Other findings include nausea, vomiting, diar-rhea, abdominal pain and tenderness, low-grade fever, and tachycardia

◆Renal cell carcinoma Usually occurring in

only one kidney, renal cell carcinoma produces

a smooth, firm, nontender mass near the

affect-ed kidney Accompanying it are dull, constantabdominal or flank pain and hematuria Othersigns and symptoms include elevated bloodpressure, fever, and urine retention Weightloss, nausea, vomiting, and leg edema occur inlate stages

◆Splenomegaly Lymphomas, leukemias,

he-molytic anemias, and inflammatory diseasesare among the many disorders that may causesplenomegaly Typically, the smooth edge ofthe enlarged spleen is palpable in the left up-per quadrant Associated signs and symptomsvary with the causative disorder but often include a feeling of abdominal fullness,

10 A B D O M I N A L M A S S

left-upper-quadrant abdominal pain and

ten-derness, splenic friction rub, splenic bruits, and

low-grade fever

◆Uterine leiomyomas (fibroids) If large

enough, these common, benign uterine tumors

produce a round, multinodular mass in the

suprapubic region The patient’s chief complaint

is usually menorrhagia; she may also

experi-ence a feeling of heaviness in the abdomen, and

pressure on surrounding organs may cause

back pain, constipation, and urinary frequency

or urgency Edema and varicosities of the lower

extremities may develop Rapid fibroid growth

in perimenopausal or postmenopausal women

needs further evaluation

S PECIAL CONSIDERATIONS

Discovery of an abdominal mass commonly

causes anxiety Offer emotional support to the

patient and his family as they await the

diag-nosis Position the patient comfortably, and

administer drugs for pain or anxiety as

needed

If an abdominal mass causes bowel

obstruc-tion, watch for indications of peritonitis—

abdominal pain and rebound tenderness—and

for signs of shock, such as tachycardia and

hy-potension

P EDIATRIC POINTERS

Detecting an abdominal mass in an infant can

be quite a challenge However, these tips will

make palpation easier for you: Allow an infant

to suck on his bottle or pacifier to prevent

cry-ing, which causes abdominal rigidity and

inter-feres with palpation Avoid tickling him because

laughter also causes abdominal rigidity Also,

reduce his apprehension by distracting him with

cheerful conversation Rest your hand on his

abdomen for a few moments before palpation

If he remains sensitive, place his hand under

yours as you palpate Consider allowing the

child to remain on the parent’s or caregiver’s

lap A gentle rectal examination should also be

performed

In neonates, most abdominal masses result

from renal disorders, such as polycystic kidney

disease or congenital hydronephrosis In older

infants and children, abdominal masses usually

are caused by enlarged organs, such as the liver

and spleen

Other common causes include Wilms’ tumor,

neuroblastoma, intussusception, volvulus,

Hirschsprung’s disease (congenital megacolon),

pyloric stenosis, and abdominal abscess

G ERIATRIC POINTERS

Ultrasonography should be used to evaluate aprominent midepigastric mass in thin elderlypatients

P ATIENT COUNSELING

Carefully explain diagnostic tests, which mayinclude blood and urine studies, abdominal X-rays, barium enema, computed tomographyscan, ultrasonography, radioisotope scan, andgastroscopy or sigmoidoscopy A pelvic or rectalexamination is usually indicated

Abdominal pain

Abdominal pain usually results from a GI der, but it can also be caused by a reproductive,genitourinary (GU), musculoskeletal, or vasculardisorder; drug use; or ingestion of toxins Attimes, such pain signals life-threatening compli-cations

disor-Abdominal pain arises from the dominopelvic viscera, the parietal peritoneum,

ab-or the capsules of the liver, kidney, ab-or spleen Itmay be acute or chronic and diffuse or local-ized Visceral pain develops slowly into a deep,dull, aching pain that’s poorly localized in theepigastric, periumbilical, or lower midabdomi-nal (hypogastric) region In contrast, somatic(parietal, peritoneal) pain produces a sharp,more intense, and well-localized discomfortthat rapidly follows the insult Movement or

coughing aggravates this pain (See Abdominal pain: Types and locations, page 12.)

Pain may also be referred to the abdomenfrom another site with the same or similar nervesupply This sharp, well-localized, referred pain isfelt in skin or deeper tissues and may coexistwith skin hyperesthesia and muscle hyperalgesia.Mechanisms that produce abdominal pain in-clude stretching or tension of the gut wall, trac-tion on the peritoneum or mesentery, vigorousintestinal contraction, inflammation, ischemia,and sensory nerve irritation

EMERGENCY INTERVENTIONS If the patient is experiencing sudden and severe abdominal pain, quickly take his vital signs and palpate pulses below the waist Be alert for signs

of hypovolemic shock, such as tachycardia and hypotension Obtain I.V access

Emergency surgery may be required if the tient also has mottled skin below the waist and a pulsating epigastric mass or rebound tenderness and rigidity.

pa-A B D O M I N pa-A L P pa-A I N 11

H ISTORY AND PHYSICAL

EXAMINATION

If the patient has no life-threatening signs or

symptoms, take his history Ask him if he has

had this type of pain before Have him describe

the pain—for example, is it dull, sharp,

stab-bing, or burning? Ask if anything relieves the

pain or makes it worse Ask the patient if the

pain is constant or intermittent and when

the pain began Constant, steady abdominal

pain suggests organ perforation, ischemia, or

inflammation or blood in the peritoneal cavity

Intermittent, cramping abdominal pain

sug-gests the patient may have an obstruction of a

hollow organ

If pain is intermittent, find out the duration of

a typical episode In addition, ask the patient

where the pain is located and if it radiates to

other areas

Find out if movement, coughing, exertion,

vomiting, eating, elimination, or walking

wors-ens or relieves the pain The patient may report

abdominal pain as indigestion or gas pain, so

have him describe it in detail

Ask the patient about substance abuse andany history of vascular, GI, GU, or reproductivedisorders Ask the female patient the date of herlast menses and if she has had changes in hermenstrual pattern or dyspareunia

Also ask about appetite changes and the onsetand frequency of nausea or vomiting Find outabout increased flatulence, constipation, diarrhea,and changes in stool consistency When was hislast bowel movement? Ask about urinary frequen-

cy, urgency, or pain Is the urine cloudy or pink?Perform a physical examination Take the pa-tient’s vital signs, and assess skin turgor andmucous membranes Inspect his abdomen fordistention or visible peristaltic waves and, if in-dicated, measure his abdominal girth

Auscultate for bowel sounds and characterizetheir motility Percuss all quadrants, noting thepercussion sounds Palpate the entire abdomenfor masses, rigidity, and tenderness Check forcostovertebral angle (CVA) tenderness, abdomi-nal tenderness with guarding, and rebound ten-

derness (See Abdominal pain: Causes and ciated findings, pages 14 to 19.)

Hypogastrium and leftflank for descendingcolon

Over affected site

Right lower quadrant

Over affected site

Over affected site

Right upper quadrant

Over affected site

Middle epigastrium andleft upper quadrant

Over affected site

Right lower quadrant

Right lower quadrantand back (rare)

Left lower quadrant andback (rare)

Right subscapular area

Groin; scrotum in men,labia in women (rare)

Back and left shoulder

Inner thighs

M EDICAL CAUSES

◆Abdominal aortic aneurysm (dissecting).

Initially, abdominal aortic aneurysm—a

life-threatening disorder—may produce dull lower

abdominal, lower back, or severe chest pain In

most cases, however, it produces constant

up-per abdominal pain, which may worsen when

the patient lies down and may abate when he

leans forward or sits up Palpation may reveal

an epigastric mass that pulsates before rupture

but not after it

Other findings may include mottled skin

be-low the waist, absent femoral and pedal pulses,

blood pressure that’s lower in the legs than in

the arms, mild to moderate abdominal

tender-ness with guarding, and abdominal rigidity

Signs of shock, such as tachycardia and

tachyp-nea, may appear

◆Abdominal cancer Abdominal pain usually

occurs late in abdominal cancer It may be

ac-companied by anorexia, weight loss, weakness,

depression, an abdominal mass, and abdominal

distention

◆Abdominal trauma Generalized or

local-ized abdominal pain occurs with ecchymoses

on the abdomen; abdominal tenderness;

vomit-ing; and, with hemorrhage into the peritoneal

cavity, abdominal rigidity Bowel sounds are

de-creased or absent The patient may have signs

of hypovolemic shock, such as hypotension and

a rapid, thready pulse

◆Adrenal crisis Severe abdominal pain

ap-pears early along with nausea, vomiting,

dehy-dration, profound weakness, anorexia, and

fever Later signs are progressive loss of

con-sciousness, hypotension, tachycardia, oliguria,

cool and clammy skin, and increased motor

ac-tivity, which may progress to delirium or

seizures

◆Anthrax, GI Anthrax is an acute infectious

disease that’s caused by the gram-positive,

spore-forming bacterium Bacillus anthracis

Al-though the disease most commonly occurs in

wild and domestic grazing animals, such as

cat-tle, sheep, and goats, the spores can live in the

soil for many years The disease can occur in

humans exposed to infected animals, tissue

from infected animals, or biological agents

Most natural cases occur in agricultural regions

worldwide Anthrax may occur in cutaneous,

in-haled, or GI forms

GI anthrax is caused by eating contaminated

meat from an infected animal Initial signs and

symptoms include anorexia, nausea, vomiting,

and fever Late signs and symptoms include dominal pain, severe bloody diarrhea, and he-matemesis

ab-◆ Appendicitis Appendicitis is a

life-threatening disorder in which pain initiallyoccurs in the epigastric or umbilical region.Anorexia, nausea, and vomiting may occurafter the onset of pain Pain localizes atMcBurney’s point in the right lower quadrantand is accompanied by abdominal rigidity,increasing tenderness (especially overMcBurney’s point), rebound tenderness, and re-tractive respirations Later signs and symptomsinclude malaise, constipation (or diarrhea),low-grade fever, and tachycardia

◆Cholecystitis Severe pain in the right

up-per quadrant may arise suddenly or increasegradually over several hours, usually aftermeals It may radiate to the right shoulder,chest, or back Accompanying the pain areanorexia, nausea, vomiting, fever, abdominalrigidity and tenderness, pallor, and diaphore-sis Murphy’s sign (inspiratory arrest elicitedwhen the examiner palpates the right upperquadrant as the patient takes a deep breath) iscommon

◆Cholelithiasis Patients may suffer sudden,

severe, and paroxysmal pain in the right upperquadrant lasting several minutes to severalhours The pain may radiate to the epigastrium,back, or shoulder blades The pain is accompa-nied by anorexia, nausea, vomiting (sometimesbilious), diaphoresis, restlessness, and abdomi-nal tenderness with guarding over the gallblad-der or biliary duct The patient may also experi-ence fatty food intolerance and frequentindigestion

◆Cirrhosis Dull abdominal aching occurs

ear-ly and is usualear-ly accompanied by anorexia, gestion, nausea, vomiting, and constipation ordiarrhea Subsequent right-upper-quadrant painworsens when the patient sits up or leans for-ward Associated signs include fever, ascites,leg edema, weight gain, hepatomegaly, jaun-dice, severe pruritus, bleeding tendencies, pal-mar erythema, and spider angiomas Gyneco-mastia and testicular atrophy may also bepresent

indi-◆Crohn’s disease An acute attack causes

se-vere cramping pain in the lower abdomen, cally preceded by weeks or months of mildercramping pain Crohn’s disease may also causediarrhea, hyperactive bowel sounds, dehydra-tion, weight loss, fever, abdominal tenderness

typi-A B D O M I N typi-A L P typi-A I N 13

(Text continues on page 18.)

14 A B D O M I N A L P A I N

SIGNS & SYMPTOMS

Abdominal pain: Causes and associated findings

Abdominal distention Abdominal mass Abdominal rigidity Abdominal tenderness Amenorrhea Anorexia Bowel sounds, absent Bowel sounds, hyperactive Bowel sounds, hypoactive Breath odor

16 A B D O M I N A L P A I N

Abdominal distention Abdominal mass Abdominal rigidity Abdominal tenderness Amenorrhea Anorexia Bowel sounds, absent Bowel sounds, hyperactive Bowel sounds, hypoactive Breath odor

with guarding, and possibly a palpable mass in

a lower quadrant Abdominal pain is commonly

relieved by defecation Milder chronic signs and

symptoms include right-lower-quadrant pain

with diarrhea, steatorrhea, and weight loss

Complications include perirectal or vaginal

fis-tulas

◆Cystitis Abdominal pain and tenderness

usually occur in the suprapubic region

Associ-ated signs and symptoms include malaise, flank

pain, low back pain, nausea, vomiting, urinary

frequency and urgency, nocturia, dysuria, fever,

and chills

◆Diabetic ketoacidosis Rarely, severe,

sharp, shooting, and girdling pain may persist

for several days Fruity breath odor, a weak and

rapid pulse, Kussmaul’s respirations, poor skin

turgor, polyuria, polydipsia, nocturia,

hypoten-sion, decreased bowel sounds, and confusion

also occur

◆Diverticulitis Mild cases usually produce

intermittent, diffuse left-lower-quadrant pain,

which may be relieved by defecation or

pas-sage of flatus and worsened by eating Other

signs and symptoms include nausea,

constipa-tion or diarrhea, low-grade fever and, in manycases, a palpable abdominal mass that’s usual-

ly tender, firm, and fixed Rupture causes vere left-lower-quadrant pain, abdominalrigidity, and possibly signs and symptoms ofsepsis and shock (high fever, chills, and hy-potension)

se-◆Duodenal ulcer Localized abdominal

pain—described as steady, gnawing, burning,aching, or hungerlike—may occur high in themidepigastrium, slightly off center, usually onthe right The pain usually doesn’t radiate un-less pancreatic penetration occurs It typicallybegins 2 to 4 hours after a meal and maycause nocturnal awakening Ingestion of food

or antacids brings relief until the cycle startsagain Other symptoms include changes inbowel habits and heartburn or retrosternalburning

◆Ectopic pregnancy Lower abdominal pain

may be sharp, dull, or cramping and constant

or intermittent in ectopic pregnancy, a tially life-threatening disorder Vaginal bleed-ing, nausea, and vomiting may occur alongwith urinary frequency, a tender adnexal mass,

poten-18 A B D O M I N A L P A I N

Abdominal distention Abdominal mass Abdominal rigidity Abdominal tenderness Amenorrhea Anorexia Bowel sounds, absent Bowel sounds, hyperactive Bowel sounds, hypoactive Breath odor

and a 1- to 2-month history of amenorrhea.

Rupture of the fallopian tube produces sharp

lower abdominal pain, which may radiate to

the shoulders and neck and become extreme

with cervical or adnexal palpation Signs of

shock (such as pallor, tachycardia, and

hy-potension) may also appear

◆Endometriosis Constant, severe pain in the

lower abdomen usually begins 5 to 7 days

be-fore the start of menses and may be aggravated

by defecation Depending on the location of the

ectopic tissue, abdominal pain may be

accom-panied by abdominal tenderness, constipation,

dysmenorrhea, dyspareunia, and deep sacral

pain

◆Escherichia coli O157:H7 E coli O157:H7

is an aerobic, gram-negative bacillus that

caus-es food-borne illncaus-ess Most strains of E coli are

harmless and are part of the normal intestinal

flora of healthy humans and animals E coli

O157:H7, one of hundreds of strains of the

bac-terium, is capable of producing a powerful toxin

and can cause severe illness Eating

under-cooked beef or other foods contaminated with

the bacterium causes the disease Signs and

symptoms include watery or bloody diarrhea,nausea, vomiting, fever, and abdominal cramps

In children younger than age 5 and the elderly,hemolytic uremic syndrome may develop andultimately lead to acute renal failure

◆Gastric ulcer Diffuse, gnawing, burning

pain in the left upper quadrant or epigastricarea commonly occurs 1 to 2 hours after mealsand may be relieved by ingestion of food orantacids Vague bloating and nausea after eat-ing are common Indigestion, weight change,anorexia, and episodes of GI bleeding alsooccur

◆Gastritis With acute gastritis, the patient

ex-periences rapid onset of abdominal pain thatcan range from mild epigastric discomfort toburning pain in the left upper quadrant Othertypical features include belching, fever, malaise,anorexia, nausea, bloody or coffee-groundvomitus, and melena However, significantbleeding is unusual, unless the patient has hem-orrhagic gastritis

◆Gastroenteritis Cramping or colicky

ab-dominal pain, which can be diffuse, originates

in the left upper quadrant and radiates or

migrates to the other quadrants, usually in a

peristaltic manner It’s accompanied by diarrhea,

hyperactive bowel sounds, headache, myalgia,

nausea, and vomiting

◆Heart failure Right-upper-quadrant pain

commonly accompanies heart failure’s

hall-marks: jugular vein distention, dyspnea,

tachycardia, and peripheral edema Other

findings include nausea, vomiting, ascites,

productive cough, crackles, cool extremities,

and cyanotic nail beds Clinical signs are

nu-merous and vary according to the stage of the

disease and amount of cardiovascular

impair-ment

◆Hepatic abscess Steady, severe abdominal

pain in the right upper quadrant or

midepigas-trium commonly accompanies hepatic

ab-scess—a rare disorder—but

right-upper-quad-rant tenderness is the most important finding

Other signs and symptoms are anorexia,

diar-rhea, nausea, fever, diaphoresis, elevated right

hemidiaphragm and, rarely, vomiting

◆Hepatic amebiasis Rare in the United

States, hepatic amebiasis causes relatively

se-vere right-upper-quadrant pain and tenderness

over the liver and possibly the right shoulder

Accompanying signs and symptoms include

fever, weakness, weight loss, chills, diaphoresis,

and jaundiced or brownish skin

◆Hepatitis Liver enlargement from any type

of hepatitis causes discomfort or dull pain and

tenderness in the right upper quadrant

Associ-ated signs and symptoms may include dark

urine, clay-colored stools, nausea, vomiting,

anorexia, jaundice, malaise, and pruritus

◆Herpes zoster Herpes zoster of the

tho-racic, lumbar, or sacral nerves can cause

local-ized abdominal and chest pain in the areas

served by these nerves Pain, tenderness, and

fever can precede or accompany erythematous

papules, which rapidly evolve into grouped

vesicles

◆Intestinal obstruction Short episodes of

intense, colicky, cramping pain alternate with

pain-free intervals in intestinal obstruction, a

life-threatening disorder Accompanying signs

and symptoms may include abdominal

disten-tion, tenderness, and guarding; visible

peri-staltic waves; high-pitched, tinkling, or

hyper-active bowel sounds proximal to the

obstruction and hypoactive or absent sounds

distally; obstipation; and pain-induced

agita-tion In jejunal and duodenal obstruction,

nau-sea and bilious vomiting occur early In distal

small- or large-bowel obstruction, nausea andvomiting are commonly feculent Completeobstruction produces absent bowel sounds.Late-stage obstruction produces signs ofhypovolemic shock, such as hypotension andtachycardia

◆Irritable bowel syndrome Lower

abdomi-nal cramping or pain is aggravated by ingestion

of coarse or raw foods and may be alleviated bydefecation or passage of flatus Related findingsinclude abdominal tenderness, diurnal diarrheaalternating with constipation or normal bowelfunction, and small stools with visible mucus.Dyspepsia, nausea, and abdominal distentionwith a feeling of incomplete evacuation mayalso occur Stress, anxiety, and emotional labili-

ty intensify the symptoms

◆Listeriosis Listeriosis is a serious infection

that’s caused by eating food contaminated with

the bacterium Listeria monocytogenes This

food-borne illness primarily affects pregnant women,neonates, and those with weakened immunesystems Signs and symptoms include fever,myalgia, abdominal pain, nausea, vomiting, anddiarrhea If the infection spreads to the nervoussystem, it may cause meningitis, characterized

by fever, headache, nuchal rigidity, and alteredlevel of consciousness (LOC)

GENDER CUE Listeriosis infection during pregnancy may lead to premature delivery, infection of the neonate, or stillbirth.

◆Mesenteric artery ischemia Always

sus-pect mesenteric artery ischemia in patients

old-er than age 50 with chronic heart failure, diac arrhythmias, cardiovascular infarct, orhypotension who develop sudden, severe ab-dominal pain after 2 to 3 days of colicky peri-umbilical pain and diarrhea Initially, the ab-domen is soft and tender with decreased bowelsounds Associated findings include vomiting,anorexia, alternating periods of diarrhea andconstipation and, in late stages, extreme ab-dominal tenderness with rigidity, tachycardia,tachypnea, absent bowel sounds, and cool,clammy skin

car-◆Myocardial infarction (MI) In MI—a

life-threatening disorder—substernal chest painmay radiate to the abdomen Associated signsand symptoms include weakness, diaphoresis,nausea, vomiting, anxiety, syncope, jugular veindistention, and dyspnea

◆Norovirus infection Abdominal pain or

cramping is a symptom commonly associatedwith noroviruses Transmitted by the fecal-oral

20 A B D O M I N A L P A I N

route and highly contagious, these viruses that

cause gastroenteritis may also produce

acute-onset vomiting, nausea, and diarrhea Less

common symptoms include low-grade fever,

headache, chills, muscle aches, and generalized

fatigue Individuals who are otherwise healthy

usually recover in 24 to 60 hours without

suffer-ing lastsuffer-ing effects

◆Ovarian cyst Torsion or hemorrhage causes

pain and tenderness in the right or left lower

quadrant Sharp and severe if the patient

sud-denly stands or stoops, the pain becomes brief

and intermittent if the torsion self-corrects or

dull and diffuse after several hours if it doesn’t

Pain is accompanied by a slight fever, mild

nau-sea and vomiting, abdominal tenderness, a

pal-pable abdominal mass, and possibly

amenor-rhea Abdominal distention may occur if the

cyst is large Peritoneal irritation, or rupture and

ensuing peritonitis, causes high fever and

severe nausea and vomiting

◆Pancreatitis Life-threatening acute

pancre-atitis produces fulminating, continuous upper

abdominal pain that may radiate to both flanks

and to the back To relieve this pain, the patient

may bend forward, draw his knees to his chest,

or move about restlessly Early findings include

abdominal tenderness, nausea, vomiting, fever,

pallor, tachycardia and, in some patients,

ab-dominal rigidity, rebound tenderness, and

hy-poactive bowel sounds Turner’s sign

(ecchymo-sis of the abdomen or flank) or Cullen’s sign

(a bluish tinge around the umbilicus) signals

he-morrhagic pancreatitis Jaundice may occur as

inflammation subsides

Chronic pancreatitis produces severe

left-upper-quadrant or epigastric pain that

radiates to the back Abdominal tenderness, a

midepigastric mass, jaundice, fever, and

splenomegaly may occur Steatorrhea, weight

loss, maldigestion, and diabetes mellitus are

common

◆Pelvic inflammatory disease Pain in the

right or left lower quadrant ranges from vague

discomfort worsened by movement to deep,

severe, and progressive pain Sometimes,

metr-orrhagia precedes or accompanies the onset of

pain Extreme pain accompanies cervical or

adnexal palpation Associated findings include

abdominal tenderness, a palpable abdominal or

pelvic mass, fever, occasional chills, nausea,

vomiting, discomfort on urination, and

abnor-mal vaginal bleeding or a purulent vaginal

dis-charge

◆Perforated ulcer In a life-threatening

perfo-rated ulcer, sudden, severe, and prostratingepigastric pain may radiate through the ab-domen to the back or right shoulder Othersigns and symptoms include boardlike abdomi-nal rigidity, tenderness with guarding, general-ized rebound tenderness, absent bowel sounds,grunting and shallow respirations and, in manycases, fever, tachycardia, hypotension, andsyncope

◆Peritonitis In this life-threatening disorder,

sudden and severe pain can be diffuse or ized in the area of the underlying disorder;movement worsens the pain The degree of ab-dominal tenderness usually varies according tothe extent of disease Typical findings includefever; chills; nausea; vomiting; hypoactive orabsent bowel sounds; abdominal tenderness,distention, and rigidity; rebound tenderness andguarding; hyperalgesia; tachycardia; hypoten-sion; tachypnea; and positive psoas and obtura-tor signs

local-◆Pleurisy Pleurisy may produce upper

ab-dominal or costal margin pain referred from thechest Characteristic sharp, stabbing chest painincreases with inspiration and movement Manypatients have a pleural friction rub and rapid,shallow breathing; some have a low-gradefever

◆Pneumonia Lower-lobe pneumonia can

cause pleuritic chest pain and referred, severeupper abdominal pain, tenderness, and rigiditythat diminish with inspiration It can also causefever, shaking chills, achiness, headache, blood-tinged or rusty sputum, dyspnea, and a dry,hacking cough Accompanying signs includecrackles, egophony, decreased breath sounds,and dullness on percussion

◆Pneumothorax Pneumothorax is a

poten-tially life-threatening disorder that can cause ferred pain from the chest to the upper ab-domen and costal margin Characteristic chestpain arises suddenly and worsens with deep in-spiration or movement Accompanying signsand symptoms include anxiety, dyspnea,cyanosis, decreased or absent breath soundsover the affected area, tachypnea, and tachycar-dia Watch for asymmetrical chest movements

re-on inspiratire-on

◆Prostatitis Vague abdominal pain or

dis-comfort in the lower abdomen, groin, ineum, or rectum may develop Other findingsinclude dysuria, urinary frequency and ur-gency, fever, chills, low back pain, myalgia,

per-A B D O M I N per-A L P per-A I N 21

arthralgia, and nocturia Scrotal pain, penile

pain, and pain on ejaculation may occur in

chronic cases

◆Pyelonephritis (acute) Progressive lower

quadrant pain in one or both sides, flank pain,

and CVA tenderness characterize

pyelonephri-tis Pain may radiate to the lower midabdomen

or the groin Additional signs and symptoms

in-clude abdominal and back tenderness, high

fever, shaking chills, nausea, vomiting, and

uri-nary frequency and urgency

◆Renal calculi Depending on their location,

calculi may cause severe abdominal or back

pain However, the classic symptom is severe,

colicky pain that travels from the CVA to the

flank, suprapubic region, and external genitalia

The pain may be excruciating or dull and

con-stant and may be accompanied by agitation,

nausea, vomiting, abdominal distention, fever,

chills, hypertension, and urinary urgency with

hematuria and dysuria

◆Sickle cell crisis Sudden, severe abdominal

pain may accompany chest, back, hand, or foot

pain Associated signs and symptoms include

weakness, aching joints, dyspnea, and scleral

jaundice

◆Smallpox (variola major) Worldwide

eradi-cation of smallpox was achieved in 1977; the

United States and Russia have the only known

storage sites for the virus, which is considered a

potential agent for biological warfare Initial

signs and symptoms include high fever,

malaise, prostration, severe headache,

back-ache, and abdominal pain A maculopapular

rash develops on the oral mucosa, pharynx,

face, and forearms and then spreads to the

trunk and legs Within 2 days, the rash becomes

vesicular and later pustular The lesions develop

at the same time, appear identical, and are

more prominent on the face and extremities

The pustules are round, firm, and embedded in

the skin After 8 to 9 days, the pustules form a

crust, which later separates from the skin,

leav-ing a pitted scar Death may result from

en-cephalitis, extensive bleeding, or secondary

infection

◆Splenic infarction Fulminating pain in the

left upper quadrant occurs with chest pain that

may worsen on inspiration Pain commonly

ra-diates to the left shoulder with splinting of the

left diaphragm, abdominal guarding and,

occa-sionally, a splenic friction rub

◆Systemic lupus erythematosus

General-ized abdominal pain is unusual in this disease

but may occur after meals Butterfly rash,

pho-tosensitivity, alopecia, mucous membrane cers, and nondeforming arthritis are character-istic signs Other common signs and symptomsinclude anorexia, vomiting, abdominal tender-ness with guarding, abdominal distention aftermeals, fatigue, fever, and weight loss Precor-dial chest pain and a pericardial rub may alsooccur

ul-◆Ulcerative colitis Ulcerative colitis may

be-gin with vague abdominal discomfort that leads

to cramping lower abdominal pain As the order progresses, pain may become steady anddiffuse, increasing with movement and cough-ing The most common symptom—recurrentand possibly severe diarrhea with blood, pus,and mucus—may relieve the pain The abdomenmay feel soft and extremely tender High-pitched, infrequent bowel sounds may accom-pany nausea, vomiting, anorexia, weight loss,and mild, intermittent fever

dis-◆Uremia Characterized by generalized or

periumbilical pain that shifts and varies in tensity, uremia causes diverse GI signs andsymptoms, such as nausea, vomiting, anorexia,and diarrhea Other findings may include bleed-ing, abdominal tenderness that changes in loca-tion and intensity, visual disturbances,headache, decreased LOC, vertigo, and oliguria

in-or anuria Chest pain may occur secondary topericardial effusion Localized or diffuse pruri-tus is common

O THER CAUSES

◆Drugs Salicylates and nonsteroidal

anti-in-flammatories commonly cause burning, ing pain in the left upper quadrant or epigastricarea as well as nausea and vomiting

gnaw-◆Insect toxins Generalized, cramping

ab-dominal pain usually occurs with low-gradefever, nausea, vomiting, abdominal rigidity,tremors, and burning sensations in the hands orfeet

S PECIAL CONSIDERATIONS

Help the patient find a comfortable position toease his distress The patient should lie in asupine position, with his head flat on the table,arms at his sides, and knees slightly flexed to re-lax the abdominal muscles Monitor him closelybecause abdominal pain can signal a life-threatening disorder Especially importantindications include tachycardia, hypotension,clammy skin, abdominal rigidity, reboundtenderness, a change in the pain’s location orintensity, or sudden relief from the pain

22 A B D O M I N A L P A I N

Withhold analgesics from the patient

be-cause they may mask symptoms Also withhold

food and fluids because surgery may be

need-ed Prepare for I.V infusion and insertion of a

nasogastric or other intestinal tube Peritoneal

lavage or abdominal paracentesis may be

re-quired

You may have to prepare the patient for a

di-agnostic procedure, such as a pelvic and rectal

examination; blood, urine, and stool tests;

X-rays; barium studies; ultrasonography;

en-doscopy; and biopsy

P EDIATRIC POINTERS

Because children commonly have difficulty

describing abdominal pain, pay close attention

to nonverbal clues, such as wincing, lethargy,

or unusual positioning (such as a side-lying

position with knees flexed to the abdomen)

Observing the child while he coughs, walks,

or climbs may offer some diagnostic clues

Also, remember that a parent’s description

of the child’s complaints is a subjective

interpretation of what the parent believes is

wrong

Abdominal pain in children may signal a

more serious disorder or a disorder that

pro-duces different associated signs and symptoms

than in adults For example, appendicitis is

more likely to result in rupture and death in

children, and vomiting may be its only other

sign Acute pyelonephritis may cause

abdomi-nal pain, vomiting, and diarrhea, but not the

classic urologic signs found in adults Peptic

ul-cer, which is becoming increasingly common in

teenagers, causes nocturnal pain and colic that

may not be relieved by food, unlike peptic ulcer

in adults

Abdominal pain in children can also result

from lactose intolerance,

allergic-tension-fatigue syndrome, volvulus, Meckel’s

diverticu-lum, intussusception, mesenteric adenitis,

diabetes mellitus, juvenile rheumatoid arthritis,

and many uncommon disorders, such as heavy

metal poisoning Remember, too, that a child’s

complaint of abdominal pain may reflect an

emotional need, such as a wish to avoid school

or to gain adult attention

G ERIATRIC POINTERS

Advanced age may decrease the

manifesta-tions of acute abdominal disease Pain may be

less severe, fever less pronounced, and signs

of peritoneal inflammation diminished or

ab-sent

Abdominal rigidity

[Abdominal muscle spasm, involuntary guarding]

Detected by palpation, abdominal rigidity refers

to abnormal muscle tension or inflexibility ofthe abdomen Rigidity may be voluntary or in-voluntary Voluntary rigidity reflects the patient’sfear or nervousness upon palpation; involuntaryrigidity reflects potentially life-threatening

peritoneal irritation or inflammation (See ognizing voluntary rigidity.)

Rec-Involuntary rigidity most commonly resultsfrom GI disorders but may also result from pul-monary and vascular disorders and from theeffects of insect toxins It’s usually accompanied

by fever, nausea, vomiting, and abdominal derness, distention, and pain

ten-EMERGENCY INTERVENTIONS After pating abdominal rigidity, quickly take the patient’s vital signs Even though the patient may not appear gravely ill or have markedly abnormal vital signs, abdominal rigidity calls for emergency interventions.

pal-Prepare to administer oxygen and to insert an I.V catheter for fluid and blood replacement The patient may require drugs to support blood

A B D O M I N A L R I G I D I T Y 23

EXAMINATION TIP

Recognizing voluntary rigidity

Distinguishing voluntary from involuntaryabdominal rigidity is a must for accurate as-sessment Review the comparison below sothat you can quickly tell the two apart

◆Painless when the patient sits up using hisabdominal muscles alone

Involuntary rigidity

◆Usually asymmetrical

◆Equally rigid on inspiration and expiration

◆Unaffected by relaxation techniques

◆Painful when the patient sits up using hisabdominal muscles alone

pressure Also prepare him for catheterization,

and monitor intake and output.

A nasogastric tube may have to be inserted to

relieve abdominal distention Because emergency

surgery may be necessary, prepare the patient for

laboratory tests and X-rays.

H ISTORY AND PHYSICAL

EXAMINATION

If the patient’s condition allows further

assess-ment, take a brief history Find out when the

dominal rigidity began Is it associated with

ab-dominal pain? If so, did the pain begin at the

same time? Determine whether the rigidity is

lo-calized or generalized Is it always present? Has

its location changed or remained constant?

Next, ask about aggravating or alleviating

fac-tors, such as position changes, coughing,

vomit-ing, elimination, and walking

Then explore other signs and symptoms

In-spect the abdomen for peristaltic waves, which

may be visible in very thin patients Also check

for a visibly distended bowel loop Next,

auscul-tate bowel sounds Perform light palpation to

locate the rigidity and to determine its severity

Avoid deep palpation, which may exacerbate

abdominal pain Finally, check for poor skin

turgor and dry mucous membranes, which

indi-cate dehydration

M EDICAL CAUSES

◆Abdominal aortic aneurysm (dissecting).

Mild to moderate abdominal rigidity occurs in

ab-dominal aortic aneurysm, a life-threatening

dis-order It’s typically accompanied by constant

up-per abdominal pain that may radiate to the lower

back The pain may worsen when the patient lies

down and may be relieved when he leans

for-ward or sits up Before rupture, the aneurysm

may produce a pulsating mass in the

epigastri-um, accompanied by a systolic bruit over the

aor-ta However, the mass stops pulsating after

rup-ture Associated signs and symptoms include

mottled skin below the waist, absent femoral and

pedal pulses, blood pressure that’s lower in the

legs than in the arms, and mild to moderate

ab-dominal tenderness with guarding Significant

blood loss causes signs of shock, such as

tachy-cardia, tachypnea, and cool, clammy skin

◆Mesenteric artery ischemia This

life-threatening disorder is characterized by 2 to 3

days of persistent, low-grade abdominal pain

and diarrhea leading to sudden, severe

abdomi-nal pain and rigidity Rigidity occurs in the

cen-tral or periumbilical region and is accompanied

by severe abdominal tenderness, fever, andsigns of shock, such as tachycardia and hy-potension Other findings may include vomiting,anorexia, diarrhea, and constipation Alwayssuspect mesenteric artery ischemia in patientsolder than age 50 who have a history of heartfailure, arrhythmias, cardiovascular infarct, orhypotension

◆Peritonitis Depending on the cause of

peri-tonitis, abdominal rigidity may be localized orgeneralized For example, if an inflamed appen-dix causes local peritonitis, rigidity may be local-ized in the right lower quadrant If a perforatedulcer causes widespread peritonitis, rigidity may

be generalized and, in severe cases, boardlike.Peritonitis also causes sudden and severe ab-dominal pain that can be localized or general-ized It can also produce abdominal tendernessand distention, rebound tenderness, guarding,hyperalgesia, hypoactive or absent bowelsounds, nausea, and vomiting Most patientsalso experience fever, chills, tachycardia,tachypnea, and hypotension

◆Pneumonia In lower lobe pneumonia,

se-vere upper abdominal pain and tenderness company rigidity that diminishes with inspira-tion Associated signs and symptoms includeblood-tinged or rusty sputum, dyspnea, achi-ness, headache, fever, sudden onset of chills,crackles, egophony, decreased breath sounds,dullness on percussion, and a dry, hackingcough

ac-O THER CAUSES

◆Insect toxins Insect stings and bites,

espe-cially black widow spider bites, release toxinsthat can produce generalized cramping abdomi-nal pain, usually accompanied by rigidity Thesetoxins may also cause low-grade fever, nausea,vomiting, tremors, and burning sensations inthe hands and feet Some patients develop in-creased salivation, hypertension, paresis, andhyperactive reflexes Children commonly arerestless, have an expiratory grunt, and keeptheir legs flexed

S PECIAL CONSIDERATIONS

Continue to monitor the patient closely for signs

of shock Position him as comfortably as ble in a supine position, with his head flat onthe table, arms at his sides, and knees slightlyflexed to relax the abdominal muscles Becauseanalgesics may mask symptoms, withhold themuntil a tentative diagnosis has been made Alsowithhold food and fluids and administer an I.V

possi-24 A B D O M I N A L R I G I D I T Y

antibiotic because emergency surgery may be

required Prepare the patient for diagnostic

tests, which may include blood, urine, and stool

studies; chest and abdominal X-rays; a

comput-ed tomography scan; magnetic resonance

imag-ing; peritoneal lavage; and gastroscopy or

colonoscopy A pelvic or rectal examination

may also be done

P EDIATRIC POINTERS

Voluntary rigidity may be difficult to distinguish

from involuntary rigidity if associated pain

makes the child restless, tense, or apprehensive

However, in any child with suspected

involun-tary rigidity, your priority is early detection of

dehydration and shock, which can rapidly

be-come life-threatening

Abdominal rigidity in children can stem from

gastric perforation, hypertrophic pyloric

steno-sis, duodenal obstruction, meconium ileus,

in-tussusception, cystic fibrosis, celiac disease, and

appendicitis

G ERIATRIC POINTERS

Advanced age and impaired cognition decrease

pain perception and intensity Weakening of

ab-dominal muscles may decrease muscle spasms

and rigidity

Accessory muscle use

When breathing requires extra effort, the

acces-sory muscles—the sternocleidomastoid,

sca-lene, pectoralis major, trapezius, internal

inter-costals, and abdominal muscles—stabilize the

thorax during respiration Some accessory

mus-cle use normally takes place during such

activi-ties as singing, talking, coughing, defecating,

and exercising (See Accessory muscles:

Loca-tions and funcLoca-tions, page 26.) However, more

pronounced use of these muscles may signal

acute respiratory distress, diaphragmatic

weak-ness, or fatigue It may also result from chronic

respiratory disease Typically, the extent of

ac-cessory muscle use reflects the severity of the

underlying cause

EMERGENCY INTERVENTIONS If the

patient displays increased accessory

mus-cle use, immediately look for signs of acute

res-piratory distress These include decreased level

of consciousness, shortness of breath when

speaking, tachypnea, intercostal and sternal

retractions, cyanosis, external breath sounds

(such as wheezing or stridor), diaphoresis,

nasal flaring, and extreme apprehension or tation Quickly auscultate for abnormal, dimin- ished, or absent breath sounds Check for airway obstruction and, if detected, attempt to restore airway patency Insert an airway or intu- bate the patient Then begin suctioning and manual or mechanical ventilation Assess oxy- gen saturation using pulse oximetry, if avail- able Administer oxygen; if the patient has chronic obstructive pulmonary disease (COPD), use only a low flow rate for mild COPD exacer- bations You may need to use a high flow rate initially, but be attentive to the patient’s respira- tory drive Giving too much oxygen may decrease the patient’s respiratory drive An I.V catheter may be required.

agi-H ISTORY AND PHYSICAL EXAMINATION

If the patient’s condition allows, examine himmore closely Ask him about the onset, dura-tion, and severity of associated signs and symp-toms, such as dyspnea, chest pain, cough, andfever

Explore his medical history, focusing on piratory disorders, such as infection or COPD.Ask about cardiac disorders, such as heart fail-ure, which may lead to pulmonary edema; alsoinquire about neuromuscular disorders, such asamyotrophic lateral sclerosis, which may affectrespiratory muscle function Note a history ofallergies or asthma Because collagen vasculardiseases can cause diffuse infiltrative lung dis-ease, ask about such conditions as rheumatoidarthritis and lupus erythematosus

res-Ask about recent trauma, especially to thespine or chest Find out if the patient has re-cently undergone pulmonary function tests orreceived respiratory therapy Ask about smokingand about occupational exposure to chemicalfumes or mineral dusts such as asbestos Ex-plore the family history for such disorders ascystic fibrosis and neurofibromatosis, which cancause diffuse infiltrative lung disease

Perform a detailed chest examination, notingabnormal respiratory rate, pattern, or depth As-sess the color, temperature, and turgor of the

patient’s skin, and check for clubbing (See cessory muscle use: Causes and associated findings, page 27.)

response to hypoxia It’s accompanied by

intercostal, supracostal, and sternal retractions

on inspiration and by grunting on expiration

Other characteristics include tachypnea,

dysp-nea, diaphoresis, diffuse crackles, and a cough

with pink, frothy sputum Worsening hypoxia

produces anxiety, tachycardia, and mental

sluggishness

◆Airway obstruction An acute upper airway

obstruction can be life-threatening; fortunately,

most obstructions are subacute or chronic

Typi-cally, this disorder increases accessory muscle

use Its most telling sign, however, is inspiratory

stridor Associated signs and symptoms include

dyspnea, tachypnea, gasping, wheezing,

cough-ing, droolcough-ing, intercostal retractions, cyanosis,and tachycardia

◆Amyotrophic lateral sclerosis (ALS)

Be-cause ALS affects the diaphragm more thanthe accessory muscles, increased accessorymuscle use is characteristic of this disorder.Other signs and symptoms include fascicula-tions, muscle atrophy and weakness, spastici-

ty, bilateral Babinski’s reflex, and hyperactivedeep tendon reflexes Incoordination makescarrying out routine activities difficult for thepatient Associated signs and symptoms in-clude impaired speech; difficulty chewing orswallowing and breathing; urinary frequencyand urgency; and, occasionally, choking and

26 A C C E S S O R Y M U S C L E U S E

Accessory muscles: Locations and functions

Physical exertion and pulmonary disease

usu-ally increase the work of breathing, taxing the

diaphragm and external intercostal muscles

When this happens, accessory muscles provide

the extra effort needed to maintain

respira-tions The upper accessory muscles assist with

inspiration, whereas the upper chest, sternum,

internal intercostal, and abdominal muscles

assist with expiration

With inspiration, the scalene muscles

ele-vate, fix, and expand the upper chest The

ster-nocleidomastoid muscles raise the sternum,

expanding the chest’s anteroposterior and gitudinal dimensions The pectoralis major ele-vates the chest, increasing its anteroposteriorsize, and the trapezius raises the thoraciccage

lon-With expiration, the internal intercostals press the ribs, decreasing the chest size Theabdominal muscles pull the lower chest down,depress the lower ribs, and compress the ab-dominal contents, which exerts pressure onthe chest

Trapezius muscle

Pectoralis majormuscle

Abdominal rectus muscle

excessive drooling (Note: Other

neuromuscu-lar disorders may produce simineuromuscu-lar signs and

symptoms.) Although the patient’s mental

sta-tus remains intact, his poor prognosis may

cause periodic depression

◆Asthma During acute asthma attacks, the

patient usually displays increased accessory

muscle use accompanied by severe dyspnea,

tachypnea, wheezing, productive cough, nasal

flaring, and cyanosis Auscultation reveals faint

or possibly absent breath sounds, musical

crackles, and rhonchi Other signs and

symp-toms include tachycardia, diaphoresis, and

ap-prehension caused by air hunger Chronic

asth-ma asth-may also cause barrel chest

◆Chronic bronchitis In this form of COPD,

increased accessory muscle use may be chronicand is preceded by a productive cough and ex-ertional dyspnea Chronic bronchitis is accom-panied by wheezing, basal crackles, tachypnea,jugular vein distention, prolonged expiration,barrel chest, and clubbing Patients with chronicbronchitis are sometimes called “blue bloaters”because of the cyanosis and weight gain fromedema that commonly occur Low-grade fevermay occur with secondary infection

A C C E S S O R Y M U S C L E U S E 27

SIGNS & SYMPTOMS

Accessory muscle use: Causes and associated findings

Barrel chest Chest pain Cough Crackles Cyanosis Diaphoresis Dyspnea Fever Muscle weakness Paralysis Stridor T T Wheezing

Major associated signs and symptoms

◆Diffuse infiltrative (or fibrotic) lung

dis-ease In diffuse infiltrative lung disease,

pro-gressive pulmonary degeneration eventually

in-creases accessory muscle use Typically, though,

the patient reports progressive dyspnea on

ex-ertion as his chief complaint He may also have

a cough, anorexia, weakness, fatigue, vague

chest pain, tachypnea, and crackles at the base

of the lungs

◆Emphysema Increased accessory muscle

use occurs with progressive exertional dyspnea

and a minimally productive cough in this form

of COPD These patients are sometimes called

“pink puffers” because of their characteristic

pursed-lip breathing, tachypnea, and a pink or

red complexion Associated signs and

symp-toms include peripheral cyanosis, anorexia,

weight loss, malaise, barrel chest, and clubbing

Auscultation reveals distant heart sounds;

per-cussion detects hyperresonance

◆Pneumonia Bacterial pneumonia initially

produces sudden high fever with chills

Associ-ated signs and symptoms include increased

ac-cessory muscle use, chest pain, productive

cough, dyspnea, tachypnea, tachycardia,

expira-tory grunting, cyanosis, diaphoresis, and fine

crackles

◆Pulmonary edema In acute pulmonary

ede-ma, increased accessory muscle use is

accom-panied by dyspnea, tachypnea, orthopnea,

crepitant crackles, wheezing, and a cough with

pink, frothy sputum Other findings include

rest-lessness, tachycardia, ventricular gallop, and

cool, clammy, cyanotic skin

◆Pulmonary embolism Although signs and

symptoms vary with the size, number, and

loca-tion of the emboli, this life-threatening disorder

may cause increased accessory muscle use

Common findings include dyspnea and

tachyp-nea that may be accompanied by pleuritic or

substernal chest pain Other signs and

symp-toms include restlessness, anxiety, tachycardia,

productive cough, low-grade fever and, with a

large embolus, hemoptysis, cyanosis, syncope,

jugular vein distention, scattered crackles, and

focal wheezing

◆Spinal cord injury An injury below Ll

typi-cally doesn’t affect the diaphragm or accessory

muscles, whereas an injury between C3 and C5

affects the upper respiratory muscles and

di-aphragm, causing increased accessory muscle

use

Associated signs and symptoms of spinal

cord injury include unilateral or bilateral

Babin-ski’s reflex; hyperactive deep tendon reflexes;

spasticity; and variable or total loss of pain andtemperature sensation, proprioception, and mo-tor function Horner’s syndrome (unilateral pto-sis, pupillary constriction, facial anhidrosis) mayoccur in lower cervical cord injury

◆Thoracic injury Increased accessory

mus-cle use may occur, depending on the type andextent of the injury Associated signs andsymptoms of this potentially life-threateninginjury include an obvious chest wound orbruising, chest pain, dyspnea, cyanosis, andagitation Signs of shock, such as tachycardiaand hypotension, occur with significant bloodloss

O THER CAUSES

◆Diagnostic tests and treatments

Pul-monary function tests, incentive spirometry, andintermittent positive-pressure breathing can in-crease accessory muscle use

S PECIAL CONSIDERATIONS

If the patient is alert, elevate the head of the bed

to make his breathing as easy as possible courage him to get plenty of rest and to drinkplenty of fluids to liquefy secretions Administeroxygen Prepare him for such tests as pul-monary function studies, chest X-rays, lungscans, arterial blood gas analysis, completeblood count, and sputum culture

En-If appropriate, stress how smoking endangersthe patient’s health, and refer him to an orga-nized program to stop smoking Also, teach himhow to prevent infection Explain the purpose ofprescribed drugs, such as bronchodilators andmucolytics, and make sure he knows theirdosage and schedule

P EDIATRIC POINTERS

Because infants and children tire sooner thanadults, they can develop respiratory failure fromrespiratory distress more quickly than adults.Upper airway obstruction—caused by edema,bronchospasm, or a foreign object—usually pro-duces respiratory distress and increased acces-sory muscle use Disorders associated with air-way obstruction include acute epiglottitis,croup, pertussis, cystic fibrosis, and asthma.Supraventricular, intercostal, or abdominal re-tractions indicate accessory muscle use