Transcript Slide 1

Abdominal Examination
H.A.Soleimani MD
Gastroenterologist
Adapted by Judy Gearhart, MD
Gastrointestinal History
www.rightdiagnosis.com
Be a detective!
Think about what all could cause this
presentation.
What are risk factors?
How to perform the physical
examination?
Exposing only the
area that are being
examined
Offer a chaperone for
both sexes.
Explain what you're
going to do
Sequential
Important aspects of physical
examination
The examiner should
continue speaking to
the patient
Showing care to his
disease and answer to
patient’s questions
Gloves should be worn when..
Examining any
individual with
exudative lesions or
weeping dermatitis
When handling
blood-soiled or body
fluid-soiled sheets
or clothing
General principles of exam
Have the patient
empty their bladder
before examination
Have the patient lie in
a comfortable, flat,
supine position
Have them keep their
arms at their sides or
folded on the chest
General principles of exam
Before the exam, ask
the patient to identify
painful areas so that
you can examine
those areas last
During the exam pay
attention to their facial
expression to assess
for sign of discomfort
General principles of exam
Use warm hand,
warm stethoscope,
and have short finger
nails
Approach the patient
slowly and
deliberately
explaining what you
will be doing
General principles of exam
 Stand right side of the
bed (tradition-depends on
patient, room, and
situation)
 Exam with right hand
(again, it depends)
Head just a little elevated
Ask the patient to keep
the mouth partially open
and breathe gently
General principles of exam
If muscles remain
tense, patient may
be asked to rest
feet on table with
hips and knees
flexed
Other helpful points on examination
Take a spare bed
sheet and drape it
over their lower body
such that it just
covers the upper
edge of their
underwear
General principles of exam
If the patient is ticklish
or frightened,
initially use the
patient’s hand under
yours as you palpate
When patient calms
then use your hands
to palpate.
Watch the patient’s
face for discomfort.
Think Anatomically
When looking,
listening, feeling and
percussing, imagine
what organs live in
the area that you are
examining.
Right Upper Quadrant (RUQ)
liver, gallbladder,
duodenum,
right kidney
and hepatic
flexure of colon
Right Lower Quadrant (RLQ)
Cecum,
appendix (in
case of female,
right ovary &
tube)
Left Lower Quadrant (LLQ)
Sigmoid
colon (in case
of female, left
ovary & tube)
Left Upper Quadrant (LUQ)
Stomach,
spleen, left
kidney, pancreas
(tail), splenic
flexure of colon
Epigastric Area
Stomach,
pancreas
(head and
body), aorta
Landmarks of the abdominal wall,
Costal margin,
umbilicus, iliac crest,
anterior superior iliac
spine, symphysis
pubis, pubic tubercle,
inguinal ligament,
rectus abdominis
muscle, xiphoid
process.
Physical Examination of the
Abdomen
Inspection
Auscultation
Percussion
Palpation
Special Tests
Appearance of the abdomen
Is Aortic pulsation?
Is it flat or Scaphoid
(Normally)?
Distended?
If enlarged, does this
appear symmetric?
With bulging or
moving?
Appearance of the abdomen
Global
abdominal
enlargement is
usually caused
by air, fluid, or
fat.
Appearance of the abdomen
Localized
enlargement,
probably distended
GB space
occupying lesion,
hepatomegaly….
An aortic aneurysm
Palpable mass
Patient feeling of
pulsation
On rare occasions, a
lump can be visible.
Appearance of the abdomen
(Skin)
Abnormal venous
patterns
Abnormal
discoloration
Umbilicus is sunken
Striae
Stretch marks are a
light silver hue.
Pregnant and obese
individuals
Cushing’s syndrome
(more purple or pink).
Appearance of the abdomen
(Skin)
Tattoos
Scars
Cullen’s sign
Ecchymosis,
periumbilical.
(intraperitoneal
hemorrhage
ruptured ectopic
pregnancy,
hemorrhagic
pancreatitis..)
Grey-Turner’s sign
Ecchymosis of
flanks.
(retroperitoneal
hemorrhage
such as
hemorrhagic
pancreatitis)
Upward flow direction indicates IVC obstruction
Outward flow pattern from umbilicus in all directions ? Portal HTN
Appearance of the abdomen
Areas which
become more
pronounced when
the patient
valsalvas are
often associated
with ventral
hernias
Visible Pulsations
More conspicuous in the
thin than in the fat
Greater in the old than in
the young.
Increased in
thyrotoxicosis,
hypertension, or aortic
regurgitation)
In those with an aortic
aneurysm and tortuous
aorta
In those who have a
mass joining the aorta to
the anterior abdominal
wall.
Visible gastric Peristalsis
Visible intestinal Peristalsis
Gastric peristalsis is
commonly seen in
neonates with
congenital
hypertrophic pyloric
stenosis
Intestinal peristalsis in
partial and chronic
intestinal obstruction
Colonic obstruction is
usually not manifest
as visible peristalsis
Appearance of the abdomen
Patient's movement
Patients with kidney
stones will frequently
writhe on the
examination table,
unable to find a
comfortable
position
Appearance of the abdomen
Patient's movement
Patients with
peritonitis prefer to lie
very still as any
motion causes further
peritoneal irritation
and pain.
Auscultation
Abdominal examination
Auscultation for bowel sounds
It is performed before percussion or
palpation
Auscultation for bowel sounds
Normal sounds are
due to peristaltic
activity.
Peristalsis: A
pregressive wavelike
movement that occurs
involuntarily in hollow
tubes of the body.
Auscultation
Listening for 15-60
seconds
Bowel sounds cannot
be said to be absent
unless they are not
heard after listening
for 3-5 minutes.
Three things about bowel
sound
Are bowel sounds
present?
If present, are they
frequent or sparse
(i.e.quantity)?
What is the nature of
the sounds
(i.e.quality)?
Bowel sound decrease
Inflammatory
processes of the
serosa
After abdominal
surgery
In response to
narcotic analgesics or
anesthesia.
Bowel Sounds Increase
Inflammation of the
intestinal mucosa
will cause
hyperactive bowel
sounds.
Auscultation for bowel sounds
Processes which
lead to intestinal
obstruction initially
cause frequent
bowel sounds,
referred to as
"rushes."
Auscultation for bowel sounds
“Rushes" means
as the intestines
trying to force
their contents
through a tight
opening.
Auscultation for bowel
sounds
“Rushes" is followed
by decreased sound,
called "tinkles," and
then silence.
Bruits
Bruits confined
to systole do not
necessarily
indicate disease.
Auscultation for
vascular sounds
(bruits)
Aortic (midline between
umbilicus and xiphoid
Renal (two inches
superior to and two
inches lateral to
umbilicus)
Common iliac (midway
between umbilicus
and midpoint of
inguinal ligament)
Auscultation for vascular sounds
(bruits)
Presence of a bruit
on the renal artery
would lend
supporting
evidence for the
existence of renal
artery stenosis.
Percussion
Abdominal examination
Percussion Sounds
Resonance (heard over lung tissue)
Tympany (heard over most of abdomen)
Dullness (heard over solid organs)
Flatness (heard over muscle)
Percussion (technique)
DIP joint of third
finger (pleximeter)
pressed firmly on the
abdomen remainder
of hand not touching
the abdomen
Same technique as for lungs
Percussion (technique)
Striking hand
should move
only at the wrist,
with only little
more than force
of gravity
Percussion (technique)
Middle finger of
striking hand
(plexor) should
knock the
pleximeter firmly,
with a strong
note
There are two basic sounds with
Percussion
Tympanitic
(drum-like)
sounds
produced by
percussing over
air filled
structures.
There are two basic sounds with
Percussion
Dull sounds that
occur when a solid
structure (e.g. liver)
or fluid (e.g. ascites)
lies beneath the
region being
examined.
Examination of Liver (Percussion)
Midclavicular line
is noted
Second
intercostal space
is noted
Two solid organs are percussable
in the normal patient
Liver:
Covered by the ribs.
Edge may protrude
1-2 centimeter below
the costal margin.
Spleen:
smaller and protected
by the ribs.
To determine the size of the liver
Percuss
hepatic dullness from
above (lung) and
below (bowel).
Normal liver span =
6 to 12 cm in the
midclavicular line.
To determine the size of the liver
Start just below the
right breast in a line
with the middle of
the clavicle.
Percussion here
should produce a
resonant note.
To determine the size of the liver
As you move
your hand down
you will percuss
over the liver,
which will
produce a duller
sound.
To determine the size of the liver
Continue
downward until
the sound
changes once
again.
This is the inferior
margin of the
liver.
Examination of Liver (Percussion)
Upper margin is
noted by first dull
percussion note
Lower margin is
noted by first
tympanitic note
Examination of Spleen
(Percussion)
Percussion at Castell’s Spot
Castell’s Spot identified
Left anterior axillary line identified
Left lower costal margin identified
Percussion at Castell’s Spot while patient
inhales and exhales deeply
Dull tone indicates
possible splenomegaly
Spleen percussion
Enlarged spleen:
produces a dull
tone, in the LUQ
Palpation
Abdominal examination
Abdominal Palpation
Technique
Light
Deep
Liver edge
Spleen tip
Kidneys
Aorta
Masses
Abdominal palpation
To palpate four
quadrants
superficially
from LLQ
counterclockwise
Light Palpation
Light Palpation
First warm your
hands by rubbing
them together before
placing them on the
patient.
Abdominal wall
depressed
approximately 1 cm
Palpation (light)
Any areas of pain or
tenderness are
reserved for
evaluation at the end
of the exam
Palpation
Light palpation assesses
Tenderness (muscle
splinting, wide eyes,
moaning, teeth
gritting).
Muscle tone,
Cutaneous
hypersensitivity
(suggests peritoneal
irritation)
Palpation
Light palpation assesses
Superficial mass
(intramural): more
prominent with head
raised
Intra-abdominal
mass: less prominent
with head raised
Deep Palpation
Deep Palpation
Use palmar surface of
fingers
Deep, firm, gentle
maneuver
Use finger pads (do
not “dig in” with finger
tips)
Deep Palpation
Palpate tender areas
last
Try to identify
abdominal masses or
areas of deep
tenderness
Two handed technique
When deep
palpation is difficult,
examiner may
want to use left
hand placed over
right hand to help
exert pressure
Normal structures that may be
palpable
Sigmoid colon
Liver
Kidney
Abdominal aorta
Iliac artery
Distended bladder
Gravid and nongravid uterus
Xyphoid process
spleen
Abdominal mass
Intra abdominal
masses or enlarged
liver, gallbladder or
spleen
Abdominal wall mass
Intra abdominal masses or enlargements of
the liver, gallbladder or spleen
will shift down with
inspiration and back
with expiration.
(not true of masses
within the abdominal
wall or retroperitoneal
structures).
Abdominal pain and
Tenderness:
Visceral
Somatic
Visceral pain
Pain from an organic
lesion or functional
disturbance within an
abdominal viscus (dull,
poorly localized, and
difficult for the patient
to characterize).
Somatic pain
Painful lesion of the
skin
Sharp, bright, and
well localized
Indicates
involvement of
parietal peritoneum
or the abdominal
wall itself
Abdominal muscle spasm
Voluntary guarding
Tensing abdominal
muscles due to
patient anxiety,
ticklishness, or
toprevent palpation to
a painful area
Involuntary guarding
Muscular spasm or
rigidity due to
peritoneal
inflammation
May be localized
(early appendicitis )or
diffuse (perforated
bowel)
Board-like rigidity
Abdominal wall is
tense, even as rigid
as a board.
Caused by the spasm
of abdominal muscle
due to peritoneal
irritation.
Palpation of Liver, Spleen,
and Aorta
Liver palpation
(Standard Method)
Start in the RUQ,10
centimeters below the
rib margin in the midclavicular line
Place left hand
posteriorly parallel to
and supporting 11th &
12th ribs on right.
Standard Method Liver palpation
Ask the patient to
take a deep breath.
You may feel the
edge of the liver press
against your fingers.
Liver palpation
(Standard Method)
Palpating hand is
held steady while
patient inhales
Liver palpation
(Standard Method)
Palpating hand is
lifted and moved
while the patient
breathes out
Alternate Method Liver palpation
Stand by the patient's
chest.
"Hook" your fingers
just below the costal
margin and press
firmly.
Hepatojugular reflux sign
If you press the liver,
you will find the
dilated jugular vein
becomes more
bulged or distended,
as from the
enlargement of liver
passive congestion
resulted from right
failure.
Spleen palpation
Support lower left rib
cage with left hand
while patient is supine
and lift anteriorly on
the rib cage.
Spleen palpation
Palpate upwards
toward spleen with
finger tips of right
hand, starting below
left costal margin.
Have the patient take
a deep breath.
Seldom palpable in
normal adults.
Palpation of Aorta
Press down deeply in
the midline above the
umbilicus with flat
palm.
The aortic pulsation is
easily felt on most
individuals.
Examination of Aorta
Hands then oriented
vertically on either
side of midline with
distal fingers at level
of pulsation; equal
pressure applied until
pulsation is palpated
A well defined, pulsatile mass, greater than
cm across, suggests an aortic aneurysm.
Special exam
Murphy’s Sign
McBurney’s
Point
Rovsing’s Sign
Psoas Sign
Obturator
Sign
Re bound
Tenderness
Costovertebral
tenderness
Shifting
Dullness
Fluid wave
Murphy’s Sign (acute cholecystitis)
Examiner’s hand is at
middle inferior border
of liver.
Patient is asked to
take deep inspiration.
If positive patient will
experience pain and
will stop short of full
inspiration
Hepatitis, subdiaphragmatic
abscess Cholecystitis
McBurney’s Point
Localized tenderness
Just below midpoint
of line between right
anterior iliac crest and
umbilicus.
Heel strike, riding
over bumps in road
while driving,
coughing, will
produce pain.
McBurney’s Point (Common Causes)
Appendicitis
Incarcerated or
strangulated hernia
Ovarian torsion (twisted
Fallopian tube)
Pelvic inflammatory
disease
Abdominal abscess
Hepatitis
Diverticular disease
Meckel''s diverticulum
Rovsing’s Sign
Patient will
experience right lower
quadrant pain (in
region of McBurney’s
Point) when left lower
quadrant is palpated.
Non-Classical Appendicitis
Iliopsoas Sign
Obturator Sign
Iliopsoas Sign
Patient lies on side, extends leg at the hip
or lies on back, flexes hip against resistance
of examiner’s hand on thigh.
Inflamed retrocecal appendix pain
Iliopsoas Sign
Anatomic basis for
the psoas sign:
inflamed appendix is
in a retroperitoneal
location in contact
with the psoas
muscle, which is
stretched by this
maneuver.
Obturator Sign
Internally rotate right leg at the hip with the knee
at 90 degrees of flexion. Will produce pain if
Obturator Sign
Anatomic basis for
the obturator sign:
inflamed appendix in
the pelvis is in contact
with the obturator
internus muscle,
which is stretched by
this maneuver.
Rebound Tenderness
(For peritoneal irritation)
Warn the patient what
you are about to do.
Press deeply on the
abdomen with your hand.
After a moment, quickly
release pressure.
If it hurts more when you
release, the patient has
rebound tenderness. [4]
Costovertebral Tenderness
(Often with renal disease)
Use the heel of your
closed fist to strike
the patient firmly
over the
costovertebral
angles.
Compare the left
and right sides.
Examination for Shifting
Dullness
Patient rolled slightly
toward the examined
side; movement of the
dull point medially is
described as “shifting
dullness” and
suggests ascites
Fluid wave