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Physical Examination of the Abdomen
- 1. Examination of the Abdomen 01 LanceCatedral, MD, MCMMO, FPCP [email protected] bottledbrain.com
- 2. Key reference andimage sources: Bates' Guide to Physical Examination and History Taking, 13th ed. Lynn S. Bickley. Wolters Kluwer.
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- 7. 13 Common or concerning symptoms GIdisorders abdominal pain indigestion, nausea, vomiting, hematemesis, anorexia, early satiety dysphagia (difficulty swallowing), odynophagia (painful swallowing) change in bowel function diarrhea, constipation jaundice Urinary and renal disorders suprapubic pain dysuria, urgency, frequency hesitancy, decreased stream polyuria, nocturia urinary incontinence hematuria flank pain and ureteral colic
- 8. 13 Mechanisms of abdominalpain Visceral pain Occurs when hollow abdominal organs such as the intestine or biliary tree contract unusually forcefully or are distended or stretched. May be difficult to localize Varies in quality; may be gnawing, burning, cramping, or aching When severe, may be associated with sweating, pallor, nausea, vomiting, restlessness. Parietal pain From inflammation of the parietal peritoneum. Steady, aching Usually more severe Usually more precisely localized over the involved structure than visceral pain Referred pain Occurs in more distant sites innervated at approximately the same spinal levels as the disordered structure. Pain from the chest, spine, or pelvis may be referred to the abdomen.
- 9. Visceral periumbilical painin early acute appendicitis from distention of inflamed appendix gradually changes to parietal pain in the right lower quadrant (RLQ) from inflammation of the adjacent parietal peritoneum. Clinical pearls Pain of duodenal or pancreatic origin may be referred to the back; pain from the biliary tree—to the right shoulder or right posterior chest.
- 10. 04 GI Tract: History Ask patientsto describe the pain in their own words, especially timing of the pain (acute or chronic); then ask them to point to the pain. Pursue important details: “Where does the pain start?” “Does it radiate or travel?” “What is the pain like?” “How severe is it?” “How about on a scale of 1 to 10?” “What makes it better or worse?” Elicit any symptoms associated with the pain, such as fever or chills; ask about their sequence.
- 11. Doubling over withcramping colicky pain signals a renal stone. Sudden knife-like epigastric pain often radiating to the back is typical of pancreatitis. Clinical pearls Epigastric pain occurs with gastroesophageal reflux disease (GERD), pancreatitis, and perforated ulcers. RUQ and upper abdominal pain are common in cholecystitis and cholangitis.
- 12. 04 Upper abdominal pain, discomfort,or heartburn: History Ask about chronic or recurrent upper abdominal discomfort, or dyspepsia. Related symptoms include bloating, nausea, upper abdominal fullness, and heartburn. Is there: Bloating from excessive gas, especially with frequent belching, abdominal distention, or flatus, the passage of gas by rectum Unpleasant abdominal fullness after normal meals or early satiety, the inability to eat a full meal Heartburn, dysphagia, or regurgitation
- 13. 12 Bloating may occurwith lactose intolerance, inflammatory bowel disease, or ovarian cancer; belching results from aerophagia, or swallowing air. Early satiety: Consider diabetic gastroparesis, anticholinergic drugs, gastric outlet obstruction, gastric cancer. Early satiety may signify hepatitis. Clinical pearls Heartburn, dysphagia, or regurgitation: Suggests GERD. Alarm: If patient fails empiric therapy Age >55 years Has “alarm symptoms” (dysphagia, pain with swallowing or odynophagia, recurrent vomiting, gastrointestinal bleeding, risk factors for gastric cancer, or palpable mass), endoscopy is warranted.
- 14. 04 Lower abdominal painor discomfort—acute and chronic If acute, is the pain sharp and continuous or intermittent and cramping? If chronic, is there a change in bowel habits? Alternating diarrhea and constipation?
- 15. RLQ pain, orpain migrating from periumbilical region in appendicitis; in women with RLQ pain, possible pelvic inflammatory disease, ectopic pregnancy, ruptured ovarian follicle Left lower quadrant (LLQ) pain in diverticulitis, diffuse abdominal pain with abdominal distention, hyperactive bowel sounds, and tenderness on palpation in small or large bowel obstruction; pain with absent bowel sounds, rigidity, percussion tenderness, and guarding in peritonitis Alternating diarrhea - constipation: colon cancer; irritable bowel syndrome Clinical pearls
- 16. 04 Abdominal pain +GI symptoms: History Nausea, vomiting, loss of appetite (anorexia) Regurgitation Coffee ground emesis (hematemesis)
- 17. Nausea, vomiting, anorexia: Pregnancy,diabetic ketoacidosis, adrenal insufficiency, hypercalcemia, uremia, liver disease. Induced vomiting without nausea in anorexia/bulimia. Regurgitation: GERD, esophageal stricture, and esophageal cancer Clinical pearls Coffee ground emesis (hematemesis): Esophageal or gastric varices, Mallory– Weiss tears, peptic ulcer disease
- 18. 04 Other GI symptoms:History Dificulty swallowing (dysphagia) If solids and liquids, neuromuscular disorders affecting motility. If only solids, consider structural conditions like Zenker diverticulum, Schatzki ring, stricture, neoplasm. Painful swallowing (odynophagia) Radiation; caustic ingestion, infection from cytomegalovirus, herpes simplex, HIV, esophageal ulceration from aspirin or NSAIDs Diarrhea, acute (<2 weeks) and chronic Acute infection Chronic in Chron disease , ulcerative colitis; oily diarrhea (steatorrhea)—in pancreatic insufficiency. Constipation Medications, especially anticholinergic agents and opioids; colon cancer, diabetes, hypothyroidism, hypercalcemia, multiple sclerosis, Parkinson disease
- 19. 04 Other GI symptoms:History Black tarry stools (melena) GI bleed Jaundice Intrahepatic: hepatocellular or cholestatic Extrahepatic: obstructed extrahepatic bile ducts, commonly the cystic and common bile ducts Ask about the color of the urine and stool. Dark urine from increased conjugated bilirubin excreted in urine (hepatitis) Acholic clay-colored stool when bilirubin excretion into intestine is obstructed
- 20. 04 Urinary Tract: History Ask aboutpain on urination, usually a burning sensation, sometimes termed dysuria (also refers to difficulty voiding. Is there: Urgency, an unusually intense and immediate desire to void Urinary frequency, or abnormally frequent voiding Fever or chills; blood in the urine Any pain in the abdomen, or back In men, hesitancy in starting the urine stream, straining to void, reduced caliber and force of the urine stream, or dribbling as they complete voiding.
- 21. 04 Urinary Tract: History Assess any: Polyuria,a signifcant increase in 24-hour urine volume Nocturia, urinary frequency at night Urinary incontinence, involuntary loss of urine: From coughing, sneezing, lifting →stress incontinence From urge to void →urge incontinence From bladder fullness with leaking but incomplete emptying →overflow incontinence
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- 24. Tips for examiningthe abdomen Make the patient comfortable in the supine position, with a pillow under the head and perhaps under the knees. Ask the patient to keep the arms at the sides. When the arms are above the head, the abdominal wall stretches and tightens, which hinders palpation. Drape the patient. Place the drape or sheet at the level of the symphysis pubis, then expose the abdomen by raising the patient’s gown to just below the nipple line above the xiphoid process.
- 25. Tips for examiningthe abdomen Before you begin, ask the patient to point to any areas of pain so that you can examine these areas last. Warm your hands by rubbing them together or placing them under lukewarm water. Approach the patient calmly and avoid quick, unexpected movements. Avoid having long fingernails that can scratch or scrape the patient’s skin
- 26. Tips for examiningthe abdomen Position yourself at the patient’s right side and proceed in a systematic fashion with inspection, percussion, and palpation. Mentally visualize each organ in the region you are examining. Watch the patient’s face for any signs of pain or discomfort. If necessary, distract the patient with conversation or questions. If the patient is frightened or ticklish, begin palpation with the patient’s hand under yours. After a few moments, slip your hand underneath to palpate directly.
- 27. 04 Abdomen: general guidelines Notethe patient’s general appearance (demeanor, distress, color, mental status). Inspect the surface, contours, and movements of the abdomen including skin temperature, color, and presence of scars or striae. Prior to palpation or percussion, place the diaphragm of your stethoscope in one abdominal region and listen for bowel sounds (presence, characteristics, bruits). Percuss the abdomen lightly in all four quadrants (tympany, dullness, area of change). Palpate lightly with one hand in all four quadrants (masses, tenderness, guarding). Palpate deeply with two hands in all four quadrants (liver edge, masses, tenderness, pulsations). Check for signs of peritonitis (guarding, rigidity, rebound tenderness).
- 28. 04 Liver Estimate the liversize along right midclavicular line by percussion. Palpate and characterize the liver edge (surface, consistency, tenderness). Spleen Percuss for splenic enlargement along Traube space. Palpate for the splenic edge with the patient supine and in the right lateral decubitus position.
- 29. 04 Kidneys Check for costovertebralangle (CVA) tenderness using fist percussion. Urinary bladder Percuss the urinary bladder (distention, tenderness). Special techniques Perform special techniques if indicated (ascites, appendicitis, cholecystitis, ventral hernia, abdominal wall mass).
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- 31. 05 Inspection contours surface movements skin: temperature, color,scars, striae, dilated veins, ecchymoses, umbilicus contour of the abdomen: flat, rounded, or protuberant bulging flanks, local bulges asymmetric? pulsations?
- 32. 07 Image adapted fromRachel S. Natividad, https://slideplayer.com/slide/14176545/ and Roshan Lall Gupta’s: Recent Advances in Surgery (Volume 14) (pp.33-52)
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- 34. 05 Auscultation Auscultate the abdomenbefore performing percussion or palpation maximum: 5 mins normoactive bowel sounds: 5 to 34 per minute hypoactive bowel sounds: <5 / min hyperactive bowerl sounds: > 34 / min typically non-specific and non-diagnostic
- 35. abdominal pulsatile mass →auscultationmay identify bruits 14
- 36. Friction rubs Friction rubsare infrequently found on abdominal examination but can occur over the liver, spleen, or an abdominal mass hepatoma, gonococcal infection around the liver, splenic infarction, and pancreatic carcinoma 15
- 37. 05 Percussion Percuss the abdomenlightly in all four quadrants to determine the distribution of tympany and dullness. Note tympanitic areas gas Note dull areas underlying mass / enlarged organ Note where tympany changes to dullness Image: https://pressbooks.library.torontomu.ca/assessmentnursing/chapter/abdomen- percussion/#:~:text=Percussion%20of%20the%20abdomen%20involves,some%20of%20the%20underl ying%20structures.
- 38. 05 Light palpation aids detection ofabdominal tenderness, muscular resistance, and some superficial organs and masses. voluntary vs involuntary guarding (rigidity) voluntary guarding DECREASES with: bending lower extremities at the hip mouth-breathing with jaws wide open exhaling
- 39. 05 Deep palpation required to delineatethe liver edge, the kidneys, and abdominal masses use the palmar surfaces of your fingers, press down in all four quadrants Abdominal masses may be categorized in several ways: physiologic (pregnant uterus) inflammatory (diverticulitis), vascular (an AAA) neoplastic (colon cancer), or obstructive (a distended bladder or dilated loop of bowel)
- 40. 21 Assessing peritonitis CLINICAL PEARL positive coughtest involuntary guarding voluntary contraction of the abdominal wall, often accompanied by a grimace that may diminish when the patient is distracted. rigidity involuntary reflex contraction of the abdominal wall from peritoneal inflammation that persists over several examinations. rebound tenderness refers to pain expressed by the patient after the examiner presses down on an area of tenderness and suddenly removes the hand. percussion tenderness.
- 41. Direct assessment islimited Percussion — estimate liver size Liver 06
- 42. Starting at thenipple line, percuss downward in the midclavicular line until lung resonance shifts to liver dullness Gently displace a woman’s breast as necessary to be sure that you start in a resonant area. Now, measure the distance between your two points in centimeters—this is the vertical span of liver dullness. Percussion 06
- 43. Palpate for theliver edge below the right costal margin. Place your right hand on the patient’s right abdomen lateral to the rectus muscle, with your fingertips done to prevent mistaking the rectus muscle for the underlying and adjacent liver. Also place your hand well below where you would expect the lower border of the liver. Press gently in and up. Ask the patient to take a deep breath. On inspiration, the liver is palpable about 3 cm below the right costal margin in the midclavicular line. Note: A palpable liver edge does not reliably indicate hepatomegaly. Palpation 06
- 44. Stand to theright of the patient’s chest. Place both hands, side by side, on the right abdomen below the border of liver dullness. Press in with your fingers and up toward the costal margin. Ask the patient to take a deep breath. Palpation: Hooking technique 06
- 45. Spleen 06 When a spleenenlarges, it expands anteriorly, downward, and medially, often replacing the tympany of stomach and colon with the dullness of a solid organ. It then becomes palpable below the costal margin
- 46. 11 Percussion First, percuss theleft lower anterior chest wall roughly from the border of cardiac dullness at the sixth rib to the anterior axillary line and down to the costal margin, an area termed Traube (semilunar) space
- 47. Percussion Second, check fora splenic percussion sign (Castell sign). Percuss the lowest interspace in the left anterior axillary line (tympanitic). Then ask the patient to take a deep breath to let the air-filled lungs and diaphragm push the spleen and percuss again. When spleen size is normal, the percussion note usually remains tympanitic despite this downward displacement by the diaphragm.
- 48. 19 Palpation With your lefthand, reach over and around the patient to support and press forward the lower left rib cage and adjacent soft tissue. With your right hand below the left costal margin, press in toward the spleen. Begin palpation low enough so that you can detect an enlarged spleen
- 49. 05 Kidney The kidneys areretroperitoneal and usually not palpable unless markedly enlarged. Assessing costovertebral angle (CVA) tenderness
- 50. 05 Urinary bladder Normally, the urinarybladder is not palpable unless it is distended above the symphysis pubis. Percussion. Percuss for dullness and the height of the urinary bladder above the symphysis pubis. Bladder volume must be 400 to 600 mL before dullness appears.
- 51. 05 Aorta Palpation. Identify aorticpulsations. Press firmly deep in the epigastrium, slightly to the left of the midline, and identify the aortic pulsations.
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- 54. common complication ofcirrhosis ascitic fluid — sinks with gravity → dullness bowel loops (with gas) — rise → tympanitic two techniques Percuss from area of central tympany to area of dullness on supine patient. Test for shifting dullness Ascites 06
- 55. 05 Start with thepatient supine then percuss for dullness outward in several directions from the central area of tympany in the abdomen. Map the border between tympany and dullness
- 56. 04 Shifting dullness Percuss the borderof tympany and dullness with the patient supine, then ask the patient to roll onto one side. Percuss and mark the borders again. In a person without ascites, the border between tympany and dullness usually stays relatively constant
- 57. How to identify an organ/ mass in ascites? ballotte 01
- 58. McBurney point tenderness Rovsingsign (indirect tenderness) psoas sign, and obturator sign Appendicitis 06
- 59. 18 McBurney point tenderness APPENDICITIS Classically, McBurney point lies2 in from the anterior superior iliac spine on a line drawn from that process to the umbilicus
- 60. 18 Rovsing sign (indirect tenderness) APPENDICITIS referred rebound tenderness.With the patient supine, press deeply and evenly in the LLQ. Then quickly withdraw your fingers. Pain in the RLQ during left-sided pressure is a positive Rovsing sign.
- 61. 18 Psoas sign APPENDICITIS With thepatient supine, place your hand just above the patient’s right knee and ask the patient to raise that thigh against your hand. Alternatively, ask the patient to turn onto the left side. Then extend the patient’s right thigh at the hip. Flexion of the thigh at the hip makes the psoas muscle contract; extension stretches it. Increased abdominal pain on either technique is a positive psoas sign, suggesting irritation of the right psoas muscle by an inflamed retrocecal appendix.
- 62. 18 Obturator sign APPENDICITIS Flex the patient’sright thigh at the hip, with the knee bent, and rotate the leg internally at the hip. This maneuver stretches the internal obturator muscle. Right hypogastric pain is a positive obturator sign, from irritation of the right obturator internus muscle by an inflamed appendix located in the pelvis. This sign has very low sensitivity.
- 63. When a patientpresent with RUQ pain suspicious for acute cholecystitis but does not have any tenderness on palpation in the RUQ → Murphy's sign Deeply palpate the RUQ at the location of the patient’s pain. Ask the patient to take a deep breath, which forces the liver and gallbladder down toward the examining fingers. Positive Murphy sign: sharp halting in inspiratory effort due to pain from palpation of the gallbladder on examination this finding is only useful in a patient who does not have tenderness in the RUQ with regular palpation. Acute Cholecystitis 06
- 64. hernias in theabdominal wall exclusive of groin hernias ask the patient to raise both legs off the table or perform a Valsalva maneuver to increase intraabdominal pressure Ventral hernia 06 Image: https://abdominalkey.com/incisional-and-ventral-hernia-repair/
- 65. “Abdomen is protuberant,soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.” Recording findings “Abdomen is protuberant, soft and nontender; no palpable masses or hepatosplenomegaly. Liver span is 7 cm in the right midclavicular line; edge is smooth and palpable 1 cm below the right costal margin. Spleen and kidneys not felt. No costovertebral angle (CVA) tenderness.”
- 66. Examination of the Abdomen 01 LanceCatedral, MD, MCMMO, FPCP [email protected] bottledbrain.com